In Vivo versus Augmented Reality Exposure in the Treatment of Small Animal Phobia: A Randomized Controlled Trial

The efficacy of augmented reality exposure therapy in the treatment of spider phobia-a randomized controlled trial

The evidence for the use of Augmented Reality (AR) in treating specific phobias has been growing. However, issues of accessibility persist, especially in developing countries. The current study examined a novel, but relatively simple therapist guided smartphone-based AR Exposure Treatment (ARET) of spider phobia. Participants who reported symptoms of Arachnophobia were randomized into one of three comparison groups: ARET (n = 20), traditional in vivo exposure therapy (IVET; n = 18) and a waitlist control group (n = 17). Behavioral approach, subjective symptom measures, and galvanic skin response were assessed pre- and post-treatment. The study was concluded with a one-month follow up assessment. Results indicated that both treatment groups showed statistically significant and clinically meaningful improvements in behavioral approach at post-test that were maintained at 1 month follow- up, compared to the wait-listed group. Moreover, the treatment groups demonstrated significant improvements in subjective symptom report at 1-month follow up. Given its utility and potential accessibility, our findings suggest that future AR evaluation research could be conducted in therapy settings with minimal resources.

Assessment of a virtual sensory laboratory for consumer sensory evaluations

As technology advances in the field of food sciences, the sensory experience of food consumption remains complex and influenced by various factors. Traditional consumer testing, often conducted in isolated booth environments, presents challenges in terms of construct validity and user engagement for perception formation. The growing accessibility and sophistication of virtual reality (VR) technology offer a promising avenue for research. This study focuses on the assessment of a virtual sensory laboratory, seamlessly integrating traditional sensory practices into the virtual realm to explore disparities in consumer responses, especially in sensory analysis. The virtual laboratory, designed for compatibility with VR gear, closely resembles a sensory booth. The virtual environment enables the researchers to change the visual clues of the products being tested as well as the surroundings (e.g., colors, furniture, or even the environment). Additionally, the level of immersion can be enhanced by playing any type of music, if needed. One crucial question is to assess the opinions of the participants, if they feel comfortable in the created environment. Specific participant numbers are omitted, and the study engages participants. The success of this initiative could signify a substantial advance in analysis and cost savings, adding a layer of significance to the study's potential impact on optimizing research practices. The study lays the groundwork for optimal VR practices and anticipates further exploration with immersive elements to deepen our understanding of how virtual reality influences consumer behaviour in food selection compared to traditional sensory methods.

The Efficacy and Therapeutic Alliance of Augmented Reality Exposure Therapy in Treating Adults With Phobic Disorders: Systematic Review

BACKGROUND

Phobic disorders are characterized by excessive fear of a stimulus that can affect the quality of a patient's life. The lifetime prevalence in adults is 7.7% to 12.5%. The current literature provides evidence-based inferences about the effectiveness of in-vivo exposure therapy (IVET) in treating phobia. However, this method can put the therapist and the client in danger, with high drop out and refusal rates. A newer approach for exposure therapy using augmented reality technology is under assessment.

OBJECTIVE

This systematic review investigated the novel technology's efficacy, cost-efficacy, and therapeutic alliance in treating adults with phobia.

METHODS

An extensive search was conducted using 4 major databases (MEDLINE, PsycINFO, Embase, and Scopus) using a comprehensive list of synonyms for augmented reality exposure therapy (ARET) and phobic disorders. The search targeted any randomized control trial testing ARET in adults with phobic disorders up to August 8, 2022.

RESULTS

A total of 6 studies were included, with 208 participants providing results. Studies investigating the efficacy of ARET compared to no intervention showed significant results (P<.05) in the ARET group improvement. Head-to-head comparative studies comparing ARET to IVET showed no significant difference (P>.05) in the effectiveness and therapeutic alliance between both therapies. Further, the results demonstrated that the ARET group had a better long-term effect than IVET, with the ability to put the patients in more situations to face the feared object.

CONCLUSIONS

The current data suggest clinically significant efficacy and a promising therapeutic alliance of ARET. However, no data are available investigating the cost-effectiveness of ARET. Further research is warranted to ascertain ARET's cost-effectiveness and examine its efficacy in other populations and anxiety conditions.

Mixed results for exposure and response prevention therapy in mixed reality for patients with contamination-related obsessive-compulsive disorder: A randomized controlled pilot study

INTRODUCTION

Technology-supported exposure and response prevention (ERP) for patients with obsessive-compulsive disorder (OCD) as tested in clinical research, holds promise but also has limitations. The present study aims to overcome these limitations by using mixed reality for ERP (MERP). The objectives of this pilot study were to evaluate the safety, feasibility, and acceptance of MERP and to identify possible obstacles.

METHODS

Twenty inpatients with contamination-related OCD were recruited and randomized to two conditions: MERP (six sessions in 3 weeks) and care as usual treatment. Patients were assessed before treatment (baseline), after the 3-week intervention period (post), as well as 3 months after post assessment (follow-up) regarding symptomatology (Y-BOCS).

RESULTS

Results showed a similar reduction in symptomatology in both groups from baseline to post. Regarding safety, no clinically significant deterioration was detected in the MERP group. Patients' evaluation of the MERP was heterogeneous. The qualitative feedback provided helpful indications for further development of the software. Sense of presence was below the midpoint of the scales.

CONCLUSION

This is the first study evaluating a MERP for patients with OCD that shows cautious evidence for the acceptance and safety of MERP. The results of the subjective evaluation suggest revisions of the software.

Improving the efficacy of exposure therapy using projection-based augmented reality for the treatment of cockroach phobia: a randomised clinical trial protocol

INTRODUCTION

In vivo exposure is the treatment of choice for specific phobia (SP), but this technique presents limitations related to access and acceptability. Augmented reality (AR) offers advantages like maximising strategies such as 'variability' (varying stimuli, durations, levels of intensity or the order of the items), control by the therapist, or 'exposure to multiple contexts', which can produce positive effects in terms of fear renewal and generalisation of the results. The aim of this study is to test the efficacy of varying the phobic stimuli during treatment with AR: using multiple stimuli (MS) versus a single stimulus (SS) in participants with SP.

