British Journal of Guidance & Counselling, 2014

Vol. 42, No. 2, 123137, http://dx.doi.org/10.1080/03069885.2013.852159

Acceptability of virtual reality interoceptive exposure for the treatment

of panic disorder with agoraphobia
Soledad Queroa,c*, M. ngeles Prez-Araa, Juana Bretn-Lpeza,c,
Azucena Garca-Palaciosa,c, Rosa M. Baosb,c and Cristina Botellaa,c
a
Departamento de Psicologa Bsica, Clnica y Psicobiologa, Universitat Jaume I, Castelln,
Spain; bDepartamento de Personalidad, Evaluacin y Tratamientos Psicolgicos, Universidad de
Valencia, Valencia, Spain; cCIBER Fisiopatologa, Obesidad y Nutricin (CB06/03), Instituto
Carlos III, Girona, Spain
(Received 1 February 2013; accepted 1 August 2013)

Interoceptive exposure (IE) is a standard component of cognitive-behavioural

therapy (CBT) for panic disorder and agoraphobia. The virtual reality (VR)
program Panic-Agoraphobia has several virtual scenarios designed for
applying exposure to agoraphobic situations; it can also simulate physical
sensations. This work examines patients acceptability of the IE component
as applied in two different ways: using VR versus traditional IE. Additionally,
it explores the relationship between users treatment expectations and
satisfaction and clinically significant change. Results showed that VR and
traditional IE were well accepted by all participants. Furthermore, treatment
expectations predicted efficacy.
Keywords: acceptability; panic disorder and agoraphobia; interoceptive exposure;
virtual reality; cognitive-behavioural therapy

Introduction
In treatment for panic disorder and agoraphobia (PDA), the efficacy of cognitive-
behavioural therapy (CBT) has been widely demonstrated. Many review and meta-
analysis studies support the efficacy of CBT programmes (Barlow, 1997, 2002; Barlow,
Esler, & Vitale, 1998; Clum, Clum, & Surls, 1993; Gould, Otto, & Pollack, 1995; Landon
& Barlow, 2004; Margraf, Barlow, Clark, & Telch, 1993; Michelson & Marchione, 1991;
Otto, Pollack, & Maki, 2000; Wolfe & Maser, 1994); hence, CBT programmes are
recommended as the treatment of choice for PDA by the American National Institute of
Health (NIH, 1991). Many of these programmes incorporate multi-component techniques
based on Barlows traditional programme (Barlow & Cerny, 1988; Barlow & Craske,
1994), including psychoeducation about the disorder, cognitive restructuring to correct
catastrophic interpretations of bodily sensations, breath retraining and relaxation training
and exposure to feared bodily sensations and agoraphobic situations. The main
component of these programmes is the exposure technique. In vivo exposure (IVE) is
used to disconfirm misappraisals and eliminate conditioned emotional responses to

*Corresponding author. Email: squero@uji.es

2013 Taylor & Francis

124 S. Quero et al.

external situations (agoraphobic situations), while interoceptive exposure (IE) is used to

