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Articles Section
One session treatment of virtual reality and cognitive behavioral therapy for phobias
67
Journal of Cognitive and Behavioral Psychotherapies,
Vol. 14, No. 1, March 2014, 67-83.
ONE SESSION TREATMENT OF COGNITIVE AND
BEHAVIORAL THERAPY AND VIRTUAL REALITY
FOR SOCIAL AND SPECIFIC PHOBIAS.
PRELIMINARY RESULTS FROM
A RANDOMIZED CLINICAL TRIAL
Ramona MOLDOVAN
*1
& Daniel DAVID
1,
2
1
Department of Clinical Psychology and Psychotherapy, Babes-Bolyai University,
Cluj-Napoca, Romania
2
Department of Oncological Sciences, Mount Sinai School of Medicine,
New York, USA
Abstract
This randomized clinical trial aimed to investigate the efficacy of one
session treatment of VRCBT (cognitive behavioral therapy combined with
virtual reality) for patients with social phobia, flight phobia and acrophobia.
Additionally we concentrated on investigating if and to what extent do
working alliance, patients’ expectations and therapists’ performance
contribute to this change. Our preliminary results include data from a
sample of 32 participants diagnosed with social phobia (N = 15), flight
phobia (N = 9) and acrophobia (N = 8) who were randomly assigned to
either immediate treatment or WL control group. Results indicated no
significant differences between the two groups. Significant differences were
shown between pre- and post-treatment for the majority of the measures
used. Patients’ expectations, working alliance and therapists’ performance
proved to be predictors of change.
Keywords:
one session treatment, social phobia, specific phobia, virtual
reality, cognitive and behavioral therapy.
Phobias are described as an exaggerated, irrational fear of specific objects
or situations, characterized by significant avoidance of any in vivo or in vitro
exposure to fear stimuli or enduring it with great distress when avoidance is not
possible. About 4.4% percent of the adult population in the USA has one or more
*
Correspondence concerning this article should be addressed to:
E-mail: ramonamoldovan@psychology.ro
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phobias which will mostly persist for years and become chronic; complete
remissions without treatment are very rare (Narrow et al., 2002).
Social phobia is the most common anxiety disorder and the 3
rd
most
common psychiatric disorder (Craske, 1999), having a one year prevalence of
3.2% in the US. It is characterized by excessive and persistent anxiety in social
situations ranging from public speaking to performing a task in the presence of
others. Most often, the severity of symptoms and degree of impairment vary,
given one’s work demands and the stability of social relations. Recent studies
show that social phobia interferes with work performance (in 93% of the cases),
social life (in 82% of the individuals) and close relationships (in 71% of the
individuals) (Ruscio et al., 2007; Wallach, 2009). A specific phobia is an intense,
irrational fear of something that poses little or no actual danger. Adults with
phobias most often realize that these fears are irrational, but they often find that
facing, or even thinking about facing the feared object or situation brings on
severe anxiety. Specific phobias are rather common as they affect 19.2 million
adults in the US. Among the simple phobia subtypes established by DSM – IV,
fear of flying has become very common in modern societies. Statistics in US and
Europe show that 10%-15% percent from the general population suffer from fear
of flying and about 20%-25% experience high levels of anxiety during flying
(Ost, 1997; Muhlberger, 2001). Acrophobia or fear of heights it also rather
common and it is known to affect 1 in 20 adults (Coelho et al., 2009).
To a great extent, phobia is the result of classical conditioning or
vicarious learning. Fear is maintained by the avoidance behavior: avoidance
impedes confronting the phobia symptoms (e.g. subjective anxiety and
physiological arousal) and therefore fear is not solved but negatively reinforced
(therefore, exposure has the role of fear extinction) (Rothbaum et al, 2000;
Emmelkamp et al., 2002). Studies investigating the impact of exposure on phobia
symptoms have provided empirical evidence showing that it plays a major role in
treatment outcome (Rothbaum et al, 2000; Emmelkamp et al., 2002; Powers &
Emmelkamp, 2008; Wolitzky–Taylor et al., 2008).