METHODS AND ANALYSIS

Participants (N=80) with a diagnosis of an SP of cockroaches will be randomised into two conditions: (1) projection-based AR exposure therapy with MS (P-ARET MS); (2) P-ARET with an SS (P-ARET SS). The measures are related to the efficacy results (fear, avoidance and negative thoughts, performance on the behavioural avoidance test (BAT) and preferences). The primary outcome measure is the BAT, and the secondary outcome measures are the BAT through AR, Fear of Cockroaches Questionnaire, Cockroach Phobia Beliefs Questionnaire, Fear and Avoidance Scales Patient's Improvement Scale, and Beck Depression Inventory Second Edition. Five evaluation moments will be included: preintervention, postintervention, and 1-month, 6-month, and 12-month follow-ups. The treatment will follow the guidelines of the 'one-session treatment'. Student's t-tests to compare the two groups on the post-test will be applied. In addition, two-way analysis of variances with repeated measures in one of the two factors (pretest, post-test and follow-ups) will be carried out to compare intragroup differences.

ETHICS AND DISSEMINATION

The Universitat Jaume I Ethics Committee (Castellón, Spain) granted approval for the study (CD/64/2019). Dissemination will include publications and presentations at national and international conferences.

TRIAL REGISTRATION NUMBER

NCT04563403.

Effectiveness of a projection-based augmented reality exposure system in treating cockroach phobia: study protocol of a randomised controlled trial

BACKGROUND

Despite being the treatment of choice for phobic disorders, in vivo exposure treatment (IVET) presents some important limitations related mainly to low acceptance and high drop-out rates. Augmented reality (AR) technologies can help to overcome these limitations. Evidence supports the use of AR in exposure treatment for small animal phobia. A new projection-based AR exposure treatment system (P-ARET) that offers the possibility of projecting the animals in a natural and non-intrusive environment has been developed. There are no randomised controlled trials (RCTs) available that have tested the efficacy of this system in cockroach phobia. This paper aims to present the protocol of an RCT that evaluates the efficacy of the P-ARET, versus an IVET group and a waiting list control group (WL), in carrying out exposure treatment for cockroach phobia.

METHODS/DESIGN

Participants will be randomly allocated to one of three conditions: (1) P-ARET, (2) IVET and (3) WL. Both treatment conditions will follow the 'one-session treatment' guidelines. As a diagnostic measure, the Anxiety Disorders Interview Schedule for Diagnostic and Statistical Manual for Mental Health Disorders-Version 5 will be used. The Behavioral Avoidance Test will be used as the primary outcome measure. Secondary outcome measures will include an attentional biases task (measured using eye-tracking technology), the Fear of Cockroaches Questionnaire, Cockroach Phobia Beliefs Questionnaire, Fear and Avoidance Scales, Beck Depression Inventory second edition, Disgust Propensity and Sensitivity Scale-Revised-12, State-Trait Anxiety Inventory, Clinician Severity Scale, and Expectation and Satisfaction with the Treatment Scale. The evaluation protocol will include pretreatment and post-treatment evaluations and 1, 6 and 12 months of follow-ups. Intention-to-treat and per-protocol analyses will be performed.

ETHICS AND DISSEMINATION

This study has been approved by the Ethics Committee of Universitat Jaume I (Castellón, Spain; 13 December 2019). The results of the presented RCT will be disseminated in presentations at international scientific meetings and peer-reviewed scientific journals.

TRIAL REGISTRATION NUMBER

NCT04563390.

Adverse Effects of Virtual and Augmented Reality Interventions in Psychiatry: Systematic Review

BACKGROUND

Virtual reality (VR) and augmented reality (AR) are emerging treatment modalities in psychiatry, which are capable of producing clinical outcomes broadly comparable to those achieved with standard psychotherapies.

OBJECTIVE

Because the side effect profile associated with the clinical use of VR and AR remains largely unknown, we systematically reviewed available evidence of their adverse effects.

METHODS

A systematic review was conducted in accordance with the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) framework across 3 mental health databases (PubMed, PsycINFO, and Embase) to identify VR and AR interventions targeting mental health diagnoses.

RESULTS

Of 73 studies meeting the inclusion criteria, 7 reported worsening clinical symptoms or an increased fall risk. Another 21 studies reported "no adverse effects" but failed to identify obvious adverse effects, mainly cybersickness, documented in their results. More concerningly, 45 of the 73 studies made no mention of adverse effects whatsoever.

CONCLUSIONS

An appropriate screening tool would help ensure that VR adverse effects are correctly identified and reported.

An internet-based self-applied rat phobia treatment using a Virtual Therapy Assistant: Study protocol for a randomized controlled trial

Specific phobias are a common anxiety disorder that deteriorates the lives of people who suffer from them. To reduce the symptoms produced by this mental disorder exposure therapies have been used. However, low- and middle-income countries, including Mexico, have the lowest rate of treatment due to multiple barriers that prevent addressing mental health problems. Self-applied treatments have been explored in previous studies, nevertheless, high dropout rates are a common problem in this kind of treatment. An alternative is using immersive self-applied treatments that could help increase adherence to the treatment. This article aims to present a study protocol to explore the feasibility of an Internet self-applied exposure treatment for rat phobias, using four types of immersive multimedia elements: images, videos, video games, and 360° videos. Also, the satisfaction and perception of a Virtual Therapy Assistant (VTA) that provides information and support to the user are described. The study protocol will compare two groups of participants, one on the waiting list, and the other will receive the self-applied treatment for rat phobia supported by the VTA. For this study, 45 participants will be recruited and the evaluation measures will be taken at four different times: baseline, post-treatment, and follow-ups at 3 and 6 months. The levels of anxiety and avoidance of the user manifested during the exposure to the multimedia elements, the improvement of the user's clinical symptoms, the level of satisfaction, the perception of effectiveness, and ease of use of the self-applied system will be evaluated. This study is expected to support the viability of self-applied treatment for rat phobias and the use of a VTA, showing the impact on treatment adherence. To the best of our knowledge, this is the first study to explore an exposure treatment for rats using different multimedia elements with the support of a VTA. The work will serve as a basis for the development of new virtual assistants that help in the treatment of other types of specific phobias. This research has been registered in Clinical Trials NCT (NCT05081323).

Use of augmented reality in mental health-related conditions: A systematic review

Objective

Augmented reality (AR) is a relatively new technology that merges virtual and physical environments, augmenting one's perception of reality. AR creates a computer-generated environment that evokes a unique perception of reality, where real and virtual objects are registered with one another, which operates interactively and in real time. Recently, the medical application of AR technology has dramatically increased with other assisted technologies, from training to clinical practice. The ability to manipulate the real environment extensively has given AR interventions an advantage over traditional approaches. In this study, we aim to conduct a systematic review of the use of AR to have a better understanding of how the use of AR may affect patients with mental health-related conditions when combined with gamification.