help patients to process bodily sensations.
According to Barlow (2008), IE is now a standard component of CBT for treating
panic disorder, although different groups regard IE differently; some highlight it as a
means for extinguishing fear responses through a habituation process (Barlow & Craske,
2007) whereas others consider it useful for disconfirming catastrophic interpretations
(Clark, 1996). Based on both perspectives, IE consists of repeatedly exposing the patients
to the feared physical sensations with the aim of reducing the distress experienced by
them. In order to do this, symptom induction exercises must be done over a few minutes.
Some examples of these exercises are hyperventilation, running on the spot, spinning
around, breathing through a narrow straw, sitting facing a heater, staring continuously at
oneself in a mirror, shaking ones head rapidly and so on (Antony, Roth Ledley, Liss, &
Swinson, 2006). Depending on the feared physical sensations of patients, it is necessary
to select the exercises that can elicit these specific sensations. As a result of the
progressive repetition of these exercises during the treatment sessions, patients can
experience these sensations as more tolerable and natural than before. Several studies
have examined the role of IE in treatment for PDA, highlighting the relevance of this
technique in such treatment (Bitran, Morissette, Spiegel, & Barlow, 2008; Craske, Rowe,
Lewin, & Noriega-Dimitri, 1997; Gragnani, Cosentino, Bove, & Mancini, 2011; Ito,
Noshirvani, Basoglu, & Marks, 1996; Ito et al., 2001; Lamplug, Berle, Milicevic, &
Starcevic, 2008; Morissette, Spiegel, & Heinrichs, 2005).
As previously mentioned, efficacious CBT programmes for treating PDA already
exist. However, a significant challenge with CBT programmes is the acceptability of
some components, including exposure. In traditional CBT programmes, as already
mentioned, this component is applied in vivo to both the agoraphobic situations and the
bodily sensations feared by the patients; IE is achieved through various exercises (such as
hyperventilation) that can evoke the appropriate bodily sensations. This way of applying
IE might be aversive and artificial, since patients with PDA experience the feared bodily
sensations when they experience actual situations (e.g. when catching a bus or shopping
at a mall). In addition, IVE has other limitations such as a lack of confidentiality and
much longer therapy durations and greater costs; IVE often requires therapists presence
outside of their consultation rooms.
In recent years, research on the use of Information and Communication Technologies
(ICT) for the treatment of psychological disorders has been conducted in order to improve
psychological treatments effectiveness or clinical utility. One such promising technology
is virtual reality (VR), which has emerged as an effective tool for applying the exposure
component and has demonstrated efficacy in the treatment of anxiety (Meyerbrker &
Emmelkamp, 2010; Opri et al., 2012; Powers & Emmelkamp, 2008).
In the specific case of PDA, VR Exposure (VRE) treatment efficacy has been
demonstrated in several studies with clinical samples that use VRE for situational exposure
(Botella et al., 2007; Choi et al., 2005; Peate, Pitti, Bethencourt, de la Fuente, & Garca,
2008; Vincelli et al., 2003). In the study conducted by Botella et al. (2007), participants
were randomly assigned to two exposure treatment conditions: IVE (wherein both
exposure to agoraphobic situations and IE were conducted in vivo) and VRE (wherein
exposure to agoraphobic situations was conducted using virtual scenarios and IE was
conducted using the effects offered by the VR program as well as traditional exercises). To
apply VRE, the Panic-Agoraphobia program was used (Botella et al., 2004). The program
can simulate several bodily sensations through sound effects (audible rapid heartbeats and
panting) and visual effects (e.g. blurred vision, double and tunnel vision). Furthermore,
 British Journal of Guidance & Counselling 125

participants in both conditions used a CBT programme with other therapeutic components
such as psychoeducation, cognitive restructuring, breathing training and relapse preven-
tion. Results showed that the treatment conditions were equally effective.
Regarding acceptability of VR treatments, some studies have examined participants
opinions before (expectations or preferences) and/or after treatment (eg. Garca-Palacios,
Hoffman, Kwong See, Tsai, & Botella, 2001). In the specific case of PDA, the first case
study in which the treatment protocol described above (Botella et al., 2007) was used
Villa, Botella, Garca-Palacios, and Osma (2007) found that the participant reported
high expectations for VRE before starting this component; furthermore, she also gave a
very positive evaluation of it at post-treatment. Likewise, participants in the controlled
study (Botella et al., 2007) reported their expectations and satisfaction with the exposure
component. Specifically, they assessed both VRE and IVE very positively; no statistically
significant differences were found between the groups expectations towards treatment
and satisfaction after application or at follow-up.
In spite of the efficacy and acceptability of VRE reported by the participants in this
study (Botella et al., 2007), the VR condition did not apply VR-IE in a controlled manner,
that is, participants received the IE component mixing both VR (e.g. double vision) and
traditional format (e.g. hyperventilating). A more recent study (Prez-Ara et al., 2010) did
compare the effects of using VR-IE and traditional methods for IE. This was done by
comparing the efficacy of a single CBT programme in two applications: one in which the
VR Panic-Agoraphobia program was used for both the situational exposure and IE
components, and another in which the VR program was used only for situational exposure,
while the IE component was applied in the traditional manner. Results showed that both
treatment conditions significantly reduced the main clinical variables at post-treatment.
These results were maintained or even improved for both conditions in six of the outcome
variables at three-month follow-up. However, no significant differences were found
between the two treatment conditions. Hence, it appears that provoking physical sensations
with VR effects was as powerful as evoking them with the traditional exercises (such as
hyperventilation, climbing or descending stairs, spinning in a chair and so on) traditionally
used in IE (Barlow, Craske, Cerny, & Klosko, 1989). These promising findings support the
utility of the Panic-Agoraphobia VR program in applying both VRE and VR-IE to
agoraphobic situations. However, as mentioned before, one important issue when using
ICT for psychological treatment is the acceptability by all potential users, not only patients
but also current and future psychologists. Therefore, the main aim of the present work is to
examine patients acceptability of the IE component as applied in two different ways (using
VR and traditional IE). Additionally, the relationship between treatment expectations and
satisfaction with clinically significant change (Jacobson & Truax, 1991) is analysed.

