A Controlled Virtual Reality Exposure Therapy Application for

Smartphones

∗

Joana Teixeira, Bruno Patr

ao and Paulo Menezes

University of Coimbra, Department of Electrical and Computer Engineering, Institute of Systems and Robotics,

Rua S

ılvio Lima, Coimbra, Portugal

Keywords:

Virtual Reality, Exposure Therapies, Serious Games, Smartphone VR.

Abstract:

Exposure therapy (ET) is often used as a therapeutic process for the treatment of a psychological disorder.

Usually, this type of therapy is challenging to apply traditionally as the therapist must expose the patient

safely to the cause of the disorder. To help surpass this problem, a virtual reality (VR) application was de-

veloped to support exposure therapy. As these therapies are based on a gradual and repetitive process, with

this application, the patient can be exposed to the phobic element at different levels of anxiety intensity as

prescribed by the therapist. This application was designed to be used either during the therapeutic sessions or

at home. While using it in therapeutic sessions, it allows the therapist to include the analysis of physiological

signals, escape movements, or other reactions during the exposure. At home, as homework for the therapy

sessions, it will allow the patient to keep training what was learned during therapy. It is being developed as a

serious game for smartphones, and users will only need a cardboard-like VR headset.

1 INTRODUCTION

The evolution of VR-based technologies is allowing

the application of new medical procedures that oth-

erwise were complicated or completely impossible.

Mental health is one of the areas where this technol-

ogy is being applied and where this work is focusing

on. Every year, anxiety disorders affect nearly 18.1%

of adults and are still registered as one of the most

commons mental disorders (Saloni Dattani and Roser,

2021). Anxiety can become a daily obstacle for those

who suffer from it, as it introduces signiﬁcant dis-

tress, with consequent impairment in the quality of

life. This is also a problem for the society since, as un-

treated mental health disorders become more severe,

social and economic costs tend to increase (Botella

et al., 2011).

Numerous authors have shown that VR experi-

ences can be compared to real ones as VR scenarios

can induce some sensations similar to the ones felt in

the physical world (Penn and Hout, 2018). VR is be-

ing increasingly used in behavioural therapies, in par-

ticular in exposure therapies that consist in exposing

the patient to anxiety triggers, so that learning, habit-

uation, desensitization, or other, will help overcome

∗

This work was supported by Fundac¸

ao para a Ci

encia e

a Tecnologia (FCT) through project UID/EEA/00048/2020

or, at least, help in the process of managing it in the

daily life. Long term studies show the effectiveness

of VR to ET in the treatment of phobias (Krzystanek

et al., 2021).

Exposure therapy has proved its efﬁcacy in the last

20 years (Botella et al., 2011; Anderson and Mol-

loy, 2020). Nevertheless, the traditional application

of this treatment does not please everyone. Some pa-

tients fear the in-real-life confrontation with phobic

elements and some therapists also tend to believe that

in real-life exposure can be unethical by provoking

uncontrollable fear to their patients and, depending

on the disorder, by not being able to maintain the ses-

sions private and violating the patient-client bound-

aries (Miloff et al., 2019). Therapists also avoid in-

vivo exposure due to the time-consuming sessions and

the work around it, for instance, catching and keep-

ing a spider in the clinic for later reuse (Hinze et al.,

2021). When compared to traditional exposure ther-

apies, virtual reality counterparts tend to be accepted

by both parties, and seen as more ethical, and help-

ful (Botella et al., 2011). They are also considered

safer, and in most cases, as effective as in-vivo expo-

sures (Anderson and Molloy, 2020). Another advan-

tage of a VRET is the fact that it can be conducted in

an medical ofﬁce, even if the elements to be explored

cannot be physically there (Miloff et al., 2019).

294

Teixeira, J., Patrão, B. and Menezes, P.

A Controlled Virtual Reality Exposure Therapy Application for Smartphones.

DOI: 10.5220/0010990300003124

In Proceedings of the 17th International Joint Conference on Computer Vision, Imaging and Computer Graphics Theory and Applications (VISIGRAPP 2022) - Volume 1: GRAPP, pages

294-301

ISBN: 978-989-758-555-5; ISSN: 2184-4321

One notable disadvantage of VR systems is their

high prices. The development of this technology in

the past four years, has led to a cost reduction and

increased quality, and that makes this issue continu-

ally less signiﬁcant. With the recent release of new

and more inexpensive virtual reality headsets, clinical

trials are more common and ﬁnd high levels of user

satisfaction with VR (Anderson and Molloy, 2020).

Although cybersickness is still one of the major ob-

stacles, considerable improvements in the devices’

quality make this issue increasingly less signiﬁcant.