Method

This systematic review followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines by searching Pubmed and Web of Science databases.

Results and Conclusion

We identified 48 relevant studies that fulfill the criteria. The studies were grouped into four categories: Neurodevelopmental disorders, anxiety and phobia, psychoeducation & well-being, and procedural & pain management. Our results revealed the effectiveness of AR in mental health-related conditions. However, the heterogeneity and small sample sizes demonstrate the need for further research with larger sample sizes and high-quality study designs.

The relative efficacy and efficiency of single- and multi-session exposure therapies for specific phobia: A meta-analysis

Exposure therapy is the preferred treatment for specific phobia (SP), with evidence supporting its efficacy whether delivered over multiple sessions or as a single session, such as One-Session Treatment. In this meta-analysis, we compared the efficiency and effectiveness of single- and multi-session exposure for SP. PsycINFO, Embase, MEDLINE, and Cochrane were systematically searched for peer-reviewed articles reporting the effects of multi-session (k = 30) and/or single-session (k = 55) in vivo exposure on SP symptoms in clinical populations (n = 1758 participants). A random-effects model was used to synthesise and compare the pre-post treatment effects (Hedges' g) on approach behaviour and self-reported SP symptoms. Mean total treatment time was significantly longer for multi-session exposure than for single-session. There were no significant differences in the pooled effect sizes of single-session and multi-session exposure at post-treatment and follow-up assessments; effect sizes were large for all outcomes. Phobia subtype significantly moderated the effect size for both treatment approaches, although the direction of association differed according to the outcome measures. Results suggest no evidence for differences in the effectiveness of single- and multi-session exposure, but single-session is more time efficient. These outcomes suggest that policies to facilitate access to single-session exposure would be beneficial.

Automated app-based augmented reality cognitive behavioral therapy for spider phobia: Study protocol for a randomized controlled trial

Background

Fear of spiders, or Arachnophobia, is one of the most common specific phobias. The gold standard treatment, in vivo exposure therapy, is effective, but comes with significant limitations, including restricted availability, high costs, and high refusal rates. Novel technologies, such as augmented reality, may help to overcome these limitations and make Exposure Therapy more accessible by using mobile devices.

Objective

This study will use a Randomized Controlled Trial design to investigate whether ZeroPhobia: Arachnophobia, a 6-week Augmented Reality Exposure Therapy smartphone self-help application, can effectively reduce spider phobia symptoms. Additionally, we will examine user-friendliness of the application and the effect of usage intensity and presence on treatment outcome.

Methods

This study is registered in the Netherlands Trial Registry under NL70238.029.19 (Trial NL9221). Ethical approval was received on October 11, 2019. One-hundred-twelve participants (age 18–64, score ≥ 59) on the Fear of Spiders Questionnaire [FSQ] will be recruited from the general Dutch population and randomly assigned to a treatment or waitlist control group. The ZeroPhobia application can be accessed on users’ smartphone. Baseline, post-test (i.e., at six weeks), 3- and 12-month follow-up assessments will be done, each including the Fear of Spiders Questionnaire as the main outcome measure as well as additional measures of anxiety, depression, user-friendliness, and presence as secondary measures and covariates.

Results

The study was funded on September 25, 2018. Data collection started in September 2021 and the study is expected to run until September 2022.

Conclusions

Our study will improve our understanding of the efficacy and feasibility of providing Exposure Therapy for spider phobia using an Augmented Reality self-help application, with the intention of making mental health care more accessible.

oVRcome - Self-guided virtual reality for specific phobias: A randomised controlled trial

OBJECTIVE

Mobile health applications for mental health are widely accessible but most have had limited research evaluation. Virtual reality exposure therapy is an emerging treatment for specific phobias. Most virtual reality studies have investigated high-end virtual reality devices, typically only available in research and limited clinical settings for a single phobia. This study evaluated the effectiveness of oVRcome, a mobile health application combining self-guided virtual reality exposure and cognitive behaviour therapy, for five specific phobias.

METHODS

This is a 2-arm 6-week randomised controlled trial, with a waitlist control group and follow-up at week 12. Participants were required to live in New Zealand; be aged 18-64 years; have a fear of flying, heights, spiders, dogs and needles; score above 4 on the Brief Standard Self-rating scale for phobic patients; and have access to a smartphone and Internet. oVRcome consists of six modules of psychoeducation, relaxation, mindfulness, cognitive techniques, exposure through virtual reality and relapse prevention over 6 weeks. The primary outcome was the change from baseline to week 6 on the Severity Measures for Specific Phobia - Adults. All analyses were performed on intention-to-treat set.

RESULTS

A total of 126 participants were randomised, and 109 completed the follow-up at week 6, for a retention rate of 86.5%. The mean change in Severity Measures for Specific Phobia - Adults score from baseline to week 6 was greater in the active group compared with the waitlist group (active group -20.53 [standard deviation = 8.24]; waitlist group: - 12.31 [standard deviation = 10.66]; p < 0.001). The effect size for this difference was 0.86.

CONCLUSION

Self-guided use of the oVRcome app was effective at reducing severity of specific phobia symptoms in a sample of people with a self-reported fear of flying, heights, spiders, dogs or needles.Trial registry clinicaltrials.gov NCT04909177.

Client's Experiences Using a Location-Based Technology ICT System during Gambling Treatments' Crucial Components: A Qualitative Study

Cognitive Behavioral Therapy is the treatment of choice for Gambling Disorder (GD), with stimulus control (SC) and exposure with response prevention (ERP) being its two core components. Despite their efficacy, SC and ERP are not easy to deliver, so it is important to explore new ways to enhance patient compliance regarding SC and ERP. The aim of this study is to describe and assess the opinion of two patients diagnosed with problem gambling and GD that used the Symptoms app, a location-based ICT system, during SC and ERP. A consensual qualitative research study was conducted. We used a semi-structured interview, developed ad-hoc based on the Expectation and Satisfaction Scale and System Usability Scale. A total of 20 categories were identified within six domains: usefulness, improvements, recommendation to other people, safety, usability, and opinion regarding the use of the app after completing the intervention. The patients considered the app to be useful during the SC and ERP components and emphasized that feeling observed and supported at any given time helped them avoid lapses. This work can offer a starting point that opens up new research paths regarding psychological interventions for gambling disorder, such as assessing whether location-based ICT tools enhance commitment rates.

