Fear fighter: Phobias, anxiety take center stage in early VR testing

VR logoEditor’s note: This is the third in a periodic series of articles focused on the potential of virtual reality technology in the medical setting. With its unique attributes, the University of Colorado Anschutz Medical Campus could lead the way in ensuring responsible and effective implementation of the gaming technology in health care.


Sitting in a soft, blue armchair in a quiet campus office, Nick Harrell slowly tensed. In his mind, the Denver librarian was standing on a busy airport curb near a line of passengers waiting their turn at a baggage check-in counter. The scene was enough to ignite his fear.

Hubley and Harrell VR session
Sam Hubley, PhD, guides Nick Harrell, a Denver librarian, through an exposure session using a virtual reality program aimed at overcoming a fear of flying.

“Nick, what sensations are you feeling?” asked psychologist Sam Hubley, PhD, who had been monitoring Harrell’s virtual airport visit from an identical chair arms-length away.

“My chest feels warm, and my throat feels tight,” said Harrell, his eyes covered by a boxy, maroon headset. Without hesitation, Hubley begins guiding his patient through relaxation exercises, helping him confront his fear of flying while averting a full-blown panic attack.

Jumping hurdles

The technique, called exposure therapy (ET), is not new. Experts have considered it the gold standard of treatment for an array of anxiety-related disorders for years. But Hubley and his colleagues on the University of Colorado Anschutz Medical Campus hope that by adding virtual reality (VR), they can make an effective therapy better.

“There are some major logistical issues with exposure therapy,” said Hubley, who works with the National Mental Health Innovation Center on campus testing virtual reality in a therapy setting. “And that’s putting it lightly.”

Hubley, who uses VR-assisted exposure therapy (VRET) at the University Family Medicine Practice in Boulder and at the Helen and Arthur E. Johnson Depression Center on the CU Anschutz Medical Campus, said the gaming technology could help overcome many obstacles that prevent some people from getting the mental health care they need.

Transporting patients

With ET, therapists begin by gradually exposing patients to places or things that trigger their fears while teaching them coping skills, eventually reaching the grand finale, whether it’s a scene of a deadly car accident for a traumatized survivor, a beer-flowing pub for an alcoholic or a bumpy airplane flight for a phobia patient.

“The center has been phenomenal in introducing us to mental health clinics and helping us put together a really good list of problems that we can help solve with virtual reality.” – Ben Lewis, Limbix Inc., co-founder

“How are we going to help somebody practice those things like deep breathing and cognitive skills while on an airplane? The short answer is: In the moment, we can’t, unless we have virtual reality,” said Hubley, assistant professor in the Department of Family Medicine in the CU Anschutz School of Medicine.

The NMHIC has launched pilot studies in 13 area mental health clinics so far, a number Executive Director Matt Vogl, MPH, said will continue to grow. Using cellphone VR technology with a platform created by Limbix, Inc., a Palo Alto, Calif., company focused solely on mental health issues, these therapists can now transplant their patients into numerous scenarios straight from their office chairs.

Feeling virtually real

Limbix applies panoramic pictures and videos of real places for an immersive, life-like experience. As an example, Vogl explained how Limbix employees mounted a 360-degree VR camera on the roof of a car and traveled to San Francisco, driving over the Golden Gate Bridge, inside heavy highway traffic, and through hill country at night, all common driving phobia triggers.

VR can induce the same feelings and physiological reactions as the real thing, Vogl said. For example, a colleague of his created a virtual crack house and did CT scans on the patients in the environment that showed they were experiencing real cravings, he said.

Enhancing therapy

Limbix was chosen as a NMHIC partner because of its emphasis on evidence-based therapies. The company shares its equipment and programs with researchers and qualified therapists only. “This is a tool designed to enhance therapy and make it more efficient and easier to access,” said Ben Lewis, Limbix co-founder. “It is not designed to replace therapists.”

Lewis said the NMHIC stands out as a leader in implementing the innovative technology in mental health care and beyond. “The center has been phenomenal in introducing us to mental health clinics and helping us put together a really good list of problems that we can help solve with virtual reality.” The company has at least 15 different exposure-therapy programs and anticipates substantial growth, Lewis said.

Matt Vogl mug
Matt Vogl, MPH

After completing seven VRET sessions, Harrell said his virtual trips to airports, including San Francisco and Denver International airports, felt real enough, one time coming close to inciting a full panic attack in the office. But he said the time-savings of VRET was the most attractive aspect.

Easing the load

“It feels less like homework,” said Harrell, one of the more than 75 million Americans who will experience some form of anxiety-related disorder in their lifetimes. Harrell, a former CU Boulder librarian, suffered a highly unexpected mid-flight panic attack about six years ago.

With a mother in the Air Force, Harrell grew up flying. “Getting on a plane was like hopping in a car,” he said, adding that he’d continued to fly for work and for pleasure as an adult, logging 40,000-plus air miles before the life-changing event.

A thwarted trip to Paris with his wife and some long train rides later, Harrell sought professional help, which gradually got him back on a plane. But it took intense dedication on his part.

“It’s really, really hard work,” Hubley said of exposure therapy. About 75 percent of people who complete exposure therapy get well and stay well, Hubley said. “But a lot of people drop out.”

Working with Hubley on his flying phobia before VR was introduced, Harrell would spend two-plus hours periodically busing to DIA for exposure work and practicing calming techniques. “It was really time-consuming,” Harrell said of the exercises he did alone in addition to his office sessions with Hubley.

Meeting a need

Hubley debriefs Harrell
Nick Harrell, left, and Sam Hubley discuss Harrell’s progress using cognitive therapy and relaxation techniques to tackle a flying phobia.

In an already strapped mental health care system, doing that type of exposure with patients is just not feasible, Vogl said. “I had a woman with a fear of flying call me shortly after we started doing VR saying: I can’t find a therapist in the state who will do exposure therapy with me,” he said.

But with VR, therapists can walk patients through the whole exposure process virtually, from buying a plane ticket, to packing the bags, to standing in the security line. Thanks to Limbix’s fear-of-flying program that includes some DIA-specific environments, Hubley has even “stood by” Harrell, as he confronted a terminal gate that reminded him of his last full panic attack.

“The more you can really let your brain experience those triggers, stick with the exposure, and reframe the negative thinking that so often goes along with anxiety, the more confidence we have about long-term protections against future relapse,” Hubley said, adding that expert guidance is critical.

“Without the right doses of exposure, re-traumatization can occur, potentially sabotaging a patient’s chance of recovery. And there’s a fine line,” he said, adding that the gaming technology makes managing the intensity level of exposures easier.

Finding the help

Harrell, who was prepping for a June plane trip with his wife with his recent sessions, said he believes there has been some improvements with the VR therapy.

“Two years ago, an exposure session at DIA would get me pretty amped up. Last time I went, I couldn’t get worked up. And the terminal VR exercises don’t bring up the same reactions and memories that they used to,” he said.

Whether using VR-assisted or traditional exposure therapy, people should seek care rather than missing out on life, Harrell said. “It might not always be pleasant, but it’s worth it,” he said. “I can say with pretty high confidence that I’m going on this next flight, whereas two years ago, I’d book a flight and say: We’ll see.”

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