In addition to conditioning studies, there is a large amount of research
showing that both dysfunctional cognitions (Beck, 1976) and irrational beliefs
(Ellis, 1979) explain to a great extent anxiety symptoms (Chambless et al., 1998;
Wolitzky-Taylor et al., 2008; Wallach et al. 2009). Rational Emotive Behavioral
Therapy (REBT) advances two main irrational beliefs as leading to anxiety:
demandingness (DEM) and awfulizing (AWF). DEM refers to absolutist
requirements, from self, others, and the world, formulated as “musts” or
“shoulds”. AWF refers to believing that a particular situation is catastrophic.
Thus, anxiety is experienced when events are incongruent with the formulated
demands of one’s goals and the person evaluates the situation as being a
catastrophe and/or unbearable, experiencing a low emotion-focused coping
potential (David et al., 2002). Cognitive and Behavioral Therapies (CBT), namely
REBT, use a number of techniques to identify and restructure dysfunctional
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One session treatment of virtual reality and cognitive behavioral therapy for phobias
69
beliefs/irrational beliefs that lead to anxiety, as well as assimilate rational
cognitions and functional responses. As a matter of fact, there is extensive
empirical data supporting the efficacy of CBT in treating phobias (Ost et al.,
1997; Chambless et al., 1998; Choy et al., 2007; Zlomke et al. 2008; Wolitzky-
Taylor et al., 2008; Wallach et al. 2009) with a large number of studies supporting
the use of treatment that combines both cognitive and behavioral (mainly
exposure) components (Ost et al., 1997; Rothbaum et al., 2000; Rothbaum et al.,
2006; Choy, 2005, Parsons & Rizzo, 2008).
In recent years, a number of new therapeutic strategies have become
increasingly widespread. Virtual reality (VR) exposure therapy has been used in
some studies as a standalone treatment (Deacon & Abramowitz, 2004; Eddy et al.,
2004; Powers & Emmelkamp, 2008) or as an adjuvant to other psychological
interventions, such as CBT. The empirical support provided by several controlled
studies conducted over the last decade show that VR exposure treatment can be
effective for treating: social phobia (Harris, Kemmerling, & North, 2002; Klinger
et al., 2005), fear of flying (Rothbaum et al., 2000, Muhlberger et al., 2001,
Rothbaum et al, 2006), fear of heights (Rothbaum et al., 1995, Emmelkamp et al.,
2002), fear of spiders (Garcia-Palacios, Hoffman, Carlin, Furness, & Botella,
2002; Powers & Emmelkamp, 2008), panic disorder (Botella et al., 2008; Powers
& Emmelkamp, 2008) and claustrophobia (Botella et al, 2000). One of the main
advantages of VR exposure over in vivo exposure is that people suffering from
anxiety disorders are more likely to seek this type of treatment; namely, they are
more likely to expose themselves in VR than in vivo, because of the lower
emotional costs and/or financial costs, especially for conditions like fear of flying,
fear of driving and social phobia (Deacon & Abramowitz, 2004; Powers &
Emmelkamp, 2008). A recent meta-analysis (Powers & Emmelkamp, 2008),
based on 13 studies using VR exposure, shows that when taking all the studies
together, the effect of VR exposure treatment is actually superior to in vivo
exposure, d = 0.35, p < .05. As the authors suggest, these findings should not be
surprising, if one takes into account the high degree of control with VR that
enables personally tailored exposure to the feared object. For the purposes of this
study, VR was used as a desensitization technique because of its advantages when
compared to in vivo techniques: the capability to design a personalized exposure
experience, low financial (i.e. taking a domestic flight) and time costs.