Effects of rhythmic eye movements during a virtual reality exposure paradigm for spider-phobic patients

Rhythmic eye movements performed during eye movement desensitization and reprocessing (EMDR) therapy have been shown to evoke a physiological de-arousal pattern.

OBJECTIVES

Here, we examined whether the efficacy of a virtual reality exposure therapy (VRET) paradigm for phobic patients could be improved by adding rhythmic eye movements.

DESIGN

Spider-phobic patients (N = 53) were randomly assigned to either a group performing rhythmic eye movements or a control group undergoing exposure without such eye movements.

METHODS

During the VRET session, heart rate, electrodermal activity, eye movements, and subjective fear ratings were recorded. Participants underwent behavioural avoidance tests before and after treatment as well as a follow-up 10-14 days later. Questionnaire data were assessed before exposure and at follow-up.

RESULTS

There were clear treatment effects in both groups with almost no group differences (i.e., the subjective fear ratings and the skin conductance response).

CONCLUSIONS

Contrary to our expectation, the implementation of rhythmic eye movements during virtual exposure did not enhance the effectiveness of the treatment. However, the eye movement group did show a significantly lower heart rate during exposure compared with the control group which might indicate a less stressful treatment.

PRACTITIONER POINTS

One-session Virtual Reality Exposure Therapy reduced fear of spiders effectively. Performing rhythmic eye movements during exposure did not enhance therapy effects. Rhythmic eye movements during exposure resulted in lower heart rate than standard exposure.

Phobia Exposure Therapy Using Virtual and Augmented Reality: A Systematic Review

A specific phobia is a common anxiety-related disorder that can be treated efficiently using different therapies including exposure therapy or cognitive therapy. One of the most famous methods to treat a specific phobia is exposure therapy. Exposure therapy involves exposing the target patient to the anxiety source or its context without the intention to cause any danger. One promising track of research lies in VR exposure therapy (VRET) and/or AR exposure therapy (ARET), where gradual exposure to a negative stimulus is used to reduce anxiety. In order to review existing works in this field, a systematic search was completed using the following databases: PubMed, ProQuest, Scopus, Web of Science, and Google Scholar. All studies that present VRET and/or ARET solutions were selected. By reviewing the article, each author then applied the inclusion and exclusion criteria, and 18 articles were selected. This systematic review aims to investigate the previous studies that used either VR and/or AR to treat any type of specific phobia in the last five years. The results demonstrated a positive outcome of virtual reality exposure treatment in the treatment of most phobias. In contrast, some of these treatments did not work for a few specific phobias in which the standard procedures were more effective. Besides, the study will also discuss the best of both technologies to treat a specific phobia. Furthermore, this review will present the limitations and future enhancements in this field.

What is the Current and Future Status of Digital Mental Health Interventions?

The prevalence of mental disorders continues to increase, especially with the advent of the COVID-19 pandemic. Although we have evidence-based psychological treatments to address these conditions, most people encounter some barriers to receiving this help (e.g., stigma, geographical or time limitations). Digital mental health interventions (e.g., Internet-based interventions, smartphone apps, mixed realities -virtual and augmented reality) provide an opportunity to improve accessibility to these treatments. This article summarizes the main contributions of the different types of digital mental health solutions. It analyzes their limitations (e.g., drop-out rates, lack of engagement, lack of personalization, lack of cultural adaptations) and showcases the latest sophisticated and innovative technological advances under the umbrella of precision medicine (e.g., digital phenotyping, chatbots, or conversational agents). Finally, future challenges related to the need for real world implementation of these interventions, the use of predictive methodology, and hybrid models of care in clinical practice, among others, are discussed.

Efficacy of an internet-based psychological intervention for problem gambling and gambling disorder: Study protocol for a randomized controlled trial

Gambling Disorder is a prevalent non-substance use disorder, which contrasts with the low number of people requesting treatment. Information and Communication Technologies (ICT) could help to enhance the dissemination of evidence-based treatments and considerably reduce the costs. The current study seeks to assess the efficacy of an online psychological intervention for people suffering from gambling problems in Spain. The proposed study will be a two-arm, parallel-group, randomized controlled trial. A total of 134 participants (problem and pathological gamblers) will be randomly allocated to a waiting list control group (N = 67) or an intervention group (N = 67). The intervention program includes 8 modules, and it is based on motivational interviewing, cognitive-behavioral therapy (CBT), and extensions and innovations of CBT. It includes several complementary tools that are present throughout the entire intervention. Therapeutic support will be provided once a week through a phone call with a maximum length of 10 min. The primary outcome measure will be gambling severity and gambling-related cognitions, and secondary outcome measures will be readiness to change, and gambling self-efficacy. Other variables that will be considered are depression and anxiety symptoms, positive and negative affect, difficulties in emotion regulation strategies, impulsivity, and quality of life. Individuals will be assessed at baseline, post-treatment, and 3-, 6-, and 12-month follow-ups. During the treatment, participants will also respond to a daily Ecological Momentary Intervention (EMI) in order to evaluate urges to gamble, self-efficacy to cope with gambling urges, gambling urge frequency, and whether gambling behaviour occurs. The EMI includes immediate automatic feedback depending on the participant's responses. Treatment acceptance and satisfaction will also be assessed. The data will be analysed both per protocol and by Intention-to-treat. As far as we know, this is the first randomized controlled trial of an online psychological intervention for gambling disorder in Spain. It will expand our knowledge about treatments delivered via the Internet and contribute to improving treatment dissemination, reaching people suffering from this problem who otherwise would not receive help.

TRIAL REGISTRATION

Clinicaltrials.gov as NCT04074681. Registered 22 July 2019.

