1
MAKING SELF-HELP VIRTUAL REALITY
EXPOSURE THERAPY ACCESSIBLE :
HARDWARE AND DESIGN CONSIDERATIONS
Naila Latif, Student, Sir Syed University of Engineering and Technology
Abstract—Virtual Reality Exposure therapy has proven to
be as effective as cognitive behavioral therapy with in vivo
exposure (Krijn, 2004). Since it is an efficacious and cost effective
alternative to in vivo exposure therapy, it can be offered to
the clients via software packages containing educational material
and self- report questionnaires considering the present state of
Virtual Reality technology. This paper aims to identify design
considerations and constraints, knowledge of which is highly
useful in developing the applications that are accessible user-
friendly, require minimal or no therapeutic contact and provide
self-help solution to the inaccessibility of anxiety treatment which
leads to a massive number of patients being left untreated.
Keywords—Anxiety, Phobia, Virtual Reality Exposure Therapy,
in vivo exposure, Presence, Subjective unit of discomfort (SUDs)
I. I NTRODUCTION
Anxiety disorder is the most prevalent mental disorder. But
the stigma attached to mental disorders in addition to the un-
availability of proper and affordable treatment leads to it being
left untreated. Virtual Reality Exposure Therapy is being stud-
ied for a long period of time and can be considered an effective
alternative to cognitive behavioral therapy (Meyerbrker et al,
2014). The major barrier in receiving any kind of treatment is
the lack of its accessibility and affordability. According to a
psychiatry journal, people generally seek treatment after 6 to
8 years of suffering from mood disorders and 9 to 23 years of
suffering from anxiety disorders(Wang et al, 2005). With the
rapid growth of interest in VR technology, the future of VRET
is promising.
As VRET becomes convenient, it will be easier to develop
standalone VRET experiences but it requires consideration of
design and hardware. Developing such virtual environments
not only requires understanding of human side of VR but
also the understanding of the specific phobias and disorders
the environment is being designed. This will make VRET
applications efficacious, affordable and accessible which will
lead to patients seeking help leading to less delay in initial
contact for treatment and delay in treatment of the disorder.
A. VRET and Accessibility
The common question asked regarding VRET is that why
is VRET considered if the option in vivo exposure therapy is
Naila Latif is with the Department of Computer Engineering, Sir
Syed University of Engineering and Technology, Karachi, Pakistan e-mail:
nailalatif1@gmail.com
available. in vivo exposure therapy with or without relaxation
is just as effective but VRET is a good alternative if not better
for the following reasons:
• VRET allows the user to have more control over the
situation (Garcia-Palacios et al, 2002). The application
that is designed a way in which the the exposure
is increased by using various levels and after taking
subjective units of discomfort (SUDs) in account will
less reluctance from patient.
• in vivo exposure can be expensive when it comes to
exposing patient to environments that are usually out
of reach. For instance, if patient had flight phobia, in
vivo exposure will be costly (Banos, R.m., et al, 2002).
There is a high chance of fear coming back after just
one session. This virtually generated environment will
be an aid is this situation or in a similar one.
• Refusal to initiate a treatment is a major issue when
it comes to in vivo exposure. According to a survey
regarding the acceptability of virtual reality (VR) expo-
sure, the refusal rate of initiating treatment with in vivo
exposure was greater than VR exposure. Thus it can be
concluded that VRET results in more people seeking
therapy. (Garcia-Palacios et al, 2007).
• Another major hindrance in seeking help is confidential-
ity. People like to keep the information regarding their
treatment confidential. According to an article published
in Journal of Health Service Psychology: Spring 2017
, ”An ethical advantage of VRET is that you can do
in-vivo-like exposures without leaving the office.”
• Virtual environment can be personalized in case of pa-
tient being anxious regarding one particulat aspect of the
phobia which makes VRET highly flexible. (Wiederhold
and Wiederhold, 2004)
B. Designing Virtual Environments for Therapy
For designing virtual environments, many considerations
are to be made. Few of the are listed thoroughly below:
1) Hardware: When designing virtual reality experiences,
the main ingredient is the choice of hardware. First decision
in the process is choosing degrees of freedom. Degrees of Free-
dom (commonly abbreviated as DOF) refers to the movement
of a rigid body inside space.
• 6 DOF: It allows translation and rotation of object in the
virtual space. In short, the user, can walk around in the
environment while moving in reality at the same time.