Material and methods

Participants
Initially, 36 people were interviewed for the study, all of whom either sought help for
their symptoms at the Emotional Disorders Clinic at Jaume I University of Castelln
(Spain) or were referred by Public Mental Health Services in Castelln and Valencia
(Spain). After the screening, nine applicants were excluded for several reasons: four did
not meet diagnostic criteria for PDA, one did not have sufficient time available and the
remaining four could not become immersed in the VR environments, thereby the VR
environments were not capable of evoking their level of anxiety (a crucial aspect for the
efficacy of the exposure technique).Therefore, 29 participants were included in this study,
126 S. Quero et al.

all of whom met DSM-IV-TR criteria (American Psychiatric Association [APA], 2000)
for the diagnoses of PDA (N = 27) or agoraphobia without PD (N = 2); 23 participants
were women (79.3%) and the remaining six were men (20.7%). The mean age was 32.79
years (SD = 8.28), and ranged from 21 to 53. Of the sample, 51.7% (N = 15) were single,
44.8% (N = 13) were partnered or married and 3.4% (N = 1) were divorced. With respect
to education levels, most of the sample (58%; N = 17) had a university degree, 27.6% (N
= 8) had a high school education and 13.8% (N = 4) had an elementary school education.

Measures
All participants received an assessment protocol designed according to the guidelines of
the National Institutes of Health Consensus Development Conference on the Treatment of
Panic Disorder held in October 1991 and reported by Shear and Maser (1994). In the
present work, we only include the measures regarding diagnosis, expectations of and
satisfaction with the treatment and the Panic Disorder Severity Scale that is used to
calculate the clinically significant change (Jacobson & Truax, 1991). A description of
these measures is presented below.

Diagnostic measure
Anxiety Diagnostic Interview Schedule IV (ADIS-IV-L; Di Nardo, Brown, & Barlow,
1994). This is a semi-structured interview designed to carry out a differential diagnosis of
the anxiety disorders included in the DSM. The ADIS-IV has demonstrated an inter-rater
reliability from satisfactory to excellent when used by expert clinicians who are familiar
with the DSM diagnostic criteria (Di Nardo, Moras, Barlow, Rapee, & Brown, 1993). In
the present study, the PD and Agoraphobia sections were used.

Measures for expectations and satisfaction regarding treatment

Expectations and satisfaction regarding the exposure treatment (adapted from Borkovec
& Nau, 1972). This questionnaire measures participants expectations for the exposure
component before treatment and their satisfaction with it after treatment. It includes six
items rated from 0 (not at all) to 10 (very much); questions addressed how logical the
treatment seemed, to what extent it could satisfy the patient, whether the patient would
recommend the treatment to others, whether it would be useful in treating other problems,
the treatments usefulness for the patients problem and to what extent it could be
aversive. Participants answered these questions after the therapist explained the rationale
for the exposure component they would receive (VR-IE or traditional IE) and before
beginning the first exposure task. Finally, they answered the same questions at post-
treatment and follow-up in order to assess their satisfaction with exposure. This
adaptation has been used in previous studies (e.g. Botella et al., 2008, 2009).

