What would you do?

How Treatment Is Conducted at the Virtual Reality

Medical Center

e began using virtual reality (VR) therapy at the Virtual Reality Medical Center (VRMC) in 1997. Before that, we had been using exposure therapy with our patients who presented with anxiety, panic, or phobias either as visualiza- tion, systematic desensitization, or in the real world (in vivo, described in chap. 3). Our initial program combined real time physiological monitoring with VR software to treat fear of flying.

The first system consisted of a rather heavy and bulky head-mounted display manufactured by Liquid Image (Can- ada), with a tracker that was very finicky and did not allow other metal objects or electric devices near it. When this occurred, the image flickered and sometimes caused the VR world to spin continuously. To counteract the front heavy head-mounted display, a bungee cord was attached to it to lighten the weight from the patient's neck. The beauty of the software, however, was that it was made specifically for the techno-phobic therapist population. Knowing that therapists would rather spend time relating to their patients than tending to computers, simple keystrokes allowed the therapist to change the scenarios from taxi to turbulence to landing. The virtual world initially seemed quite cartoonish when we first began training therapists, and we wondered whether it really would work. When we used the system

47 http://dx.doi.org/10.1037/10858-004 Virtual Reality Therapy for Anxiety Disorders: Advances in Evaluation and Treatment, by B. K. Wiederhold and M. D. Wiederhold Copyright © 2005 American Psychological Association. All rights reserved.

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on a research assistant with a subclinical phobia of flying, we found that it indeed did elicit anxiety both subjectively and objectively (heart rate increase and sweat gland activity increase). We then started work on developing a clinical protocol that would help us decide whether VR exposure was superior to imaginal exposure (a method used by many San Diego area clinicians to treat fear of flying). The study results showed that VR treatment was indeed a better and more effective method, and in fact in that small study (10 participants in each of 3 groups), there was a 90% success rate for VR therapy versus a 20% success rate for imaginal exposure (Wiederhold, 1999). (Success was determined by the participant no longer meeting criteria for specific phobia according to the Diagnostic and Statistical Manual of Mental Dis- orders [4th ed., Text Revision; DSM-TV-TR; American Psychiatric Associ- ation, 2000].)

Since 1997, VRMC has expanded the offering of VR systems and protocols, and now we treat a wider range of disorders using advanced technologies, such as the Internet, videoconferencing, VR, robots, and advanced physiological monitoring systems. We currently treat fear of flying, fear of driving, claustrophobia, agoraphobia and panic, general- ized social phobia, fear of public speaking, fear of heights, PTSD result- ing from motor vehicle accidents, eating disorders, body dysmorphic disorder, and attention deficit disorder. We are also investigating the use of VR treatment as an adjunctive therapy to medication for distrac- tion and pain mitigation for unpleasant or painful medical procedures.

VRMC serves as a clinical research facility, a beta test site for testing and validating new technologies, a training center for individuals pursu- ing doctorate degrees in a variety of disciplines, and a clinical site offering services to the community, with a sliding fee scale based on income level. The non-profit 501(c)(3) affiliate, the Interactive Media Institute, also sponsors public education, research studies, and an inter- national conference with presentations by clinicians, researchers, and funding agencies.

Though treatment at the VRMC includes new technologies, therapy performed here is grounded in traditional cognitive-behavioral therapy (CBT) techniques. CBT is based on the idea that emotions are intercon- nected with thoughts. The key to this type of therapy is the examination of how thoughts and feelings interact to drive behavior. CBT teaches patients to gain control over behaviors and cognitions to affect emo- tions. The cognitive part of treatment involves working with automatic thought patterns and investigating how they tie into emotions. The behavioral part of treatment includes looking at actions and determin- ing what reactions are most common in specific situations. For example, for a flying phobic, a behavior (buckling the airline seatbelt) may be

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How Treatment Is Conducted 49

immediately followed by a thought (the plane is going to crash if I stay here), which in turn affects emotions (panic!). By changing the initial thought through education, relaxation and coping techniques, and repeated exposure, the emotion no longer automatically takes hold. VR enhances the essential exposure component of treatment.