According to previous findings, one of the mechanisms behind VR
exposure treatment is the construct of presence (Wiederhold & Wiederhold, 2005;
Price & Page, 2007). Presence is defined as subjectively experiencing the VR
environment as real and behaving accordingly (Lee, 2004; Price & Page, 2007;
Witmer & Singer, 1998). Immersion refers to one’s capacity of becoming easily
absorbed by experiences like reading novels, watching movies and thus predicts
presence in VR (Witmer & Singer, 1998). A recent study (Price & Page, 2007)
indicated that the more intense the phobic anxiety, the higher the level of presence
in VR will get, as in these cases the anxious response tends to be easily primed by
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vague, ambiguous stimuli. Price and Page’s study (2007) shows that presence is
necessary for the VR exposure to work (i.e. a high level of presence is associated
with a high level of phobic anxiety during exposure). However it may not be
enough for the patient to take benefit from VR exposure. Their study indicates
that presence only moderately impacts on the relation between anxiety
experienced prior the exposure treatment and anxiety experienced during the VR
exposure. Conceptually it turns out that both presence and immersion would play
a moderator role of the relation between pre-treatment and post-treatment anxiety.
To further investigate these results, measures of both presence and immersion
were included in the present study.
Traditionally, studies have employed multiple treatment sessions,
spanning from a minimum of 3 (e.g. Emmelkamp et al., 2002) to a maximum of
about 12 sessions (Parsons & Rizzo, 2008), which were conducted mostly on
clinical populations. In the last 15 years, several studies have addressed the
question of one session treatment being effective for phobias. One session
treatment was first introduced in a controlled study conducted by Ost et al. (1992)
on injection phobia, followed by more controlled trials for flight anxiety (Ost et
al., 1997) and claustrophobia (Ost et al., 2001). Results of these latter studies
indicated that the improvements brought by 5 sessions of treatment (combining
CBT with in vivo exposure) over one session treatment were not significantly
higher. Two recent meta-analytic studies (Wolitzky–Taylor et al., 2008; Powers &
Emmelkamp, 2008) investigated whether there is a treatment dose effect on
treatment outcome. The first meta-analysis (Wolitzky–Taylor et al., 2008) showed
that there is only a tendency for more sessions to be associated with better
treatment outcome, d = .35, p = .06. Likewise, the findings of Powers &
Emmelkamp (2008) showed only a trend of more sessions having a larger effect
on treatment response (ß = .11, p = 0.06), but the statistical significance was not
reached. In addition to these results, research investigating the effects of one
session treatment and VR exposure (Muhlberger et al., 2001) showed very good
results (f = 0.38, p < .05). Therefore, there are adequate grounds for one session
treatment to be taken into consideration as an alternative treatment for simple and
social phobia.
The current study
This randomized controlled trial aimed to investigate the efficacy of one
session treatment of VRCBT (cognitive behavioral therapy combined with virtual
reality) for patients diagnosed with social phobia, flight phobia and acrophobia.
Additionally, our aim was to further investigate whether and to what extent do
working alliance, patients’ expectations and therapists’ performance contributed
to this change. Current progress and primary results of this trial are presented.
The following predictions were made within the study: (1) The VRCBT
immediate treatment condition will outperform the control condition on
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participants’ both symptoms and mechanisms of change; (2) Therapists’
performance is significantly associated with patients’ outcome change; (3)
Patients’ expectations are significantly associated with their outcome change; (4)
Working alliance is significantly associated with patients’ outcome change; (5)
The relation between pre-treatment and post-treatment anxiety is moderated by
immersion and presence.
Method
Design
Participants were equally allocated between one of the two parallel arms
corresponding to treatment conditions: (1) cognitive behavioral therapy combined
with virtual reality (VRCBT) and (2) wait-list (WL). A randomization plan was
generated by an independent researcher in order to randomly allocate
participants to one of the two conditions. For allocation of the participants,
a computer-generated list of random numbers was used. The independent
researcher was responsible for allocation concealment by using a secure
computer-assisted method. Once participants were informed about their
participation to the study, storage of data and use of anonymous results in
publications, signed consent was obtained. Following the pre-test, participants in
the experimental condition entered the VRCBT one session treatment. The WL
control group received no treatment until all participants in the experimental
group completed the treatment. Contact details from the research assistant and the
principal investigator were also provided.