Clinically significant change measure

Panic Disorder Severity Scale (PDSS; Shear et al., 1992). This is a clinical scale that
assesses important features of panic disorder and agoraphobia. Specifically, the scale rates
frequency and distress of panic and panic-like sensations (limited symptom episodes),
severity of anticipatory anxiety, severity of situational avoidance and severity of
impairment or interference in work and social areas. The mean in a sample presenting
 British Journal of Guidance & Counselling 127

panic disorder without agoraphobia or with moderate agoraphobia was 1.59 (SD = 0.43)
(Shear et al., 1997).

Experimental conditions, treatment and therapists

The present work is a between-group design with two experimental conditions: (1) VR
Interoceptive Exposure Simultaneous Condition (VR-IE; N = 14); and (2) Interoceptive
Exposure Traditional Condition (T-IE; N = 15). Participants were randomly assigned to
each of the experimental conditions. It included repeated measurement (pre-treatment,
post-treatment and three-month follow-up).
The treatment included application of a CBT programme for PDA adapted from
Barlows group (Barlow & Craske, 1994) and Clarks group (Salkovskis & Clark, 1991)
and was the same applied in Botella et al.s study (2007). It included several therapeutic
components that were applied in a maximum of eight individual sessions: two
psychoeducation sessions and a maximum of six exposure sessions, depending on the
participants needs. The therapeutic components included: (1) psychoeducation on
anxiety and PDA; (2) cognitive restructuring; and (3) exposure to internal and external
stimuli. The main component was exposure: it was applied in two different ways,
depending on the treatment condition. Participants in the VR-IE condition were
simultaneously exposed to audio and visual effects such as rapid heartbeat, panting,
blurred vision, double vision and tunnel vision (see Figure 1) and agoraphobic scenarios
in virtual settings (see Figure 2), for approximately 50 minutes (a description of the VR
system is described in the next paragraph). In the T-IE condition, the participants were
exposed to the agoraphobic scenarios using VR (for approximately 25 minutes), while the
IE was carried out in the traditional way; namely, relevant physical sensations were
elicited using standard exercises such as hyperventilation, running on the spot, spinning
around, breathing through a narrow straw, shaking ones head rapidly and so on (see
Figure 3) for approximately 25 minutes.
Participants in each of the treatment conditions were not given explicit self-exposure
instructions. The mean number of sessions received in both treatments was very similar:
VR-IE: M = 5.54 (DT = 0.87); T-IE: M = 5.33 (DT = 1.17).
Nine therapists participated in the study, all of whom had a Masters degree or PhD in
psychology. They were trained in applying CBT programmes for PDA and were
supervised by expert clinicians.

Virtual reality program for the treatment of PDA

Regarding the apparatus and software used during the sessions treatment, a brief
explanation is presented in Table 1.
The VR program Panic-Agoraphobia (Botella et al., 2004) has six virtual scenarios.
The first scenario is the training room. This is a neutral scenario that engages the
participants in order to familiarise them with the VR scenarios. The other five scenarios
are clinically significant for PDA patients and include a house, the subway, a bus, a
shopping mall and a tunnel. The first one, the house, consists of a living room (with a TV,
a radio, a phone and an answering machine to receive messages) where the patients can
interact with the virtual objects with the aim of treating the anticipatory anxiety that PDA
patients usually experience. In addition, an elevator is included in the house scenario to
go out. The subway scenario consists of an underground station where the patient can
take the train with the option of leaving and entering each station. The main objective of
128 S. Quero et al.

Figure 1. Visual effects simulated by the VR Panic-Agoraphobia program.

this scenario is the treatment of one of the most frequent agoraphobic situations: the use
of public transportation. Another scenario related to exposure to public transportation is
the bus. In this scenario two routes are available: a short route and a long route. In
addition, the patient has the opportunity to cross streets and squares while away from
home. The shopping mall is another clinically significant scenario. The shopping mall has
two levels: the books and music section (on the ground floor) and the supermarket section
(on the first floor). In this scenario the patient can interact with the virtual objects and buy
the objects requested. The final scenario is the tunnel. It consists of a dark and never-
ending tunnel. The objective of this scenario is to expose the patients to agoraphobic
behaviours that can take place in situations where finding the exit or escaping when
experiencing a panic attack is difficult.
As previously mentioned, exposure to internal and external stimuli can be carried out
simultaneously in each virtual scenario. The program can simulate several bodily
sensations such as audible rapid heartbeats and panting, which can be regulated as low,
moderate or high speed. Visual effects can also be used at the same time, such as blurred
vision, double and tunnel vision (see Figure 4). In addition, each scenario includes several
modulators that can be used to gradually increase the difficulty of the situation (e.g.