Integrating virtual realities and psychotherapy: SWOT analysis on VR and MR based treatments of anxiety and stress-related disorders

The use of virtual reality (VR) and mixed reality (MR) technology in clinical psychology is growing. Efficacious VR-based treatments for a variety of disorders have been developed. However, the field of technology-assisted psychotherapy is constantly changing with the advancement in technology. Factors such as interdisciplinary collaboration, consumer familiarity and adoption of VR products, and progress in clinical science all need to be taken into consideration when integrating virtual technologies into psychotherapies. We aim to present an overview of current expert opinions on the use of virtual technologies in the treatment of anxiety and stress-related disorders. An anonymous survey was distributed to a select group of researchers and clinicians, using an analytic framework known as Strengths, Weaknesses, Opportunities, and Threats (SWOT). Overall, the respondents had an optimistic outlook regarding the current use as well as future development and implementation of technology-assisted interventions. VR and MR psychotherapies offer distinct advantages that can overcome shortcomings associated with traditional therapy. The respondents acknowledged and discussed current limitations of VR and MR psychotherapies. They recommended consolidation of existing knowledge and encouraged standardisation in both theory and practice. Continued research is needed to leverage the strengths of VR and MR to develop better treatments.Abbreviations: AR: Augmented Reality; MR: Mixed Reality; RCT: Randomised Controlled Trial; SWOT: Strengths, Weaknesses, Opportunities, and Threats; VR: Virtual Reality; VR-EBT: Virtual Reality Exposure-Based Therapy.

Effectiveness of a smartphone-based, augmented reality exposure app to reduce fear of spiders in real-life: A randomized controlled trial

Although in vivo exposure therapy is highly effective in the treatment of specific phobias, only a minority of patients seeks therapy. Exposure to virtual objects has been shown to be better tolerated, equally efficacious, but the technology has not been made widely accessible yet. We developed an augmented reality (AR) application (app) to reduce fear of spiders and performed a randomized controlled trial comparing the effects of our app (six 30-min sessions at home over a two-week period) with no intervention. Primary outcome was subjective fear, measured by a Subjective Units of Distress Scale (SUDS) in a Behavioural Approach Test (BAT) in a real-life spider situation at six weeks follow-up. Between Oct 7, 2019, and Dec 6, 2019, 66 individuals were enrolled and randomized. The intervention led to significantly lower subjective fear in the BAT compared to the control group (intervention group, baseline: 7.12 [SD 2.03] follow-up: 5.03 [SD 2.19] vs. control group, baseline: 7.06 [SD 2.34], follow-up 6.24 [SD 2.21]; adjusted group difference -1.24, 95 % CI -2.17 to -0.31; Cohen's d = 0.57, p = 0.010). The repeated use of the AR app reduces subjective fear in a real-life spider situation, providing a low-threshold and low-cost treatment for fear of spiders.

Creative Intervention for Acrophobia Sufferers through AIVE Concept

This research applies exposure to the visual appearance technology of virtual reality (VR). The motivation for this research is to generate a creative intervention by using regular smartphone devices and implementing them in VR using Google Cardboard as a medium visual display for exposure therapy at high altitudes. The VR application in this research is called acrophobia immersive virtual exposure (AIVE), which utilizes the Unity3D software to develop this treatment therapy application. The utilization of exposure therapy was carried out as a therapeutic medium for acrophobia sufferers. A commissioner was given to measure the usefulness of applications and devices in the VR environment created, and as many as 20 users had tested the VR device. The existing questionnaire was revised to develop a questionnaire for acrophobia sufferers, which was then used as an index measurement in the VR environment. The research is expected to be used to design a simulator and as a therapeutic medium using immersive VR devices in future studies.

Virtual reality for the enhancement of emotion regulation

In recent decades, a growing body of literature has focused on emotion regulation (ER), which refers to the ability to implement strategies in order to modulate emotional responses and reach desirable goals. To date, impaired ER (i.e., emotion dysregulation) has been identified as a transdiagnostic factor across a wide range of psychopathological conditions, which shows the importance of improving patients' ability to regulate negative and positive emotions in clinical practice. In addition to the increasing evidence showing its efficacy in the treatment of several clinical conditions, virtual reality (VR) has recently emerged as a potentially powerful tool for enhancing ER, thus breaking new ground in the development of cutting-edge transdiagnostic interventions. In the present narrative review, we will provide an overview of the existing evidence about VR-based interventions in the field of ER, emphasizing the promising findings and the barriers that still have to be addressed. To this aim, the available VR-based literature will be analysed in relation to four categories of ER strategies: situational strategies, attentional strategies, cognitive strategies, and response modulation strategies. Furthermore, new emerging fields of research targeting innovative aspects of ER will be highlighted, including the use of VR to promote positive emotions and interpersonal ER skills. Besides, its cost-effectiveness will be discussed, taking into account the costs for both developers (e.g., clinicians and researchers) and end-users. Finally, future directions in this promising field of research will be outlined.

Cockroaches are scarier than snakes and spiders: Validation of an affective standardized set of animal images (ASSAI)

Research on emotional processes has been closely related to the use of emotional stimuli, promoting the development of different standardized sets of images. However, some kinds of images that would be relevant in clinical psychology research are not available, especially for small animal phobias. The aim of the present study is to validate a set of animal images that includes images of cockroaches, which are not present in the current sets of images. Two hundred and forty images depicting five types of animals (cockroaches, spiders, snakes, cats, and butterflies) were collected from online public domains. Four hundred and twenty-four participants (72.9% women) took part in the study rating the images in two affective dimensions (i.e., valence and arousal). Cockroach pictures were rated as significantly more unpleasant than pictures of spiders, snakes, butterflies, and cats. Moreover, results revealed that women rated cockroach, spider, and snake pictures as more negative than men did. Also, women in comparison with men rated cockroach images as more arousing. The results highlight the importance of using images of cockroaches, due to their high negative valence, which even exceeds that of snakes and spiders, the unpleasant animals typically used in phobic research. This set of images can be useful in research on small-animal phobias.

Blended transdiagnostic group CBT for emotional disorders: A feasibility trial protocol

INTRODUCTION

Emotional disorders (anxiety and depressive disorders) are a relevant public health concern associated with high prevalence, high costs, and important disability. Therefore, research priorities include designing and testing cost-effective interventions to reach everyone in need. Internet-delivered interventions for emotional disorders are effective and can help to disseminate and implement evidence-based treatments. However, although these treatments are generally effective, not all patients benefit from this treatment format equally. Blended treatments are a new form of intervention that combines the strengths of face-to-face and Internet approaches. Nevertheless, research on blended interventions has focused primarily on individual therapy, and less attention has been paid to the potential of using this format in group psychotherapy. This study aims to analyze the feasibility of blended transdiagnostic group CBT for emotional disorders. The current article describes the study protocol for this trial.

