A Controlled Study of Virtual Reality Exposure Therapy for the Fear of Flying Barbara Olasov Rothbaum Department of Psychiatry and Behavioral Sciences Emory University School of Medicine Larry Hodges College of Computing Georgia Institute of Technology Samantha Smith Department of Psychiatry and Behavioral Sciences Emory University School of Medicine Jeong Hwan Lee College of Computing Georgia Institute of Technology Larry Price The Psychological Corporation ABSTRACT Fear of flying (FOF) affects an estimated 10—25% of the population. Patients with FOF ( N = 49) were randomly assigned to virtual reality exposure (VRE) therapy, standard exposure (SE) therapy, or a wait-list (WL) control. Treatment consisted of 8 sessions over 6 weeks, with 4 sessions of anxiety management training followed by either exposure to a virtual airplane (VRE) or exposure to an actual airplane at the airport (SE). A posttreatment flight on a commercial airline measured participants' willingness to fly and anxiety during flight immediately after treatment. The results indicated that VRE and SE were both superior to WL, with no differences between VRE and SE. The gains observed in treatment were maintained at a 6-month follow up. By 6 months posttreatment, 93% of VRE participants and 93% of SE participants had flown. VRE therapy and SE therapy for treatment of FOF were unequivocally supported in this controlled study. Fear of flying (FOF) is a significant problem, affecting an estimated 10% to 25% of the population ( Agras, Sylvester, & Oliveau, 1969 ; Deran & Whitaker, 1980 ), or approximately 25 million adults in the United States ( Deran & Whitaker, 1980 ). In addition, approximately 20% of those who do fly depend on alcohol or sedatives during flights ( Greist & Greist, 1981 ). Avoidance of flying causes sufferers serious vocational and social consequences. Several FOF programs have been described and tested, including stress inoculation training, systematic desensitization, flooding, implosion, and relaxation treatments ( Beckham, Vrana, May, Gustafson, & Smith, 1990 ; Haug, Brenne, Johnson, Berntzen, Gotestam, & Hugdahl, 1987 ; Howard, Murphy, & Clarke, 1983 ), but many have been criticized for not including a posttreatment flight to evaluate outcome ( Haug et al., 1987 ). The difficulty and expense of using actual airplanes and flights for exposure have daunted many researchers and therapists despite the prevalence and impact of FOF. Some FOF programs exist in large metropolitan cities, often sponsored by airlines, but these programs have not been subjected to rigorous evaluation. Virtual reality (VR) offers a new human—computer interaction paradigm in which users are no longer simply external observers of images on a computer screen but are active participants within a computer-generated three-dimensional virtual world. Virtual environments differ from traditional displays in that computer graphics and various display and input technologies are integrated to give the user a sense of Journal of Consulting and Clinical Psychology © 2000 by the American Psychological Association December 2000 Vol. 68, No. 6, 1020-1026 For personal use only--not for distribution. Page 1 of 119/5/2001http://spider.apa.org/ftdocs/ccp/2000/december/ccp6861020.htmlpresence or immersion in the virtual environment. The most common approach to the creation of a virtual environment is to outfit the user in a head-mounted display. Head-mounted displays consist of separate display screens for each eye, along with some type of display optics, stereo earphones, and a head-tracking device. The user is presented with a computer-generated view of a virtual world that changes in a natural way with head and body motion. What distinguishes VR from a mere multimedia system or an interactive computer graphics display is a sense of presence. A sense of presence is also essential to conducting exposure therapy. Researchers of emotional processing theory as it is applied to anxiety disorders ( Foa & Kozak, 1986 ; Foa, Steketee, & Rothbaum, 1989 ) purport that fear memories can be construed as structures that contain information regarding stimuli, responses, and meaning. Therapy is aimed at facilitating emotional processing. It has been proposed that, for this to occur, the fear structure must be activated and modified. Exposure therapy, in which the patient is intentionally confronted with the feared stimuli in a therapeutic manner, activates the fear structure through confrontation with the feared stimuli, which elicits the fearful responses. The processes of habituation and extinction in which the feared stimuli cease to elicit anxiety aid modification of the fear structure, making its meaning less threatening. Any method capable of activating the fear structure and modifying it would be predicted to improve symptoms of anxiety. Thus, VR exposure therapy (VRE) has been proposed as a new medium for exposure therapy. Rothbaum et al. (1995) conducted the first controlled study applying VR to the treatment of a psychological disorder: VRE was incorporated in the treatment of acrophobia. Participants were repeatedly exposed to virtual foot bridges of varying heights and stability, outdoor balconies of varying heights, and a glass elevator that ascended 50 floors. VRE was effective in significantly reducing fear of and improving attitudes toward heights, whereas no change was noted in the control group. Seven out of the ten VRE treatment completers exposed themselves to height situations in real life during treatment although they were not instructed to do. Physical symptoms of anxiety described by the participants while in virtual height situations included sweating, abdominal discomfort usually described as "butterflies," loss of balance or light-headedness, heart palpitations, pacing, tremulousness or shaking, feeling nervous or scared, weakness in the knees, tightness in the chest, and feeling tense ( Hodges et al., 1995 ). VRE has also been effective in two case studies of patients with FOF ( Rothbaum, Hodges, Watson, Kessler, & Opdyke, 1996 ; Smith, Rothbaum, & Hodges, 1999 ) and in a case study treating a person with spider phobia ( Carlin, Hoffman, & Weghorst, 1997 ). VRE is potentially an efficient and cost-effective treatment of FOF. The current study sought to determine the relative efficacy of VRE and standard exposure (SE) compared with wait list (WL) control in the treatment of FOF. It was predicted that (a) VRE
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