Figure 2. Distribution of the devices, the therapist and the patient in the consulting room during
the VRE.
 British Journal of Guidance & Counselling 129

Figure 3. Examples of traditional exercises of IE (breathing through a narrow straw, hyperventila-

tion and spinning around).

number of people, threatening conversations, length of the trips in the subway and in the
bus, elevator damage, length of the queue or problems with a credit card in a shopping
mall and so on), making it possible to advance the exposure according to each patients
needs in a controlled manner. Figure 2 shows the distribution of the devices, the therapist
and the patient in the consulting room. A full description of the Panic-Agoraphobia
program can be found in Botella et al. (2004).

Procedure
An initial interview was applied to the 36 people who came to seek help at the Emotional
Disorders Clinic. All participants meeting PDA criteria underwent a deeper assessment

Table 1. Apparatus and software.

Computer Pentium IV (2.8 GHz, 1 GB RAM and CD-ROM drive)

Graphic card PCI Express 128 MB with support for OpenGL and support for a 60-Hz
rest frequency at 640 x 480 resolution
Visual devices
Patient V6 (Virtual Research) head-mounted display
Therapist 17 monitor
Tracker device (patient) InterTrax 2
Navigation and
interaction devices
Patient Mouse
Therapist Keyboard
Audio devices
Patient V6 headphones
Therapist Standard headphones
Virtual ambient software 3 DIVE running on Microsoft Windows (95, 98, ME, 2000 or NT 4.0,
with Service Pack 6)
130 S. Quero et al.

Figure 4. Virtual scenarios of the VR Panic-Agoraphobia program.

and signed the consent form for the study. The assessment protocol included two sessions
of one and a half hours each. After the assessment, participants were randomly assigned
to one of the two experimental treatment conditions (VR-IE or T-IE). Finally, after
completing the treatment programme, all participants were again assessed at post-
treatment and at three-month follow-up.

Results
Acceptance of the exposure component
Table 2 shows means and standard deviations obtained for the questions regarding
participants expectations and satisfaction with the treatment. Firstly, before treatment,
participants in both treatment conditions evaluated the exposure component very
positively. Furthermore, there were significant statistical differences between the two
conditions regarding expectations for the treatment: before treatment, participants in the
Table 2. Expectations and satisfaction with the exposure component (at post-treatment and three-
month follow-up).

Expectations Satisfaction Satisfaction

Pre-test Post-test Follow-up

VR-IE T-IE VR-IE T-IE VR-IE T-IE

Logical 9.17 (0.83) 8.31 (1.03) 9.50 (0.85) 9.28 (0.91) 9.18 (0.75) 9.72 (0.47)
Satisfaction 9.00 (8.23) 8.23 (1.53) 9.64 (0.84) 9.36 (1.28) 9.45 (0.52) 9.91 (0.30)
Recommend to 9.17 (1.19) 8.69 (1.49) 9.71 (0.61) 9.57 (0.94) 9.91 (0.30) 10.00 (0.00)
others
Utility for other 9.17 (1.03) 7.46 (2.57) 9.21 (0.97) 8.43 (1.70) 9.00 (1.26) 9.27 (1.01)
problems
Utility for 8.33 (1.23) 8.00 (1.78) 9.50 (0.65) 9.21 (1.12) 9.18 (1.25) 9.80 (0.42)
patients
problem
Aversiveness 3.42 (3.09) 4.25 (2.14) 2.78 (2.81) 3.93 (3.34) 3.45 (3.75) 3.72 (4.10)
VR-IE = Virtual Reality Interoceptive Exposure; T-IE = Traditional Interoceptive Exposure.
 British Journal of Guidance & Counselling 131