METHOD AND ANALYSIS

A one-armed pilot trial will be conducted. Participants will be 30 adults suffering from DSM-5 anxiety and/or depressive disorders. The treatment consists of a blended transdiagnostic group intervention delivered during a period of 24 weeks. Groups of 6 to 10 patients will attend a total of eight 2-hour, face-to-face sessions, alternated with the use of an online platform where they will find the contents of the treatment protocol. The intervention has four core components: present-focused awareness, cognitive flexibility, identification and modification of behavioral and cognitive patterns of emotional avoidance, and interoceptive and situational exposure. These components are delivered in 16 modules. Assessments will be performed at baseline, during the treatment, at post-treatment, and at 3-month follow-up. Clinical and treatment acceptability outcomes will be included. Quantitative and qualitative data (participants' views about blended group psychotherapy) will be analyzed.

ETHICS AND DISSEMINATION

The trial has received ethical approval from the Ethics Committee of Universitat Jaume I (September 2019) and will be conducted in accordance with the study protocol, the Declaration of Helsinki, and good clinical practice. The results of this study will be disseminated by presentation at conferences and will be submitted for publication in a peer-reviewed journal.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT04008576. Registered 05 July 2019, https://clinicaltrials.gov/ct2/show/NCT04008576.

Effect of augmented reality books in salivary cortisol levels in hospitalized pediatric patients: A randomized cross-over trial

OBJECTIVE

This study sought to assess the effect of reading augmented reality (AR) books on salivary cortisol levels in hospitalized pediatric patients compared to reading a standard children's book.

METHODS

This was a randomized, two-period, cross-over trial in hospitalized children aged 7-11 years. AR books currently in the market were used as intervention. Complete block randomization was used to randomize the order of the intervention. Children allocated to the 'AR-first' group received the book, a tablet and were left to interact independently with the technology for an hour. After a 48 -h wash-out period, children received a standard book. 'Standard-book-first' group received only the standard book and after wash-out received the tablet and the AR book. Salivary cortisol and a validated visual analogue scale (VAS) for psychological stress were assessed at the beginning and at the end of each intervention.

RESULTS

A total of 29 children were recruited in the study. One was lost during follow up. Cortisol levels decreased after the AR intervention (P = 0.019). Nevertheless, the decrease was not greater than the one associated to reading the standard book. VAS scores increased after the AR intervention (P < 0.001).

DISCUSSION

There is evidence of order and sequence effects that might explain results. First assessment of AR-based interventions on stress. Results justify further research.

CONCLUSIONS

There was no evidence that reading AR books diminished cortisol levels more than reading a standard book. AR-books improved VAS score for psychological stress compared to a standard book.

Spider Phobia: Neural Networks Informing Diagnosis and (Virtual/Augmented Reality-Based) Cognitive Behavioral Psychotherapy-A Narrative Review

Recent fMRI studies on specific animal phobias, particularly spider phobia (arachnophobia), have identified a large variety of specific brain regions involved in normal and disturbed fear processing. Both functional and structural brain abnormalities have been identified among phobic patients. Current research suggests that both conscious and subconscious fear processing play a crucial role in phobic disorders. Cognitive behavioral therapy has been identified as an effective treatment for specific phobias and has been associated with neuroplastic effects which can be evaluated using current neuroimaging techniques. Recent research suggests that new approaches using virtual (VR) or augmented reality (AR) tend to be similarly effective as traditional "in vivo" therapy methods and could expand treatment options for different medical or individual scenarios. This narrative review elaborates on neural structures and particularities of arachnophobia. Current treatment options are discussed and future research questions are highlighted.

Tips for Effective Implementation of Virtual Reality Exposure Therapy in Phobias-A Systematic Review

Background: The high incidence of phobias and the limited accessibility of psychotherapy are the reasons for the search for alternative treatments that increase the availability of effective treatment. The use of virtual reality (VR) technology is an option with the potential to overcome the barriers in obtaining an effective treatment. VR exposure therapy (VRET) is based on a very similar rationale for in vivo exposure therapy. The study aimed to answer the question of how to perform exposure therapy in a virtual reality environment so that it is effective. Methods: A systematic review of the literature, using PRISMA guidelines, was performed. After analysis of 362 records, 11 research papers on agoraphobia, 28 papers on social phobia and 10 about specific phobias were selected for this review. Results: VRET in agoraphobia and social phobia is effective when performed from 8 to 12 sessions, on average once a week for at least 15 min. In turn, the treatment of specific phobias is effective even in the form of one longer session, lasting 45-180 min. Head mounted displays are an effective technology for VRET. Increasing the frequency of sessions and adding drug therapy may shorten the overall treatment duration. The effectiveness of VRET in phobias is greater without concomitant psychiatric comorbidity and on the condition of inducing and maintaining in the patient an experience of immersion in the VR environment. Long-term studies show a sustained effect of VRET in the treatment of phobias. Conclusion: A large number of studies on in VR exposure therapy in phobias allows for the formulation of some recommendations on how to perform VRET, enabling the effective treatment. The review also indicates the directions of further VRET research in the treatment of phobias.

The clinical potential of augmented reality

Augmented reality (AR) is a rapidly emerging technology that superimposes digital objects onto real-world scenes as viewed in real time through a smartphone, tablet, or headset. Whereas AR has been adopted for retail, entertainment, and professional training, it also has potential as a novel, mobile, and efficacious treatment modality for psychological disorders. In particular, extinction-based therapies (e.g., anxiety, substance use disorders) could utilize AR to present stimuli in natural environments, enhancing generalizability beyond the clinic. The limited psychological literature on AR has focused on the treatment of simple phobias. Here, with the goal of bringing this technology to the attention of clinicians and researchers, we describe AR, contrast it with virtual reality, review the theoretical foundation for extinction-based therapies, provide examples for the treatment of substance use disorders, and identify theoretical, practical, and implementation-based research questions.

Recent developments in the intervention of specific phobia among adults: a rapid review

Specific phobia is highly prevalent worldwide. Although the body of intervention studies is expanding, there is a lack of reviews that summarise recent progress and discuss the challenges and direction of research in this area. Hence, this rapid review seeks to systematically evaluate the available evidence in the last five years in the treatment of specific phobias in adults. Studies published between January 2014 to December 2019 were identified through searches on the electronic databases of Medline and PsychINFO. In total, 33 studies were included. Evidence indicates that psychotherapy, and in particular cognitive behaviour therapy, when implemented independently or as an adjunctive, is a superior intervention with large effect sizes. Technology-assisted therapies seem to have a beneficial effect on alleviating fears and are described to be more tolerable than in vivo exposure therapy. Pharmacological agents are investigated solely as adjuncts to exposure therapy, but the effects are inconsistent; propranolol and glucocorticoid may be promising. A handful of cognitive-based therapies designed to alter fear arousal and activation pathways of phobias have presented preliminary, positive outcomes. Challenges remain with the inherent heterogeneity of specific phobia as a disorder and the accompanying variability in outcome measures and intervention approaches to warrant a clear conclusion on efficacy.