Participants
The inclusion criteria for the study were (1) age over 18 years old; (2)
meeting the DSM DSM-IV diagnostic criteria for social phobia, or for one of the
two specific phobias investigated (flight phobia and acrophobia) and (3) not being
in psychotherapy or on medication. 32 subjects who met the criteria (15 females,
17 males) entered the study.
A second category of participants was represented by the 4 clinical
psychologists trained in cognitive and behavioral therapies who conducted all
therapy sessions; none of them had previous experience in psychotherapy. A fifth
therapist was trained in using the VR technology and participated as a co-therapist
during the VR intervention.
Measurements
Outcome measures
The Structured Clinical Interview for DSM IV (SCID; First, Spitzer,
Gibbon, & Williams, 1995) was used to establish if the participants met the
diagnostic criteria for either social phobia or simple phobias - flight phobia or
acrophobia. Liebowitz Social Anxiety Scale (LSAS, Liebowitz, 1987) includes 24
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items, 13 relating to performance anxiety and 11 concerning social situations. The
scale version has high reliability and validity properties (Wallach et al., 2009).
Flight Anxiety Situation Questionnaire (FAS; Nousi et al., 2008). This is
a 32 item self-report measure, with participants assessing anxiety related to
various flight situation on a 5 point Likert scale. The internal consistency of the
subscales of the FAS is very good (Nousi et al., 2008). Acrophobia Questionnaire
(AQ; Cohen, 1977). This questionnaire has two subscales: anxiety and avoidance.
State-Trait Anxiety Inventory –Y Form (STAI-Y, Spielberger, 1973). It is
a 40 items inventory measuring anxiety botha as state and trait. Subjective Units
of Distress (SUDs). In order to accurately describe high or low anxiety,
participants were trained as to use a 0 to 100 scale (Wolpe, 1973) in order to
indicate the level of anxiety they experience. SUDs were used every 3 minutes
during VR exposure.
Cognitive mechanisms
The Self Statements during Public Speaking Scale (SSPS, Hofmann &
DiBartolo, 2000). This is a 10-item questionnaire consisting of two 5-item
subscales: “Positive Self-Statements” and “Negative Self-Statements”. The scale
has high reliability and good validity (Wallach et al., 2009).
Fear of Negative Evaluation Scale – brief version (BFNE; Leary, 1983).
The brief version of the fear of negative evaluation scale (FNE; Collins et al.,
2002) was chosen for this study given its benefits of quick administration and
good psychometric properties; the brief version of the scale correlates highly with
the original scale FNE (r = .96) and has shown very good reliability on clinical
population (Collins et al., 2005).
Flight Anxiety Modality Questionnaire (FAM; Gerwen et al., 1999). It is
an 18-item self-report questionnaire, measuring 2 symptom modalities of anxiety
expression in flight situations: somatic modality (physical symptoms) and
cognitive modality (distressing cognitions). The internal consistency of the FAM
subscales are adequate (Nousi, Gerwen & Spinhoven, 2008).
Attitudes and Beliefs Scale II (ABS II; DiGiuseppe, Leaf, Exner, &
Robin, 1988). This scale evaluates rational and irrational beliefs described by
Albert Ellis (1979). It consists of 72 items rated on a 5 point Likert scale and
measures 3 factors: irrational beliefs, context of irrational beliefs and phrasing
modality (rational vs. irrational). For this study, ABS II was used to evaluate the
change in the etiopatogenetical mechanisms of social and specific phobia
following the VRCBT treatment.
Expectations were assessed by asking patients to rate their answers on a
Visual Analogue Scale (VAS) their answers. 3 expectations were assessed: (1)
“To what extent do you expect your fear to get better?”; (2) “To what extent do
you expect psychotherapy to help reduce your fear?”; (3) “To what extent do you
expect Virtual Reality to help reduce your fear?”
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Virtual reality measures.