Also in this respect, the careful design of applica-

tions (Patr

ao et al., 2015), and the fact that most ex-

posure scenarios do not need fast displacements in the

VR space, may contribute to reduce the percentage of

users experiencing this type of discomfort.

It is commonly accepted that VR and ET are use-

ful with anxiety disorders, especially for disorders

such as zoophobia, aerophobia, acrophobia, among

others. However, psychologists who are specialized

in other disorders like eating disorders, ADHD and

OCD also believe VRET can be an alternative treat-

ment with success (Lindner et al., 2019). In the

case of OCD, VR is capable of provoking symptoms

such as anxiety in patients and compare the results to

healthy control. So, with the help of VR, therapists

can recognize OCD symptoms and diagnose this dis-

turb easier (Van Bennekom et al., 2021). Nowadays,

the main question is no longer if VRET is indeed as

effective as in-vivo ET, but how to engage the patient

to keep working on himself and not giving up for lack

of interest.

Since the concept of computer games has been

emerging as a powerful new economic, cultural, and

educational force (Botella et al., 2011), serious games

are also becoming more popular among people of all

ages.

Serious games, unlike traditional computer

games, are alternative educational, training, or ther-

apeutic tools that go beyond mere entertainment

(Lievense et al., 2021) and are an effective medium

for creating a non-threatening and engaging learn-

ing environment (Fitzgerald and Ratcliffe, 2020). It

has been proven that serious games can change be-

haviour (Botella et al., 2011) and reduce disorder-

related symptoms (Lau et al., 2017). It actively en-

gages the player and promotes change within a safe

virtual environment (Lievense et al., 2021), eliminat-

ing both the privacy issue and the out-of-control el-

ements that worried the therapists. Since it has an

entertaining form, the ethical conﬂict of provoking

fear in the patients is also toned down and is more

acceptable between professionals. This type of game

places its goal outside the game itself. According to

the self-determination theory, there are two types of

motivation that may inﬂuence the retention of a per-

son in one activity - extrinsic motivation and intrinsic

motivation (Lievense et al., 2021). From a gaming

perspective, extrinsic motivation leads to material re-

wards, or cheering messages for other players. For in-

stance, when the player receives ﬁctional coins to pur-

chase bonuses or elements in the game. On the other

side, intrinsic motivation is based on personal interest,

the ﬁnal reward is related to each individual (Fischer

et al., 2019). Serious games thrive on intrinsic mo-

tivation since the player must have personal goals to

succeed in the game. The different levels of the seri-

ous games are achieved with the acquisition of skills

or therapeutic progress (Botella et al., 2011). If the

players have a clear purpose and the goals and levels

of the game are clearly deﬁned, then the game is well

accepted, and the engagement is enhanced (Fitzgerald

and Ratcliffe, 2020). The use of serious games and

gamiﬁcation principles to promote treatment for men-

tal illness had high levels of feasibility and acceptabil-

ity among both users and providers (Fitzgerald and

Ratcliffe, 2020). The current problem is no longer the

effectiveness of VR and the application of exposure

therapy, but the user experience itself that can lead to

more positive or negative results (Tao et al., 2021).

The application of VR can follow quite different

approaches. Some aim to develop an application for

smartphones to be used at home without the presence

and/or without the consultation of a therapist. These

applications can sometimes be a serious game or a se-

lection of VR scenarios that the user needs to explore.

In this case, the progress achieved is measured by the

user or by the application itself. However, this can

make the situation worse by exposing the user to lev-

els of disturbing elements that he/she is not prepared

to face, thus incubating the fear even more.

The problem we perceived with the current home-

use application, is that it does not engage the user

to come home after a day of work to use it. This is

a big problem with exposure therapy, as it requires

constant exposure to the anxiety source to eventually

overcome the problem. Other commonly used ap-

proaches consist of the application of VR in-clinic

sessions with the constant presence of the therapist

that walks through all the stages with the patient, and

maintaining full control of the exposure level through

out the session.

1.1 Contributions of the Paper

This work presents the development of a immersive

application to promote learning and coping with anx-

iety, tuned for a speciﬁc clinical case. The ultimate

A Controlled Virtual Reality Exposure Therapy Application for Smartphones

295

goal is to facilitate the therapist work and help the

patient to reach a level of well-being by overcoming

constraining anxiety and/or phobias.

To this end, a serious game is proposed that allows

the user to have fun while learning how to manage his

anxiety in the presence of whatever triggers it. The

player levels up in the game as the therapeutic goals

are met and according to the therapist. This serious

game will aim at not only anxiety disorders but also

other disorders such as OCD and ADHD, making it

possible for the therapist to personalize it to the pa-

tient needs.