VR-IE condition considered the exposure component more logical (t = 2.276, g.l. = 23,
p 0.032) and useful for other problems (t = 2.208, g.l. = 23, p 0.042) than the T-IE
participants did. Secondly, at post-treatment, participants in both conditions also
evaluated the exposure component very positively (see Table 2), and no differences
were found for any of the questions included in the satisfaction scale. Finally, participants
in both treatment conditions continued to report a very positive opinion for all questions
in the satisfaction scale at three-month follow-up (see Table 2). After three months,
participants in the T-IE condition reported being more satisfied with the exposure
component (t = 2.50, g.l. = 20, p 0.021) than those in the VR-IE condition.

Regarding participants opinions about the aversiveness of the exposure component,

although no statistically significant differences were found between the two treatment
groups, participants offered the VR-IE condition found this method more acceptable than
those offered the T-IE condition at pre-treatment, post-treatment and three-month follow-
up (see Table 1).

Clinically significant change at post-treatment and follow-up

Clinically significant change was calculated for PDSS scores using Jacobson and Truaxs
(1991) index. As shown in Table 3, at post-treatment over 60% of the participants,
irrespective of their treatment conditions (VR-IE: 61.5%; T-IE: 64.3%), fell into the
category of recovered or improved, with no statistically significant differences among
treatments. At three-month follow-up, a higher percentage of participants, again
irrespective of their treatment conditions (VR-IE: 91.7%; T-IE: 76.9%), fell into the
category of recovered or improved, with no differences among treatments (see
Table 3).

Regression analysis results

A stepwise regression analysis was conducted to explore the ability of the expectations
and satisfaction scales to predict clinically significant change. As independent variables,
the different scales for expectations, satisfaction at post-treatment and satisfaction at
follow-up were included; the dependent variable was the Jacobson and Truax Index
(1991) for PDSS at post-treatment and follow-up. Results in Table 4 show that clinical
improvement at post-treatment was predicted by satisfaction with the treatment at follow-
up (specifically by the question To what extent was the exposure component useful for
your problem?) and by expectations towards treatment (specifically by the question To

Table 3. Clinically significant change for PDSS scores at post-treatment and three-month
follow-up.

Post Follow-up

VR-IE T-IE VR-IE T-IE

n (%) n (%) n (%) n (%)

Recovered 7 (53.8%) 9 (64.3%) 11 (91.7%) 10 (76.9%)

Improved 1 (7.7%) 0 (0%) 0 (0%) 0 (0%)
No change 5 (38.5%) 5 (35.7%) 1 (8.3%) 3 (23.1%)
VR-IE = Virtual Reality Interoceptive Exposure; T-IE = Traditional Interoceptive Exposure.
132 S. Quero et al.

Table 4. Stepwise regression analysis between expectations and satisfaction scales and Clinically
Significant Change Index for PDSS at post-treatment and three-month follow-up.

DV (clinically IV (Expectations and satisfaction at post- R2

significant change) treatment and follow-up) change t p

Post-treatment Treatment satisfaction at follow-up .31 0.78 4.04 .002**

Expectations about the treatment .30 0.59 3.05 .010*
Follow-up Expectations about the treatment .26 0.51 2.29 .037*
** p < 0.01; * p < 0.05
DV = Dependent Variables; IV = Independent Variables.

what extent are you satisfied with the treatment component you are going to receive?).
Finally, at three-month follow-up, the clinical improvement continued to be predicted by
treatment expectations, although not by satisfaction with it.