Immersive tendencies questionnaire (ITQ; Witmer & Singer, 1998). This
34 item scale measures the psychological state of feeling absorbed, or immersed
in virtual reality. All items are rated on a 1 to 7 point Likert scale. The scale has
good very good psychometric properties (Witmer & Singer, 1998).
Presence questionnaire (PQ; Witmer & Singer, 1998). This scale
evaluates the subjective experience of having been in the virtual environment,
even when one is physically situated in another. PQ consists of 32 questions
corresponding to several factors thought to be correlated to presence such as:
involvement/control, naturalness, auditory stimulation, haptic response,
resolution, and interface quality. The scale is reliable and has a good internal
consistency: = .81 (Witmer & Singer, 1998).
Psychotherapy measures.
Working Alliance Inventory (WAI, Horvath & Greenberg, 1989). To
assess the therapeutic alliance, we used the short version of the Working Alliance
Inventory. The WAI is a 12-item self-report global measure of the working
alliance. Items are rated on a 7-point Likert scale. Good construct validity has
been established, and evidence of concurrent and predictive validity has been
provided (Horvath & Symonds, 1991).
Treatment
The one session treatment was preceded and followed by an assessment
session. The treatment explored within this study consists of 2 components: CBT
intervention and VR intervention.
The CBT protocol was based on REBT theory (Ellis, 1979) with
participants learning to identify the irrational beliefs that lead to anxiety and
unproductive behaviors (avoidance, escape etc.) and to dispute these irrational
beliefs as well as assimilate alternative rational beliefs. Participants also learnt
how the avoidance behaviors maintain anxiety instead of solving it and how
exposure to the feared situation can reduce anxiety and avoidance tendencies. The
CBT session ended with the therapist establishing together with the participants
the hierarchy of their feared situations on a 7 point Likert scale (1 = no fear, 7 =
extreme fear). This list served as input for orienting the flow of the VR exposure
scenarios in order to make it as personally tailored as possible.
The VR environment for social phobia and flight phobia was provided via
a head mounted display (HMD). Both audio and visual cues consisted of elements
that are very specific to each exposure environment and resemble with real life
situations. For acrophobia, a CAVE (computer automatic virtual environment)
system using multiple projection screens that generate stereoscopic images in a
cube like setting was used. Given the one session treatment format examined in
this study, the VR exposure consisted of 4 scenarios of 15 minutes each, separated
by short breaks. The level of fear during exposure was measured using the
Subjective Units of Discomfort (SUDs, Wolpe, 1973) ranging from 0 (no fear
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response) to 100 (overwhelming fear). Participants were trained to assess their
fear on the 0-100 scale prior to the VR exposure and ratings were requested every
3 minutes and in difficult moments. The principle behind the VR exposure was
progressive desensitization. - the exposure starts with the situation in which the
level of fear is at minimum (i.e. friendly, positive audience, applauses) and
gradually progresses to the type of situation in which the participant reported to
feel the highest level of anxiety (e.g. difficult questions).
Procedure
All those interested in participating in this study underwent the SCID
screening for social phobia and the two specific phobias: flight phobia and
acrophobia. Following the SCID screening, the selected participants were
randomized in one of the two groups (VRCBT and WL) and were invited to
attend an assessment session. At the end of the assessment sessions, participants
with social phobia were told that for the treatment session, they will need to
prepare two tasks: a 5-7 minutes presentation about any topic they like, which
they will have to deliver twice during the VR intervention and a presentation
about them as they will attend an interview during their exposure in VR.
Participants with either flight phobia or acrophobia received no special
instructions before entering the treatment. The one session treatment consisted of
2.5 hours of CBT (2 hours at the beginning of treatment, and 30 minutes at the
end of the VR intervention for consolidating therapy gains) and 1.5 hours of
exposure in VR. In total, each participant spent about 4-5 hours at the treatment
venue. Four therapists with similar backgrounds and training, with no previous
experience in psychotherapy conducted all psychotherapy sessions. Their
performance was assessed by listening to all recordings of the sessions and by
rating their performance using the REBT Therapy Rating Scale.