What has technology allowed us to do now that was not possible before? It has allowed us to treat our patients more effectively, without the difficulties of imaginal exposure, and efficiently, without the safety, cost, and confidentiality concerns that arise with in vivo exposure (Rothbaum, Hodges, Anderson, Price, & Smith, 2002; Wiederhold, Jang, Gervitz, et al., 2002). It has allowed us to appeal to a group of individuals who had previously tried imaginal therapy without success because they lacked visualization skills. It has allowed us also to reach out to a group of individuals who were too overwhelmed by the thought of being stuck on a real freeway or on a 30-minute airplane flight that are part of the in vivo treatment. We can slowly and systematically advance our patients through therapy and the fear hierarchy as physiol- ogy stabilizes and as a sense of mastery is reached in various scenarios. Patients can become empowered and increase their level of self-efficacy. The system allows continued physiological monitoring during expo- sure, which helps the therapist identify precisely the cues that trigger anxiety and fear.

Technology also allows interoceptive exposure to be conducted in "near real world settings." Patients can breathe rapidly to bring on sensations of hyperventilation while standing in an open field (virtu- ally) or driving on a virtual freeway. By allowing patients to recreate panicky feelings in a setting similar to the one they encounter in the real world, they can begin to understand that those feelings are "danger- ous" only because of the cognitions associated with them. They are not really going to have a heart attack or go crazy when those feelings occur. By practicing skills in a virtual driving or flying scenario, they appear to gain more understanding of their cognitive distortion of real world experiences. They can also practice conventional coping skills such as breathing and relaxation in a setting similar to what they experience in the real world. It is important to remember that VR therapy is used only as a tool, an adjunct, to traditional CBT.

Will the virtual experience eventually replace in vivo, real life exposure? Certainly not today, and proof of therapeutic success still requires performance in real world settings. The goal of therapy remains what it always has been: We want patients to be able to overcome their avoidance and discomfort in real world settings. What we find with virtual reality is that skills learned in the virtual world do in fact generalize and transfer to the real world. There is much discussion in

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the VR community about the appropriate level of fidelity to realism required during therapy (see chap. 6). Some of the more technical and adventurous members try to achieve better and better resolution and realism. We have found, however, that for phobia treatment, animated images are sufficient to elicit anxiety. Some patients have actually said the animated image might be preferable. For instance, we have found that in the fear of flying scenario, because the scene is not an exact replica of a plane, the patient does not get caught up in minor discrepan- cies that distract from the task. Rather, as therapy progresses, the patient begins to "fill in the blanks" and makes the experience very personal. One patient said she could imagine the flight attendant asking her if she wanted the "chicken" or "beef" dinner. Another reported smelling "jet fuel" though no such smell was present in the VR treatment session. Patients shape and create their own virtual experience, and as they become more present and immersed in the virtual world, therapeutic benefit occurs. As Banos and her colleagues (1999) described it, patients exhibit a "willing suspension of disbelief," which allows them to become present in the virtual world (p. 147). They give themselves permission to become immersed, to relinquish control, and to allow the stimuli to become real. As one patient told us, "VR is in your face—you can't escape it!" It is difficult to drift off task because numerous senses are stimulated during the experience. Soon after we set up the clinic, the computer malfunctioned once during the exposure session. One of our patients said, in effect, "Wow, I was on the plane flying and then when the computer stopped it was like, oh yeah, I'm just in the office. But until then, I was there on that plane."

Patients often report experiences previously forgotten and out of their conscious memory. Often these are pleasant memories of such things as how they used to love to travel by air or drive long distances. Some patients do, however, disassociate during the experience. There- fore, caution must be exercised not to progress these patients too quickly through the virtual experience. Clinicians should look for a lack of physiological or subjective arousal as a sign of dissociation, because therapy is not successful if a patient does not stay present. Patients may have used dissociation as a defense mechanism in the past, and only by providing a safe and trusting environment and by progressing at a slow pace can they stay on task. This is necessary so that continuous exposure occurs and leads to desensitization and habitua- tion. By monitoring the patient's physiology and by observing his or her outward demeanor, it is possible to see whether the pace is too fast for that patient. In addition, because the therapist can communicate with the patient by microphone, direct contact can be maintained if necessary.