Discussion and conclusions

The main purpose of this work was to offer data about the acceptability of the IE
component applied using VR for the treatment of PDA. With regard to this aim, results
obtained showed that all participants in both conditions had positive opinions about the
exposure component they were going to receive before treatment and were highly
satisfied with it after treatment. Furthermore, this positive evaluation was maintained at a
three-month follow-up visit. Regarding the differences between the two treatment
conditions, before exposure treatment started, participants in the VR-IE condition
considered this way of applying exposure more logical and useful for other problems
than participants in the T-IE group. However, at three-month follow-up, participants who
received the T-IE condition reported being more satisfied with the exposure component
than those who received the VR-IE condition. No differences were found in the
remaining variables in any other assessment period. At this point, we would like to
highlight that participants in both treatment conditions considered the exposure
component acceptable and a little aversive at the three assessment periods (pre-treatment,
post-treatment and follow-up), with participants offered the VR-IE method finding it a
little more acceptable (but not significantly) (see Table 1).
Acceptability data obtained in the present work are consistent with those obtained in
previous works assessing CBT exposure treatment for PDA using a VR Panic-
Agoraphobia program (Botella et al., 2007; Villa et al., 2007). In addition, similar
results have been obtained for other emotional disorders such as specific phobias
(Botella et al., 2008; Garca-Palacios, Botella, Hoffman, & Fabregat, 2007; Rothbaum
et al., 2006), post-traumatic stress disorder, complicated grief or adjustment disorder
(Baos et al., 2009). In these studies, participants showed a good opinion of the VRE
before and/or after treatment. Only one study found in the literature, conducted by
Tarrier, Liversidge, and Gregg (2006), showed different results. Specifically, although
participants in this study considered that the VRE treatment was less uncomfortable
than IVE or imaginal exposure, they preferred these treatments over VRE. However,
one important limitation of this work was that the participants were students who, after
receiving information about the symptoms that are characteristic of PTSD, were asked
to choose between 14 PTSD treatments. Therefore, these results cannot be generalised
to clinical samples.
 British Journal of Guidance & Counselling 133

A second objective was to explore the relationship between treatment acceptability

and participants clinical improvement reached at post-treatment and at three-month
follow-up. In order to assess this, firstly, we calculated Jacobson and Truaxs (1991)
clinically significant change index for the PDSS. Results showed that over 60% of
participants, regardless of their treatment condition (VR-IE or T-IE), fell into the category
of recovered or improved, with no differences between them at post-treatment. This
percentage increased to over 75% at three-month follow-up, again with no differences
between groups. In addition, for both treatment conditions and at both assessment periods
the higher percentage of participants fell into the recovered category (see Table 2).
Secondly, a regression analysis was applied to explore whether treatment expectations
and opinion could predict clinical improvement. Results showed that, at post-treatment,
clinically significant change was predicted by treatment satisfaction reported by the
participants after three months (specifically, how useful they found the exposure
treatment they had received) and by the expectation they recorded before treatment. At
three-month follow-up, clinically significant change continued to be predicted by
participants expectations about the treatment but not by their treatment satisfaction.
These results suggest that high participant expectations about finding the treatment
satisfactory for them may have an important role in their improvement.
Patients expectations have been regarded as a variable affecting the course of
psychotherapy for more than 50 years (Greenberg, Constantino, & Bruce, 2006). As
Glass, Arnkoff, and Shapiro (2001) point out, clients expectations for therapeutic gain
are related to outcome in most studies. However, no causal conclusions can be drawn
since the literature on role expectations is equivocal, and the relatively few studies on
client preferences have yielded primarily negative and mixed results. Therefore, results
obtained in the present work provide some support for the role of treatment expectations
in clinical improvement. They are also consistent with the results obtained in another
work that also uses VRE for the treatment of fear of flying (Price, Anderson, Henrich, &
Rothbaum, 2008). Specifically, compared to lower levels, higher expectations for
treatment outcome yielded stronger rates of symptom reduction from the beginning to
the end of treatment on two standardised self-report measures on fear of flying.
Specifically regarding PDA, only one other study reflected similar results (Southworth
& Kirsch, 1988). In this study, participants with agoraphobia received in vivo exposure
sessions. The high expectancy group was told that the sessions were part of treatment,
and the low expectancy group was told the sessions were part of assessment for treatment.
Participants in the former group, who held expectations of therapeutic benefit, showed
substantially greater behavioural improvement and improved more rapidly than
participants who were led to believe that repeated exposure to a phobic situation was
the purpose of assessment. No study exploring the specific relationship between treatment
expectations and VR therapy outcome for PDA was found in the literature.
However, these promising findings should be taken with caution, since the sample
size in the present study was small and no long-term follow-up data are available. Despite
these limitations, however, we believe that this work contributes to the improvement of
CBT programmes for the intervention of PDA by justifying the use of VR in exposure
therapy. For example, using VR to apply exposure might make the treatment more
palatable. Moreover, making treatments that use ICT more acceptable for patients may be
useful to increase treatment adherence. Furthermore, although preliminary, results
obtained in the present study suggest that having high expectations about VRE treatment
(applied in either of the two experimental conditions) is central for the patients
134 S. Quero et al.