Results
Participants
A flow diagram indicating the participants’ progress through the phases
of the study is shown in Figure 1. Of the 32 participants who entered the study, 15
were diagnosed with social phobia (6 males and 9 females), 8 had acrophobia (6
males and 2 females) and 9 flight phobia (5 males and 4 females). Univariate
ANOVAs showed no significant differences between groups regarding
demographic variables (e.g. age, sex).
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Figure 1. Flow diagram of the progress through the phases of the study
VRCBT
: n=16
Participants assessed: n=16
Dropouts: n=0
WL
: n=16
Participants assessed: n=16
Dropouts: n=0
Analysis
Analysed
: n=16
Analysed: n=16
Enrollment
Assessed for eligibility (n=54)
Participants meeting inclusion criteria (n=32)
Excluded (n=22)
Not meeting inclusion criteria (n=22)
Participants included (n=32)
Arms
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Treatment outcomes
All outcome, cognitive and virtual reality variables were first measured
and then compared to determine if there were any significant differences between
the two groups before treatment. Analyses revealed no significant differences
between groups at the pre intervention assessment on any of the measures.
Means and standard deviations of variables investigated within the study
are summarized in Table 1.
Table 1. Means and standard deviations of all variables examined in the study.
Variables Pre intervention Post intervention Follow up
General measures (N = 32)
STAI-S M = 48.26 (SD = 3.23)
M = 47.65 (SD = 3.76) M = 47.53 (SD = 3.52)
STAI-T M = 46.97 (SD = 3.32) M = 47.32 (SD = 2.50) M = 47.33 (SD = 2.49)
R (ABS II) M = 39.72 (SD = 18.03)
M = 35.84 (SD = 16.72)
M = 37.41 (SD = 17.67)
IR(ABS II) M = 68.44 (SD = 18.46)
M = 66.41 (SD = 19.90)
M = 65.97 (SD = 20.62)
Social anxiety (N = 15)
BFNE M = 47.00 (SD = 10.94)
M = 41.14 (SD = 8.89) M = 43.64 (SD = 10.92)
SSPS-P M = 9.36 (SD = 5.79) M = 13.57 (SD = 6.13) M = 14.00 (SD = 5.24)
SPSS-N M = 15.57 (SD = 5.89) M = 10.07 (SD = 4.46) M = 10.43 (SD = 4.62)
LSAS M = 66.21 (SD = 16.32)
M = 45.29 (SD = 9.49) M = 44.93 (SD = 9.62)
Flight phobia (N = 9)
FAS M = 20.22 (SD = 6.03) M = 15.33 (SD = 4.63) M = 14.56 (SD = 5.07)
FAM-C M = 28.22 (SD = 3.86) M = 21.89(SD = 4.37) M = 20.56 (SD = 4.92)
FAM-S M = 30.22 (SD = 10.97)
M = 22.89 (SD = 8.95) M = 21.78 (SD = 8.94)
Acrophobia (N = 8)
AQ M = 55.57 (SD = 19.09)
M = 54.86 (SD = 20.48)
M = 54.14 (SD = 17.63)
STAI-S = state anxiety, STAI-T = trait anxiety, BFNE = fear of negative evaluation,
SSPS-P/SSPS-N = positive/negative self-statements during public speaking, LSA = social
anxiety, FAS = flight anxiety situation, FAM-C/FAM–S = flight anxiety modality
(cognitive and somatic), AQ = acrophobia anxiety, IR = irrationality, R = rationality
Following treatment, we evaluated the overall treatment efficacy: the
independent variable in this analysis was the treatment group (VRCBT versus
WL) and the dependent variables were measures assessing the treatment outcome
and cognitive mechanisms. The analysis yielded no significant differences on any
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of the measures between the two groups. As acrophobia patients’ descriptive
statistics showed least change, patient data were removed and statistical analyses
were rerun. Results indicated no significant differences on any of the measures
between VRCBT and WL. For additional analyses we used patients’ scores from
both groups altogether.