Virtual Reality for Anxiety Disorders: Rethinking a Field in Expansion

The principal aim to this chapter is to present the latest ideas in virtual reality (VR), some of which have already been applied to the field of anxiety disorders, and others are still pending to be materialized. More than 20 years ago, VR emerged as an exposure tool in order to provide patients and therapists with more appealing ways of delivering a technique that was undoubtedly effective but also rejected and thus underused. Throughout these years, many improvements were achieved. The first section of the chapter describes those improvements, both considering the research progresses and the applications in the real world. In a second part, our main interest is to expand the discussion of the new applications of VR beyond its already known role as an exposure tool. In particular, VR is enabling the materialization of numerous ideas that were previously confined to a merely philosophical discussion in the field of cognitive sciences. That is, VR has the enormous potential of providing feasible ways to explore nonclassical ways of cognition, such as embodied and situated information processing. Despite the fact that many of these developments are not fully developed, and not specifically designed for anxiety disorders, we want to introduce these new ideas in a context in which VR is experiencing an enormous transformation.

Advances in Surgical Training Using Simulation

Simulation involves the re-creation of real-life situations, processes, or structures for the purpose of improving safety, effectiveness, and efficiency of health care services: simulation provides a controlled and safe environment for training and assessment. In an age in which regulatory burdens, fiscal challenges, and renewed focus on patient safety increasingly constrain surgical residency programs, innovation in teaching is vital for the future of oral and maxillofacial surgery (OMS) training. Of the simulation technologies in modern day health care education, many have found their way into OMS training. This article reviews these technologies, and some examples of their uses in OMS.

Virtual reality applications for chronic conditions management: A review

Background: Virtual Reality (VR) as a computer technology that simulating real environments and situations exploited in numerous healthcare areas such as chronic diseases. The significance of timely treatment and rehabilitation of patients with chronic conditions is high due to the long lasting nature of these conditions. This paper sought to perform a review of published works in the field of VR application in chronic conditions for treatment and rehabilitation purposes.

Methods: We searched the MEDLINE database through PubMed in April 2016 for retrieving published papers from January 2001 to December 2015. From 117 retrieved papers, 52had the inclusion criteria, and their full texts were accessible. Data were extracted from papers based on following items: the name of the first author, year of the study, applied VR methods, type of condition and disease, number of subjects that participated in the study, and finally the status of success and failure of VR application. Data were analyzed using descriptive analysis.

Results: Results of the reviewed investigations have been considered in two main categories including treatment oriented papers (n=38, 73%) while twenty of these papers have been conducted on phobias (53%); also, there are rehabilitation-oriented experiments (n=14, 27%) while thirteen of these papers have been performed on stroke. In 40 papers (77%), the VR technology application reported proper and in 11 papers (21%) the application of VR resulted in relatively proper outcomes and only there is a work (2%) with poor results for VR intervention.

Conclusion: VR technology has been increasingly used in recent years for treatment and rehabilitation purposes among patients affected by chronic conditions in order to motivate them for more successful management.

Exploring the Relationship Between the Acceptability of an Internet-Based Intervention for Depression in Primary Care and Clinical Outcomes: Secondary Analysis of a Randomized Controlled Trial

Background: Depression is one of the most prevalent psychological disorders worldwide. Although psychotherapy for depression is effective, there are barriers to its implementation in primary care in Spain. The use of the Internet has been shown to be a feasible solution. However, the acceptability of Internet-based interventions has not been studied sufficiently. Objective: To assess the acceptability of an Internet-based intervention (IBI) for depression in primary care, and explore the relationship between expectations and satisfaction and the improvement in the clinical variables in primary care patients receiving this intervention. Furthermore, it offers data about the effects of some sociodemographic characteristics on these acceptability variables and analyzes whether the expectations are related to finalizing the intervention. Methods: Data were based on depressive patients who were participants in a randomized controlled trial. In the present study, we present the data from all the participants in the Internet intervention groups (N = 198). All the participants filled out the expectation and satisfaction scales (six-item scales regarding treatment logic, satisfaction, recommending, usefulness for other disorders, usefulness for the patient, and unpleasantness), the Beck Depression Inventory-II, and the secondary outcome measures: depression and anxiety impairment, and positive and negative affect. Results: Results showed that participants' expectations and satisfaction with the program were both high and differences in expectations and satisfaction depended on some sociodemographic variables (age: older people have higher expectations; sex: women have greater satisfaction). A positive relationship between these variables and intervention efficacy was found: expectations related to "usefulness for the patient" were a statistically related predictor to the results on the BDI-II (Beta = 0.364), and the perception of how logical the treatment is (Beta = 0.528) was associated with change in the clinical variable. Furthermore, the higher the expectations, the higher the improvements exhibited by the patients in all measures evaluated during the ten intervention modules. High expectations were also directly related to finalizing the intervention. Conclusions: This is the first study in Spain to address this issue in the field of IBIs for depression in primary care. The IBI showed high acceptance related to the intervention's efficacy and completion. Research on IBI acceptability could help to implement the treatment offered. Clinical Trial Registration: www.ClinicalTrials.gov, identifier NCT01611818.

Virtual Reality, Augmented Reality, and In Vivo Exposure Therapy: A Preliminary Comparison of Treatment Efficacy in Small Animal Phobia

This study aggregated data from three randomized control trials to explore the differential efficacy of three forms of exposure therapy, namely, in vivo (iVET), virtual reality (VRET), and augmented reality (ARET), in the treatment of small animal phobia. Additionally, baseline patient characteristics were used to detect subgroups of patients who showed a differential response to certain treatment modalities. Primary measures were distance covered, anxiety during the behavioral avoidance test (BAT), and overall fear of small animals. A repeated-measures analysis of variance was used to explore the overall treatment effect across the exposure modalities. A cluster analysis and an analysis of moderation were conducted to explore differential response to treatments. The main study finding was that the three treatment conditions were similarly efficacious in the treatment of small animal phobia for all study outcomes. Only for distance covered, our results revealed a tendency for iVET to be more effective than VRET and ARET in participants with worse performance on the BAT before treatment. The present study findings provide further evidence for the comparable efficacy of the three forms of exposure. Our results also suggest that, overall, treatments are likely to be similarly effective, regardless of the individual baseline characteristics (i.e., fear, anxiety, and age), whereas pretreatment scores on distance covered in the avoidance test might be used to personalize treatments (iVET may be preferable when participants perform worse at pretreatment).