2 DESIGNING A FRIENDLY

SPACE FOR ET

The concept explored is the development of a serious

game to facilitate the application of ET for both the

patient and the therapist. The patient can comfortably

use the application at home by only needing a smart-

phone, and a VR headset for smartphones, such as

Google Cardboard.

The design of the VR environment can integrate

ET with different types of disorders elements. VR is

commonly associated with anxiety disorders. How-

ever, psychologists believe that VR can also help

other non-anxiety related disorders, and this serious

game aims to meet those expectations.

Due to its high popularity among all ages and

its versatility, the game ”Escape Room” is one ex-

ample of how this serious game can present itself.

The player needs to complete several tasks and gather

clues to escape the current room. By changing rou-

tines and adding new clues, the patient will be con-

stantly entertained and stimulated to maintain engage-

ment. It allows to prevent disinterest and conse-

quently keep the patient exposed, as if the patient

loses interest, the therapeutic progress will decrease.

However, as the concept of this game may, on itself,

trigger some disorders like claustrophobia, it can be

changed to other possible less anxiety-prone games

such as treasure hunting.

The escape-room scenario creates the perfect con-

text to contain multiple and different mini-games.

The disturbing elements are to be included in those,

allowing the patient to take a break between expo-

sures without leaving the VR environment and con-

sequently not losing any sense of presence. In the

case of arachnophobia, the anxiety disorder that will

serve as an example throughout the article has a pho-

bic element, the spider, so there are mini-games that

only show images of it, and others present themselves

with a virtual representation of the animal. Each mini-

game addresses a different anxiety level and has small

therapeutic goals. Since the patient must have a grad-

ual exposure to the phobic elements, with the mini-

games the patient can be exposed slowly from images

to videos to the actual virtual presence.

3 DESIGN AND

IMPLEMENTATION OF A

VIRTUAL COMFY SPACE FOR

The mobile application developed has to address

some complex issue in terms of displacement and in-

teraction within the game. As for the home usage, the

patient will use it in a cardboard conﬁguration, there-

fore no joysticks, gamepads, or other game controllers

should be considered. By consequence the only pos-

sibility is to use the head orientation itself to support

the interaction with the VR environment in its various

aspects, as will be discussed bellow.

This limited interaction form presented some chal-

lenges in the game’s development, such as playing

only moving the head and avoiding any fast move-

ments to prevent motion sickness. As reported by

(Anderson and Molloy, 2020), people who suffer

from mental health illnesses tend to be more prone

to cyber-sickness, so this was a subject that received

particular attention.

3.1 Interact with the VR Environment

To interact with the VR environment the patient can

search for speciﬁc points that will light up to let him

know that there is the possibility to interact with and

a small pointing sphere will change colour to the in-

verted colour of the object that it collides with. The

sphere simultaneously represents the point where the

player is looking at in the game, and is the interaction

element. In fact, its collision with the active elements

of the virtual world is exploited to enable the player to

select objects, move within the game space, or interact

with the mini-games. Whenever the sphere is placed

on top of an active element it immediately starts in-

ﬂating showing the interactive control, and activating

the element after a while.

Some places are important to the game ﬂow, such

as where a code can be inserted, or where the mini

games are playable. Because of this characteristic,

small blue moving circles are placed in those speciﬁc

locals to grab the attention of the player that it is im-

portant to move at some point to that location as can

be seen in Fig 1.

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296

Since interaction is limited, and motion sickness

is an issue, so travelling to different places in the

room consists of a fade-in, turning the screen slowly

black, and a fade-out in the correct position, turning

the screen slowly back to the initial state, maintain-

ing the rotation and the height the player was in. The

player can only move in the ground plane.

Figure 1: Teleport circle.

3.2 The Interaction with the

Mini-games

The serious game is sequential with an exposure lad-

der where some have a lower anxiety level and others

are more intense. In the higher difﬁculty, all imple-

mented anxiety sources are present. The game itself

also has some variations between plays, such as dif-

ferent images and random placement of the matches

in the case of a memory matching game card.

Since sometimes the patient can have more difﬁ-

culties in an exposure given by a speciﬁc mini-game,

the therapist can request the patient to play only that

mini-game without the need to play the full serious

game, and for that there is the possibility playing in-

dividual mini-games.

The interaction between each mini-game also

needed to be analysed to create a random yet sequen-

tial relation between them. Upon completing each

one, a digital code is provided to the player and acts

as a bridge between the mini-games. The codes are

presented differently, forming a ﬁnal colour code to

unlock the last door and ﬁnish the escape room (Fig

2). The mini games also present hints once ﬁnished

like where the code is or to where it is to be inserted.