Further on, Paired Samples T Tests were performed in order to examine
whether VRCBT treatment significantly reduced symptoms and cognitive
mechanisms for pre- to post- treatment. Results are indicated in Table 2.
Table 2. Paired t-test results for pre-test and post-test.
Phobia Variables t-test values
General measures
STAI-S t(30) = .75, p > .05
STAI-T t(30) = -.58, p > .05
IR (ABS2) t(30) = 1.80, p > .05
R (ABS2) t(30) = 1.47, p > .05
SUDs t(30) = 3.22, p < .05
Social phobia
SSPS-P t(13) = -6.50, p < .05
SSPS-N t(13) = 3.93, p < .05
BFNE t(13) = 3.06, p < .05
LSAS t(13) = 5.48, p < .05
Flight phobia
FAS t(7) = 5.93, p < .05
FAM-S t(7) = 4.00, p < .05
FAM-C t(7) = 8.29, p < .05
Acrophobia
AQ t(6) = .25, p > .05
STAI-S = state anxiety, STAI-T = trait anxiety, SUD = Subjective Units of Distress,
BFNE = fear of negative evaluation, SSPS-P/SSPS-N = positive/negative self-statements
during public speaking, LSA = social anxiety, FAS = flight anxiety situation, FAM-
C/FAM–S = flight anxiety modality (cognitive and somatic), AQ = acrophobia anxiety, IR
= irrationality, R = rationality
While no significant differences were identified for general measures
(e.g. anxiety, irrational beliefs), all other results indicated significant differences
between measures prior and post treatment, except for acrophobia.
Further on, we looked at a possible moderating effect of immersion and
presence on the relation between pre-test and post-test anxiety was investigated.
Results haven’t reached statistically significance.
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Expectations
In order to investigate whether expectations have any impact on change
(i.e. anxiety, cognitive mechanisms), bivariate correlations were performed
between the three expectations we assessed and change (the difference between
pre intervention and post intervention scores).
Table 3. Correlations between expectations, irrational beliefs and anxiety.
Expect fear to
get better
Expect therapy to
help fear
Expect VR to
help fear
R (ABS2) -.27 -.45* -.35*
IR (ABS2) .59* .61* .48*
STAI-S .18 .15 .27
SUDs -.40* -.47* -.30
*p < .05
Data indicate significant correlations between expectations and all
outcome changes, except for STAI-S. Expecting psychotherapy to help reduce
fear explains 21% of gains in rational beliefs, 38% of improvement by reducing
irrational beliefs and 22% of reduction of fear during the intervention. Expecting
VR to help reduce fear explains 13% of gains in rational beliefs and 23% of the
decrease in irrational beliefs. Generally, expecting fear to improve following the
intervention explains 35% of the decrease in irrational beliefs and 16% of the
decrease of fear during exposure. Some of the non-significant correlation
coefficients further suggest the association between expectations and both
cognitions (expecting fear to get better and rational beliefs: r=-.27) and anxiety
(expecting VR to help fear and STAI-S: r=.27 and SUDs r=-.30): these results
would have been significant at p < .05 if the sample of participant were N = 60.
Working alliance
The relation between working alliance (both assessed by therapist – WAI-
T and by patients – WAI-C) and change (the difference between pre intervention
and post intervention scores) was assessed by computing bivariate correlations.
Results are presented in Table 4.
Results indicate significant correlations between working alliance, as
measured by the patient, and change in anxiety (measured by means of subjective
units of distress), rationality and irrationality. Further analyzing this set of data, it
can be concluded that working alliance (assessed by the patient) explains 31% of
the variance in rationality increase, 35% of the variance in irrationality reduction
and 39% of anxiety during exposure.
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Table 4. Relation between working alliance and outcome measures.