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How Treatment Is Conducted 51

Patients who seek therapy at VRMC undergo initial intake and evaluation as part of their first visit. In general, the best candidates for VR therapy are those who (a) do not have medical contraindications, (b) do not have a history of cybersickness, and (c) are easily able to become immersed or present in the virtual world. (Medical contraindi- cations to VR treatment are discussed in detail in chap. 5.) The type of clinical disorder encountered during the initial intake can often determine whether VR therapy is an appropriate choice. The selection criteria are the same as those used in treating any other patient with an anxiety disorder when the presence of other co-morbid conditions can have a significant impact on therapeutic success. Additional factors are those that apply to any patient seeking mental healthcare services, namely, commitment to therapy, willingness to undergo the therapeu- tic process, and faithful completion of "homework assignments" be- tween therapy sessions.

Before participants in our initial fear of flying controlled study began therapy, we administered a Tellagen Absorption Scale to determine absorption ability and the Stanford Hypnotizability Profile to determine hypnotizability. The Tellagen Absorption Scale and Hypnotic Induction Profile have been found to correlate highly with each other, and now patients are given only the Tellagen Absorption Scale. On the basis of studies by Baftos et al. (1999) and our clinical observations we also administer the Dissociative Experience Scale. If they score low on the Tellagen Absorption Scale, however, it may take several sessions to become immersed, whereas those who score high on the Tellagen Absorption Scale may find themselves a part of the world on the first exposure. Those who have a strong need to stay in control and not let go must also be encouraged to give themselves permission to become immersed. We have also found that for the most resistant among patients, it is sometimes effective to put them into a light hypnotic state prior to exposure, so that their conscious, vigilant mind may give way to a more relaxed way of processing.

All patients are encouraged to enter into a relaxed state prior to exposure, performing five or more minutes of slow, diaphragmatic breathing with visual feedback. This serves both to increase their skill set by developing coping mechanisms in the real and virtual worlds and to develop a sense of mastery. Our extensive clinical experience with more than 4,000 patients has led us to conclude that treatment is more effective when the patients are relaxed.

A brief review of session structure follows. This is provided as a template; it can vary from individual to individual depending on the particular circumstances and needs.

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Intake Session

During the intake session, the therapist takes a thorough history of the patient's presenting problem. Some patients come in knowing what has caused their phobia, whereas others do not remember its begin- nings. This session is very much like the initial intake session of a conventional therapy, involving discussion with the therapist. At this point, education about the nature of CBT is important. We want pa- tients to actively participate in their own recovery and to understand the therapeutic process. Patients are given homework assignments, usually from commonly found patient workbooks. A typical assignment for this session may be to read a chapter about anxiety. Patients are given self-report questionnaires to take home, complete, and bring back to the next session.

Treatment Session 1

The first treatment session begins with a Psychophysiological Stress Profile (Diaz, Vallejo, & Comeche, 2003), which is a simple procedure designed to record baseline heart rate, breathing, and other noninvasive physiological measures. This helps the therapist determine how the patient's body would react to and recover from stress, and it allows the patient to become familiar with the physiological monitoring devices at the clinic. When the profile is completed, the therapist discusses the basic physical and mental reactions to stress and anxiety with the patient. The therapist teaches the patient some breathing skills and gives the patient a relaxation tape to take home. We feel it is important for patients to leave with a tool and to make a commitment to practice their breathing 4-5 days per week. An additional assignment is also given from the patient workbook.

Session 2

During session 2, the patient again practices breathing skills with visual feedback on a computer screen. The patient and therapist review ques- tionnaires that were completed. The therapist teaches thought stopping

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How Treatment Is Conducted 53

and rationale refutation techniques and answers any questions the patient may have about the workbook assignment. (All therapists at VRMC are required to read the patient workbooks before beginning to treat patients so that they are familiar with the material and tech- niques the patients are learning.) Next, the therapist introduces the VR hardware and allows the patient to become familiar with navigating in a neutral virtual environment. This session does not involve exposure to anxiety-inducing simulations, because it is important for a patient to understand the methods behind the treatment and to be able to practice the traditional therapeutic cognitive techniques that they were taught before becoming involved in the VR phase of their treatment. A hierarchy of feared situations is then constructed and is used to determine how VR therapy will proceed, as well as to schedule in vivo exercises between sessions.