improvement in the short term (post-treatment) and in the medium term (three-month
follow-up).
On the other hand, the simultaneous use of VR-IE and VR situational exposure, apart
from being well accepted by the PDA participants included in this work, may offer
several advantages. This method of applying the exposure component is conducted in the
consulting room, and is therefore easier for therapists to apply. Thus, it can increase
therapeutic confidentiality and reduce costs related to therapists travel expenses.
Furthermore, the therapeutic situation is more ecological (e.g. experiencing rapid
heartbeats immediately upon entering a mall), enabling therapists to simulate certain
sensations (such as blurred vision or double vision) that might be difficult to evoke with
standard exercises. Finally, VR might create a more intense IE experience overall by
combining VR-IE (e.g. evoking blurred vision) simultaneously with traditional in vivo IE
(such as hyperventilating).
In conclusion, the present study emphasises the utility of VR for the treatment of
PDA as an alternative to certain traditional therapeutic components, such as IE, in the
hopes of improving the acceptability of psychological treatments. Now it is crucial to
open new directions in order to extend the use of VR to more people who may need it. A
key aspect will be the combination of VR and the internet. This will allow the use of VR
environments that have proven to be effective in treating several mental disorders and
have also been well accepted by patients in a self-applied way over the internet. Related
to this, in the UK, CBT computerised self-applied programs such as Beating the Blues
for depression and Fear Fighter for the treatment of phobias and panic disorder
(Kenwright, Liness, & Marks, 2001; Marks, Kenwright, McDonough, Wittaker, &
Mataix-Cols, 2003; MCrone et al., 2004; Proudfoot et al., 2003) are included in the
recommendations stated by the National Institute of Clinical Excellence (NICE) guide-
lines to be used in the public health context.

Notes on contributors
Soledad Quero has been Professor of Clinical Psychology at Universitat Jaume I (UJI) (Spain) since
2004. Her main research line is the application of communication and information technologies to
improve psychological treatments for emotional disorders. She has been principal investigator in
several projects. She is clinical supervisor and training coordinator of the Emotional Disorders
Clinic at UJI.
ngeles Prez-Ara is a Research Fellow and PhD student at Universitat Jaume I (Spain). She
finished her Masters degree in 2009. Her main research line is the application of information and
communication technologies to the treatment of emotional disorders. Currently she is working on
her doctoral thesis about augmented reality exposure for specific phobias.
Juana Bretn-Lpez has a PhD in Clinical Psychology from the University of Granada and has been
a Professor of Psychological Treatments at Universitat Jaume I (Spain) since 2008. Her main
research interests are anxiety disorders, especially the use of new technologies to treat phobic
disorders. She has participated in several research projects granted by national and European funds.
Dr Azucena Garca-Palacios is Professor of Abnormal Psychology at Universitat Jaume I (UJI)
(Spain) since 2002. Her main research line is the design and testing of clinical applications based on
information and communication technologies for emotional disorders. She has been principal
investigator in several projects. She is the clinical coordinator of the Emotional Disorders Clinic
at UJI.
Rosa Maria Baos is Full Professor of Psychopathology at the University of Valencia. She is the
director of the Masters course in Multidisciplinary Intervention in Eating and Personality
Disorders at this university. Her main research line is focused on the application of technologies to
 British Journal of Guidance & Counselling 135

clinical psychology for the understanding and treatment of mental disorders and promoting
wellbeing.
Cristina Botella has been Full Professor of Clinical Psychology at Universitat Jaume I (UJI) (Spain)
since 1992. Her main research line is the design and testing of clinical applications based on
information and communication technologies for emotional disorders. She has been principal
investigator in more than 30 research projects. She is the director of the Emotional Disorders Clinic
at UJI.

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