Outcome change Pearson’s correlations
WAI-C
R (ABS2) -55*
IR (ABS2) .59*
SUD -.62*
STAI S .24
WAI-T
R (ABS2) -.01
IR (ABS2) .21
SUD -.26
STAI S .22
*p < .05
Therapists’ performance
Therapists’ performance, assessed using the REBT Therapy Rating Scale,
is indicated below. Overall, therapy performance ranged from 46 to 62 with a
mean of 55.37 (SD = 4.48).
Table 5. Therapists’ performance (means and standard deviations).
REBT TRS
Therapist 1 58.00 (SD = 3.10)
Therapist 2 56.16 (SD = 4.53)
Therapist 3 50.83 (SD = 4.26)
Therapist 4 56.2 (SD = 2.77)
Further on, therapists’ performance was correlated with therapy outcome
(i.e. anxiety, cognitive mechanisms). Therapists’ performance did not correlate
with change in rationality/irrationality or with general measures of anxiety. Also,
most likely due to the very small number of patients with either social (N = 15),
plane (N = 9) or heights (N = 8) phobia, no significant associations between
results on any of these measures and therapists’ performance were identified.
However, change in subjective ratings of fear during exposure (mean SUD 1 -
mean SUD 4) - did correlate significantly with therapists’ performance: r = .42, p
< .05. In other words, 19% of the change in anxiety occurring during
psychotherapy is accounted for by therapists’ performance.
We also wanted to investigate whether therapists’ performance is
associated with working alliance (both assessed by therapists and assessed by
patients). Results indicated that working alliance, when assessed by patients, is
significantly correlated with therapists’ performance (r = .41, p < .05). The
relation between therapists’ ratings of working alliance and their performance was
not significant (r = .13, p > .05).
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Ramona Moldovan & Daniel David
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Discusssion
This study was structured around several objectives. First, we wanted to
investigate in a randomized clinical trial the efficiency of one session
treatment using cognitive and behavioral therapy and virtual reality in treating
social and specific phobia; here, we were interested in clarifying not only if
treatment works (both in terms of outcome and mechanisms), but also if and to
what extend do working alliance, patients’ expectations and therapists’
performance contribute to this change. Analyses revealed no significant
differences between VRCBT and the WL at post treatment. Scores for all
variables investigated were in the hypothesized direction but the level of
significance was not reached. Given the small sample size these results are not
unexpected. Analyses further indicated that while no significant differences
were identified for general measures (such as anxiety, irrational beliefs),
except for acrophobia, all other results indicated significant differences
between measures when investigating the course of change from prior to post
treatment. These results indicate that further studies, conducted within a larger
sample size may identify significant effects. In investigating the impact of
expectations, data indicate significant associations between expectations and most
outcome changes. Expectations have a low to medium effect size in explaining
changes in rational and irrational cognitions and reduction of fear during the
intervention. Further analyses indicate that working alliance (assessed by the
patient) has a medium effect size in explaining rationality and irrationality
change in patients, as well as change of anxiety symptoms during treatment.
Another important result of our study was that the therapists’ performance
had a significant impact in accounting for change in anxiety symptoms during
psychotherapy, explaining 19% of the change in anxiety levels during the
intervention., Despite the existing literature support (Price & Page, 2007), the
contribution of immersion and presence to treatment outcome was not supported
in this study.
The present study is not without its limitations. In light of the small
sample size, all findings should be interpreted with caution. Our conclusions
regarding differences between conditions are only suggestive from this
perspective and are in need of additional empirical evidence. Another limitation is
that participants were rather heterogeneous in terms of their clinical diagnosis.
Although the etiopathogenetic mechanisms and psychological interventions are
very similar for phobias, a trial investigating a more homogenous sample would
be more informative.
To date, this is the first study conducted on a clinical sample that
investigates the effects of one session treatment (VRCBT treatment) for social
phobia and specific phobias (flight phobia and acrophobia). An important
contribution of this study is that it addresses simultaneously psychotherapy
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One session treatment of virtual reality and cognitive behavioral therapy for phobias
81
components such as working alliance, patients’ expectations and therapists’
performance.
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