A Psychologist’s Journey to Treating Phobias with VR

VRforHealth invites you to learn about the work of Howard Gurr, licensed psychologist in New York State, and his journey toward the use of Virtual Reality Therapy in helping patients overcome phobias and anxieties and assist in the enhancement of mindfulness. Since the pandemic, Howard practices VR therapy remotely. He also created the “Directory of VR Therapists International” to help like-minded therapists refer patients to one another in different geographies.

Denise Silber: You’ve been interested in VR therapy from its beginnings in the US. How did you get started?

Howard Gurr: I became interested in the therapeutic use of Virtual Reality over 20 years ago, before any programs were available commercially to solo practitioners. At the time, I was both in private practice and employed as a school psychologist, and interested in helping children with learning issues. Dr. Skip Rizzo had developed a virtual environment, a classroom for children with Attention Deficit Disorder. His classroom exposed the child to distractions and the program then measured the child’s attention; unfortunately, that program was not available at that time. I subsequently became interested in using VR to treat executives with public speaking anxiety, in their own offices. I contacted the only company that had a program. However, their program, Virtually Better, did not work on a laptop, so my idea was tabled.

In 2015, I learned of Psious, in Barcelona who was then producing VR environments that worked on cellphones. The representative came to my office on Long Island, with a demo for me to try personally. At first, the program was not having an effect on me. Suddenly, I was placed in a balcony scenario, and although I knew I was in my office, my brain would not let me take a step forward. I realized that this anxiety was being triggered by a previous experience I’d had in a tall building. I understood the mechanism. When people have an anxiety connected to a particular environment, the therapist can show them a similar scenario, provoke the problem, and work on it with them. This is Exposure Therapy.

I bought the system and began by testing it for months on non-patient volunteers, friends and family. When I understood how to go through all the steps, to take the patient from a state of anxiety to calm, I introduced the program to certain patients.

DS: What are the steps of your therapy?
HG: My therapeutic approach is multi-pronged. In the beginning, I teach people three major things: how thoughts affect behavior, the physiology of anxiety, how to control anxiety. Next, I put them in a virtual environment. I start slowly, with a relaxing environment, so that I can get an idea if they can tolerate it. Some people can’t tolerate VR. It is very rare, but they may have a history of vertigo or feel dizzy for the first time.

Once they understand what it means to be in a virtual environment, I move them into the environment that causes them a problem. For a person afraid of flying, I can modify the scenario to raise their anxiety all through their journey. It can be before they leave home, during the cab drive, in the airport terminal, on the plane. I can change their seating, the weather, the behavior of other passengers, the ease of takeoff and landing. We start very simply and move up a progression. I will progressively put the patient in an environment they would otherwise avoid. I might put someone whom I’ve treated in a turbulent plane at night in a thunderstorm. If they can tolerate that, they may be good to go!

DS: How do you communicate with the patient during the VR portion of the session?
HG: Some people say you should not speak to a patient while they are experiencing VR, because this would be the intrusion of a disembodied voice. I don’t agree. I use the environment to work with the patient. I speak or text, depending on the scenario.

DS: How has the Coronavirus epidemic impacted your clientele as a psychologist?
HG: I maintain my practice over telephone, video, and VR format since March 13, 2020, when the Covid-19 confinement began in New York. I could now see patients face-to-face but I don’t, because the guidelines from the American Psychological Association are too stringent. We need to take the patient’s temperature and check two days later to make sure that they’re not sick. Also, how do we protect one another during 45 minutes of discussion in a closed office. We bought air purifiers and masks, but I became leery. My adult patients are fine with distance consultations. However, it is much harder to get children to tell us what is going wrong. If I ask how they are doing, they answer that they are fine. I now have to get the parents more involved than usually.

DS: Are people who don’t get to socialize much in ordinary circumstances faring better now?
HG: For the majority of people, Covid19 has exacerbated stress, anxiety, and depression. In addition, they have lost the outlets they used to have for their stress reduction. Conversely, for the socially anxious patients who cannot always handle what others consider ordinary social activity, Covid-19 has allowed them to avoid the sources of their anxieties, since it is now normal to stay home and do nothing. When school re-opens, I believe more children will experience “school phobia”, which leads to truancy issues. Like adults, some children have a high level of anxiety and want to avoid situations that trigger them.

DS: You’ve observed how efficient VR therapy is for phobias. What are your takeaways?
HG: Simply put, with virtual reality for phobias, I can accomplish in seven or eight sessions of 20-25 minutes within our 45-minute session, what would take months without virtual reality. Without VR, I would either have to ask people to use their imagination to create a scenario they prefer to avoid or can’t visualize, or I have to re-create the situation that provokes their anxiety… bring a dog to my office, take them on an elevator, or on a plane. I think you see what I mean. VR is a nearly ideal solution. For people afraid to drive, I can show them the local highway, the Long Island Expressway, with the full, real drive they would make, entrance to exit.

I am stunned that more therapists do not use VR exposure therapy. I don’t understand the debate about whether VR is reimbursable. It is exposure therapy. In addition, fortunately, more and more insurance companies understand this. When I explain how it works, the insurers do get it.

The virtual environment gives us everything we need for the treatment. It just makes good clinical sense to use the fastest way to get something done.

DS: Your website practitioner locator is designed to help therapists meet other therapists. Can you tell us more?
HG: Since I am known in the professional community as a therapist who uses VR for phobias, when there is a phobia to address quickly; other therapists send me a patient. If the patient has a fear of flying that needs urgent resolution, I’ll take a few sessions to get them ready and send them back to their psychologist when we are done.

Unfortunately, it’s difficult to locate VR therapists in the US. There may be others, but I personally know of only five in the 2000 licensed psychologists on Long Island. Very few schools teach VR, and we cannot practice across state lines. So, we need to work with distance referrals to other psychologists who practice VR. The purpose of my directory, vrttherapists.com is to help practitioners find one another and be able to make those referrals, as well as learn from one another. Thanks for your support in my quest.

See also this earlier video with Howard Gurr