Sessions 3-8

During session 3, and in all subsequent sessions, the therapist reviews homework with the patient and discusses any difficulties or questions on worksheets in the workbook. Then, the therapist records a baseline of the patient's diaphragmatic breathing. At this point, most patients are ready to begin exposure in the VR world. The head-mounted display is placed on the patient, and he or she is given a little time to become oriented and comfortable with how to move about and interact in this world. Lights are turned off in the( therapy room to block external stimuli. Exposure to the least anxiety provoking scenarios then begins. The therapist monitors the patient's physiological reactions during the VR exposure and records them for review with the patient after expo- sure concludes. After a 20-minute exposure, the therapist switches on the lights and removes the head-mounted display from the patient. The patient is asked to estimate his or her subjective units of distress levels. Although the estimate is based on patient memory of anxiety and is not done in real time, it was found during the first 6 months of using the virtual worlds that asking the patient for anxiety ratings during virtual exposure actually decreased presence and immersion levels, thereby reducing treatment efficacy. Patients actually said it was "popping" them out of the experience.

Next, the patient's physiological reactions to the world are reviewed and discussed. As with imaginal and in vivo therapy, as the patient becomes more aware of his or her own reactions, the cognitive distor- tions seem to diminish as treatment proceeds. The therapist then

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reviews any clinical observations with the patient. Patient comments about the VR world, including suggestions for improvements in future iterations, are also noted. The patient spends only 20 minutes of each therapy session immersed in VR. In fact, most of the session is spent in traditional therapist-patient interaction.

To understand more fully how patients progress through therapy, we are developing a model that compares both objective and subjective responses to the virtual world. The model described below examines the role of synchrony and compares various patterns of objective and subjective arousal.

Most of the hundreds of patients treated at the VRMC who pre- sented with a specific phobia but no trauma required on average of 8-10 sessions of VR exposure. There is a range of individual responses that can be easily addressed by the VR sessions. Those presenting with, PTSD resulting from a motor vehicle accident may require 12-15 ses- sions to resolve their anxiety. Probably our shortest treatment time was with a male in his 70s who came to us more than 2 years ago because he was afraid to drive on freeways. He came for an intake session, a breathing retraining session, and one exposure session. He called prior to the next scheduled appointment to say he did not require our services any longer because he was fine. Since then, he has returned all completed posttreatment follow-up questionnaires reporting contin- uing lowered anxiety scores and a return to normal driving on the freeway.

As mentioned above, we use a variety of evaluative measures to help patients progress through therapy. These range from subjective to objective as shown in Figure 4.1. Subjective units of distress are recorded before and after treatment and are used to determine the level of anxiety the patient feels during the presentation of virtual

Subjective

Suds Self-Report Scales Overt Behavioral Observation Physiology

Objective

Evaluative measures used during virtual reality treatment sessions. SUDS = subjective units of distress.

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How Treatment Is Conducted 55

stimuli. Also before and after treatment, patients are given self-report questionnaires to help determine the amplitude of fear as well as the specific parts of a situation that elicits anxiety—such as take-offs versus turbulence versus purchasing a ticket for individuals with flying phobia—and to see how these fears are affected by treatment. Overt clinical observation refers to the therapist's observation during the VR exposure. Is the patient sitting passively, gripping the arms of the chair, or is the patient interacting with the world but in a more relaxed manner? These observations should be discussed with the patient after the exposure is completed. Physiology is measured noninvasively as part of the session to provide an objective measurement of patient anxiety and to see how patient physiology reacts as sessions progress and desensitization occurs.

After more than 3,000 sessions with patients at the VRMC, we have also been able to classify patients into four groups based on a framework that uses both subjective and objective (physiology) mea- sures of anxiety. The framework can be seen in Figure 4.2. Current physiological classification is based on skin resistance; an updated ver- sion of this framework includes heart rate variability (Wiederhold, Jang, & Wiederhold, 2002). Patients in Group 1 of the framework exhibit high objective and subjective anxiety when placed in the virtual world. These patients tend to become highly immersed, or present, in the virtual world and quickly become a part of it. Their fear structure is activated and open to change, and they tend to progress through treatment rapidly (Foa & Kozak, 1986).

An example: We had a patient who had been fearful of flying for 27 years. Her specific fear was of crashing during the flight. When

Aroused

SUDS

High Low

1 2 _o "o

<£ Normal

Subjective units of distress (SUDS) versus skin resistance.

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given the Hypnotic Induction Profile and Tellegen Absorption Scale, she scored high on both, indicating that she had the ability to become quickly absorbed into activities. This was true also of the VR exposure. During the first session she reported subjective units of distress levels that increased to 95 (out of a possible 100). Her skin resistance also showed dramatic decrease during the VR flight, indicating arousal—at one point it was 40% below baseline levels. This patient was exposed to the VR a total of 6 times, each for 20 minutes in duration, and has been flying successfully since. At 3-year follow-up, her fear had not returned.