Deterioration rates in Virtual Reality Therapy: An individual patient data level meta-analysis

Ample evidence supports the use of Virtual Reality (VR) for anxiety disorders. Nonetheless, currently there is no evidence about moderators or potential negative effects of VR treatment strategies. An Individual Patient Data (IPD) approach was employed with 15 retrieved datasets. The current study sample was composed of 810 patients. Randomized control trials (RCTs) for each primary outcome measure were performed, in addition to moderator analyses of the socio-demographic variables. Deterioration rates were 14 patients (4.0%) in VR, 8 (2.8%) in active control conditions, and 27 (15%) in the WL condition. With regard to receiving treatment, patients in a waiting list control condition had greater odds of deteriorating than in the two active conditions, odds ratios (ORs) 4.87, 95% confidence interval (CI) [0.05, 0.67]. In the case of the socio-demographic variables, none of them were associated with higher or lower odds of deterioration, with the exception of marital status in the WL condition; married people presented a significantly lower probability of deterioration, OR 0.19, 95% CI [0.05, 0.67]. Finally, when comparing pooled effects of VR versus all control conditions, the OR was 0.61 (95% CI 0.31-1.23) in favor of VR, although this result was not statistically significant. This study provides evidence about the deterioration rates of a therapeutic VR approach, showing that the number of deteriorated patients coincides with other therapeutic approaches, and that deterioration is less likely to occur, compared to patients in WL control groups.

The acceptability of an Internet-based exposure treatment for flying phobia with and without therapist guidance: patients' expectations, satisfaction, treatment preferences, and usability

PURPOSE

Internet-based treatments have been tested for several psychological disorders. However, few studies have directly assessed the acceptability of these self-applied interventions in terms of expectations, satisfaction, treatment preferences, and usability. Moreover, no studies provide this type of data on Internet-based treatment for flying phobia (FP), with or without therapist guidance. The aim of this study was to analyze the acceptability of an Internet-based treatment for FP (NO-FEAR Airlines) that includes exposure scenarios composed of images and real sounds. A secondary aim was to compare patients' acceptance of two ways of delivering this treatment (with or without therapist guidance).

PATIENTS AND METHODS

The sample included 46 participants from a randomized controlled trial who had received the self-applied intervention with (n = 23) or without (n = 23) therapist guidance. All participants completed an assessment protocol conducted online and by telephone at both pre- and posttreatment.

RESULTS

Results showed good expectations, satisfaction, opinion, and usability, regardless of the presence of therapist guidance, including low aversiveness levels from before to after the intervention. However, participants generally preferred the therapist-supported condition.

CONCLUSION

NO-FEAR Airlines is a well-accepted Internet-based treatment that can help enhance the application of the exposure technique, improving patient acceptance and access to FP treatment.

Review of Virtual Reality Treatment in Psychiatry: Evidence Versus Current Diffusion and Use

PURPOSE OF REVIEW

This review provides an overview of the current evidence base for and clinical applications of the use of virtual reality (VR) in psychiatric practice, in context of recent technological developments.

RECENT FINDINGS

The use of VR in psychiatric practice shows promise with much of the research demonstrating clinical effectiveness for conditions including post-traumatic stress disorder, anxiety and phobias, chronic pain, rehabilitation, and addictions. However, more research is needed before the use of VR is considered a clinical standard of practice in some areas. The recent release of first generation consumer VR products signals a change in the viability of further developing VR systems and applications. As applications increase so will the need for good quality research to best understand what makes VR effective, and when VR is not appropriate for clinical services. As the field progresses, it is hopeful that the flexibility afforded by this technology will yield superior outcomes and a better understanding of the underlying mechanisms impacting those outcomes.

Recent Progress in Virtual Reality Exposure Therapy for Phobias: A Systematic Review

This review is designed to systematically examine the available evidence about virtual reality exposure therapy's (VRET) efficacy for phobias, critically describe some of the most important challenges in the field and discuss possible directions. Evidence reveals that virtual reality (VR) is an effective treatment for phobias and useful for studying specific issues, such as pharmacological compounds and behavioral manipulations, that can enhance treatment outcomes. In addition, some variables, such as sense of presence in virtual environments, have a significant influence on outcomes, but further research is needed to better understand their role in therapeutic outcomes. We conclude that VR is a useful tool to improve exposure therapy and it can be a good option to analyze the processes and mechanisms involved in exposure therapy and the ways this strategy can be enhanced. In the coming years, there will be a significant expansion of VR in routine practice in clinical contexts.

The Use of Virtual Reality to Facilitate Mindfulness Skills Training in Dialectical Behavioral Therapy for Borderline Personality Disorder: A Case Study

Borderline personality disorder (BPD) is a severe mental disorder characterized by a dysfunctional pattern of affective instability, impulsivity, and disturbed interpersonal relationships. Dialectical Behavior Therapy (DBT®) is the most effective treatment for Borderline Personality Disorder, but demand for DBT® far exceeds existing clinical resources. Most patients with BPD never receive DBT®. Incorporating computer technology into the DBT® could help increase dissemination. Immersive Virtual Reality technology (VR) is becoming widely available to mainstream consumers. This case study explored the feasibility/clinical potential of using immersive virtual reality technology to enhance DBT® mindfulness skills training of a 32 year old female diagnosed with BPD. Prior to using VR, the patient experienced difficulty practicing DBT® mindfulness due to her emotional reactivity, and difficulty concentrating. To help the patient focus her attention, and to facilitate DBT® mindfulness skills learning, the patient looked into virtual reality goggles, and had the illusion of slowly “floating down” a 3D computer-generated river while listening to DBT® mindfulness training audios. Urges to commit suicide, urges to self harm, urges to quit therapy, urges to use substances, and negative emotions were all reduced after each VR mindfulness session and VR mindfulness was well accepted/liked by the patient. Although case studies are scientifically inconclusive by nature, results from this feasibility study were encouraging. Future controlled studies are needed to quantify whether VR-enhanced mindfulness training has long term benefits e.g., increasing patient acceptance and/or improving therapeutic outcome. Computerizing some of the DBT® skills treatment modules would reduce cost and increase dissemination.