• 3 DOF: If one wants to design an experience where
users sits at a chair or a couch and interacts with
environments with out changing the translation in
physical world, 3 DOF system should be enough and
preferred.
For exposure therapy, the choice of hardware depends on how
phases and levels are planned. It also depends on the kind of
phobia. For instance, for spider phobia, a sitting experience is
appropriate and enough where as claustrophobia may require
some movement towards an elevator or a room.
It is also possible to achieve that effect with way-point
system or a movement mechanics in 3DOF environment but
simulation sickness should be kept in check while doing that.
2) Sound: Similar to the reality we live in, it is important
in VR that sounds come from a proper source. This does
not only help with interactivity but also helps in making
sure that immersion never breaks at any point. It keeps the
distractions away too. Few design decisions that you have to
make regarding sound are:
• 2D or 3D Audio: 2D sounds are usually used for
2D screens and applications. If a VR experience, has
different sound sources, then 3D audio should be
preferred.
• Mono or Stereo: Stereo makes a user feel that he is
located in a three dimensional sound source. Mono
sounds save disk space but they are better suited for 2D
designs.
• Binaural Sounds: 3D sounds can be used to draw a
user’s attentions. It is particularly important in a VR
experience because user can look in any direction and
sound must make sense to the user.
Sounds in VRET are to be carefully picked and It is
proven that stereo sounds should be used. According to a
research, people can differentiate between stereo and mono
sounds. This result had a great effect on the developed
environment.(Hoekstra, 2013)
Another question that arises is if 3D audio has any relation
with the presence in the environment. The results presented by
research state that ”significant difference in spatial perception
was found between 3D audio and stereo or dolby surround,
although the median score indicated a trend in favour of 3D
audio.” (Hoekstra, 2013)
It is better to not have many distractions in the environment
and relevant sounds should be used. If a voice assistant is to
be included, it is better to make sure that it’s not adding to
anxiety of the patient which may lead to patient dropping out
of therapy.
2
3) User Interface: Designing UI for a VR experience is a
rather challenging task. There are all kinds of options available
which will be stated for assistance. But it entirely depends on
how the environment is setup. Design of user interface depends
on many factors.
The first factor to consider is UI design. The possibilities
for UI design are:
• 3D Menu: A whole 3 setup with buttons, sliders and
other options available in 3D is one possibility. But it
should be made sure that all the options are visible to
the user. If sound or other techniques are used to draw
user’s attention towards it then test should be run to
make sure its working.
• Another possibility is a flat screen menu.
This screen menu is 2D and contains all the buttons
and options for the user. This requires less development.
• Popping menu on a button click is another option.
This is difficult to develop but useful for the user.
Instructions are to be provided to user for the buttons.
Another factor is considering if the therapy is therapist led
or minimal or therapeutic contact. A research summarized the
guidelines and preference for therapist led sessions. These are
summarized as (Brinkman, Willem-Paul, et al, 2010):
• Therapists should be provided an automated
environment .
• Provide therapists with the input from the user including
SUD scores, their comments, options they choose and
their current status.
• Design for error prevention by not allowing therapists to
trigger inappropriate simulation events.
• Provide therapists with predefined comment flags to
record events in the session.
• In a VRET environment where the position of the patient
is fixed in the VR world, therapists do not need an
external viewpoint of the VR world with a projection
of the patient
R EFERENCES
[1] Meyerbroker, Katharina. Virtual Reality Exposure Therapy. The Wi-
ley Handbook of Anxiety Disorders, Apr. 2014, pp. 13101324.,
doi:10.1002/9781118775349.ch63.
[2] Wang, Philip S., et al. Failure and Delay in Initial Treatment Contact
After First Onset of Mental Disorders in the National Comorbidity Survey
Replication. Archives of General Psychiatry, vol. 62, no. 6, Jan. 2005,
p. 603., doi:10.1001/archpsyc.62.6.603.
[3] Garcia-Palacios, A, et al. Virtual Reality in the Treatment of Spider
Phobia: a Controlled Study. Behaviour Research and Therapy, vol. 40,
no. 9, 2002, pp. 983993., doi: 10.1016/s0005-7967(01)00068-7.
[4] Banos, R.m., et al. ”Virtual Reality Treatment of Flying Phobia. IEEE
Transactions on Information Technology in Biomedicine, vol. 6, no. 3,
2002, pp. 206212., doi:10.1109/titb.2002.802380
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[5] Garcia-Palacios, A., et al. Comparing Acceptance and Refusal Rates of

Virtual Reality Exposure vs. In Vivo Exposure by Patients with Specific
Phobias. Cyber Psychology Behavior, vol. 10, no. 5, 2007, pp. 722724.,
doi:10.1089/cpb.2007.9962.
[6] Virtual Reality Exposure Therapy: Bringing in Vivo Into the Office.
National Register, 26 May 2017, www.nationalregister.org/pub/the-
national-register-report-pub/journal-of-health-service-psychology-spring-
2017/virtual-reality-exposure-therapy-bringing-in-vivo-into-the-office/.
[7] Wiederhold, Brenda K., and Mark D. Wiederhold. The Effect of Pres-
ence on Virtual Reality Treatment.Virtual Reality Therapy for Anx-
iety Disorders: Advances in Evaluation and Treatment., pp. 7786.,
doi:10.1037/10858-006.
[8] Krijn, M, et al. Virtual Reality Exposure Therapy of Anxiety Disorders:
A Review. Clinical Psychology Review, vol. 24, no. 3, 2004, pp. 259281.,
doi:10.1016/j.cpr.2004.04.001
[9] Hoekstra, A.R.D. 3D Audio for Virtual Reality Ex-
posure Therapy. TU Delft Repositories, 1 Jan. 1970,
repository.tudelft.nl/islandora/object/uuid:cee403d1-2999-4224-b71c-
6dc3116dc1e1/?collection=research.

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