Patients in Group 2 show high levels of physiological arousal when exposed to the VR world, but they report low levels of subjective anxiety. This may be due to an inability to admit their fears to the therapist or it could be a sort of emotional numbing or a disconnect between what their minds are experiencing and what the body is feeling. An example of a patient we saw who fit into this category was a young man who feared having a panic attack on the airplane and being unable to find an escape. Prior to coming to treatment, he had been teased about having to "go play with video games" to overcome his fear. When he was placed in the VR flying situation, his skin resistance decreased by 45%, a clear indication of anxiety. He rated his own distress levels as 1 (out of 100), indicating that he had felt no fear. He was encouraged to try and relinquish control and to allow himself to become a part of the world. He did continue treatment, and in subse- quent sessions he was able to report anxiety, as well as show physiologi- cal arousal. He admitted later that he was initially embarrassed that a "cartoon" could generate so much anxiety. We would say that he was "transformed" into a "Group 1-like" individual. He was able to fly, but he required more sessions because of his initial resistance.

Group 3 individuals report high levels of arousal subjectively but show relatively little physiologically. Individuals in this group may be reporting what they think the therapist wants to hear, and they may score high on social desirability scales. They may also have some sort of "disconnect" between mind and body. If an individual is coming for treatment as part of an insurance claim, there clearly is the issue of secondary gain.

One patient in this group had tried many "quick fixes" to overcome her fear of flying. She had heard about our successes with VR on a television program and traveled from out of state to be seen. She quickly established rapport with the therapist. When she was placed in the VR flying situation, she reported moderate anxiety (30) although little physiological arousal was detected (skin resistance decreased by only 5%). After she reported her distress levels to the therapist, the therapist showed her her skin resistance level. At this time the patient "confessed"

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How Treatment Is Conducted 57

that she had not really been able to become immersed or feel anxious but that she did not want the therapist to be displeased with her. The therapist explained that it was normal for some people to experience no anxiety at first exposure to the VR situation. In subsequent sessions, the patient, who had scored low on hypnotizability and absorption, was able to become immersed in the VR world, become aroused physio- logically and subjectively, and then become desensitized. She had traveled to our center by train, but she was able to fly home.

Patients in Group 4 show no subjective or objective arousal. They either have no phobias at all, or they have phobias but are unable to become immersed or present in the virtual world. These individuals report subjectively what their bodies are also objectively telling us. In fact, we find that many nonphobic individuals actually become more relaxed during the passive VR environments, such as flying! One indi- vidual who participated in an early study at our center reported liking to fly and gave a subjective distress rating of 0. Physiologically, she actually had an increase in skin resistance during the flying experience, showing that she had actually became more relaxed than at baseline.

We have found that patients must become both subjectively and objectively aroused when moving through the VR experience if they are to become desensitized to their fears. This statement is based on what others have reported for more than 30 years (Foa & Kozak, 1986; Hodgson & Rachman, 1974; Lang, Melamed, & Hart, 1970; Rachman, 1978). Their research has shown that the phobic individual's fear must be activated both subjectively and objectively in order for that anxiety to decrease. Without the use of physiological parameters, it is difficult to tell whether the fear structure has been accessed and is open to change.

The patient is viewed as an integral part of the treatment team at VRMC and is encouraged to always take an active part in recovery. Therapist, developer, and patient form a powerful triad with a shared goal of effecting recovery. With the patient's permission, system devel- opers often sit in on therapy sessions to see exactly how the patient interacts with their system. This leads to more user-friendly systems and allows the developer to see exactly what difficulties the patient might experience with the system and what improvements can be made. This also allows the patient to discuss firsthand what additions to the virtual world might be beneficial. The therapist can also express his or her assessment to the developer of what changes might be desir- able. By having the patient as part of the team, software can be tweaked as development continues, rather than building a "pretty" but nonfunc- tional system. Although the cost of improvement of these systems may be high in this initial development stage, actual clinical practice using these perfected systems is cost effective.

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After using this system for more than 5 years, the lessons we learned have allowed us to continue to develop new applications for the evaluation and treatment of mental health disorders. We try to maintain contact with all our patients after treatment ends, sending post-treatment follow-up questionnaires every 6 months. Our success rate as determined by improved patient scores in relation to DSM-IV-TR criteria currently stands at 91.6% overall, and we are striving to im- prove that rate.

Many of our newer VR systems now incorporate real-time digital video into the VR world. This allows patients with a fear of public speaking to bring in a PowerPoint presentation, port it directly into the virtual world, and practice a speech over and over before they deliver it at a conference or meeting. Videoconferencing capabilities also allow us to begin therapy with patients who are, at first, too agoraphobic to leave their home for treatment. Internet worlds and videoconferencing allow those with social phobia to practice their social skills and conver- sational abilities prior to going into the world. The Internet allows audio and videoconferencing, creating real time visual and audio contact. Feedback, whether positive or negative, is also real time. By seeing the patient interact with others in a realistic way, the therapist can spot any remaining deficits and work to ameliorate them prior to real world interactions outside the therapist's office.

Some believe that technology creates a barrier between patient and therapist. We have not found this to be the case. For the entire time the patient is in the office, we watch, monitor, and interact with them. The technology only provides a medium by which we can more effec- tively help our patients help themselves.

Whether to include physiology during the treatment session will vary depending on clinician. Our experience shows that the use of physiological feedback and training does add to treatment efficacy. In our controlled study completed in 1999 (Wiederhold, Gervitz, & Spira, 2001) we treated 30 subjects with fear of flying. Those who received VR therapy without physiological feedback had an 80% treatment success rate, whereas those who received VR therapy with physiological feedback for six exposure sessions had a 100% treatment success rate. Patients report to us that the use of physiological feedback allows them to become aware of anxiety when it is at a much lower level, so that they can then begin practicing coping mechanisms such as positive self-talk and diaphragmatic breathing. It also allows those who feel the need to be in control to know that they can control their thoughts and bodily reactions. In a subsequent 3-year follow-up of these patients no one in the physiological feedback group had experienced a relapse, but recidivism did occur in the group receiving VR therapy with no feedback.

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How Treatment Is Conducted 59

When we first began treating patients, we attached a subwoofer to the bottom of a regular office chair so that the patient could feel vibrations during takeoff, turbulence, and landing in the virtual flight scenarios. Since that time, we have created rooms dedicated to different phobias with tactile augmentation. For instance, for patients with a fear of driving, the virtual experience now includes sitting in a real car seat, fastening a seat belt, driving with a steering wheel, brake, and gas pedal, and sitting with a vibrating platform to simulate motor vibra- tions, and the driving experience becomes even more real. For patients with a fear of flying, the virtual experience is augmented by making them sit in real airline seats, on the back row of a coach section of the plane, and with their seat belts fastened before takeoff. When patients do baseline breathing, they are facing the back of an airline seat. Then, when they go into the virtual world, they are also looking at the back of an airline seat (although they can turn their head and look around the plane or out the window). This seems to help "ground" them in the virtual world and appears to add to their sense of immersiveness. For patients with a fear of heights, they hold on to a cold, metal railing in the real world, and in the virtual world, they are standing on a scaffolding elevator with a steel railing. As they ascend higher and higher the sound of wind can be heard in the virtual world, and in the real world a fan is aimed toward them, and vibrations under their feet are generated by the audio amplifier mounted under the vibrating platform. (Platforms are shown in Figures 4.3, 4.4, and 4.5.) We try to make the experience as realistic as possible, and all the while the patients know that at any point they can escape the experience should they choose. In 5 years, however, we have only had one patient feel the need to do this, and this was because a flashback had occurred

For those patients who require continued exposure or who cannot tolerate the virtual world because of a vestibular abnormality, we do continue treatment in the real world. We also offer patient education such as airport tours and tours of the local aerospace museum. VR treatment is only one piece of a full multimodal therapy; it is not seen as replacing the other useful components of traditional anxiety treatments.Co

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F I G U R E 4 . 3

Vibrating platform with actual automobile seat, steering wheel, and gas and break pedals to augment virtual reality while driving.

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How Treatment Is Conducted 61

F I G U R E 4 . 4

These are actual airline seats placed on a vibrating platform that the patient sits in while undergoing exposure therapy for aviophobia. The legroom reproduces the actual dimensions in a typical coach cabin. Be sure to fasten your seatbelt.

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F I G U R E 4 . 5 .

This vibrating steel platform is used for treatment of fear of heights. The fan, which is augmented by the sound, is used to simulate wind.

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