For instance, as can be seen in Fig 4, once the drawer

is opened a line of sparkle particles ﬂow to the correct

keypad. If the code inserted is correct it will change

color to green, if not it changes color to red (Fig 3).

Figure 2: Color Code Keypad and Codes found.

The static mini-games such as memory card

matching and puzzles are played in a similar man-

ner. Spark particles appear where the player is staring

at and like moving, the interactive sphere increases

and when full the game develops. In the case of the

”ﬁnd the differences game”, the spark particles do not

show and the sphere does not increase unless it is to

press the hint button. However it is still necessary to

wait two seconds looking ate the same spot to play.

This happens to avoid giving the difference location

away. On more dynamic mini-games, like the maze,

the phobic element follows the interactive sphere and

the game is played by controlling its location.

A Controlled Virtual Reality Exposure Therapy Application for Smartphones

297

Figure 3: Correct and wrong color code inserted.

Figure 4: Hint after opening drawer.

4 BREAKING DOWN THE

EXPOSURE INTO MINI-GAMES

The mini-games serve to expose the patient to the dis-

order element. The time between each mini-game act

as a pause of exposure or even as a panic emergency

escape. The patient can leave the mini-game, take a

break wondering the virtual room and resume it when

calmer, preventing the break of the sense of presence.

The serious game starts with all the mini-games

hidden. When the patient inserts the codes onto the

keypad, the corresponding mini-game uncover itself.

Each one executes isolated, being coordinated by the

main script. This format enables the therapist to re-

quire the patient to play only one of the mini games

without it being necessary to play the escape room.

The chosen mini-games to develop in the concept

of ”Escape Room” and arachnophobia are:

• Memory Card Matching

• Find the Differences

• Slide Puzzle

• Rotating Puzzle

• Maze

In the ”Memory Card Matching” mini-game (Fig.

5), the user has constant contact with different im-

ages of its anxiety source. When playing, if the cards

turned do not make a pair, they turn themselves back.

As the game proceeds, the number of images exposed

increases, and the anxiety may make it harder to com-

plete. The mini-game leads to the necessity to memo-

rise a determined image’s position and details to cor-

respond with its duplicate. This mini-game also al-

lows the player to decide if he wants to see the inan-

imate disorder related element. In order to keep the

challenge level constant between game session, each

image position is randomized at the beginning of the

game. After completing all the matches, a code ap-

pears in the room. This code will lead to the next

mini-game.

Figure 5: Memory Matching Card Game.

The ”Find the Differences” mini-game (Fig. 6)

consists of two very similar images with slight differ-

ences between them which the user has to ﬁnd and

mark.

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298

The game starts hidden behind a closet. After

acquiring the code from the memory matching card

game, the player can insert it onto the keypad, and the

mini-game appears. To play, the user selects a posi-

tion on either the images. After waiting two seconds,

if it corresponds to a difference, a red doughnut will

target the spot as found. If not, then nothing happens.

If needed, a hint feature will help the player com-

plete the mini-game. The hint consists of the pho-

bic element moving towards the difference’s position.

Depending on the level of exposure, this element can

be the phobic element. In the case of arachnophobia, a

spider shows the patient where one of the differences

is. All the animated phobic elements show a neutral

white sphere if the patient is playing the lowest inten-

sity.

Figure 6: Find the Differences Game.

The maze (Fig. 7), according to the selected dis-

turb, may have different aspects. For instance, to

OCD, the lines are not straight, and some lights turn

on and off while passing on a speciﬁc part of the

path. For ADHD, distractions such as random blink-

ing lights or sounds can easily make it harder for the

patient to concentrate on the task. If it is arachnopho-

bia or other small animal-related phobias, the phobic

element follows the position of the user’s head, and

the goal is to lead the animal to the end of the maze

without it touching the walls. The maze path shuf-

ﬂes between predeﬁned paths. Along the maze there

are several platforms. The phobic element must touch

every platform or the ﬁnal color is not provided.

The last two mini-games are two different kinds of

puzzles: a rotating puzzle and a slide puzzle, but the

therapeutic goal is similar, making the patient gradu-

ally assemble the image related to the anxiety source.

Nine pieces of the same image constitute the rotating

puzzle, and the player needs to rotate each one, 90 de-

grees at a time, to build the ﬁnal image and complete

the mini-game. The slide puzzle consists of 8 pieces

of the same image and a blank spot of the same size

as the other parts of the image. The player must move

the pieces within the available space until the ﬁnal im-

age appears.

Figure 7: Maze Game.

5 THE THERAPIST ROLE ON A

CONNECTED APP

The presence of a therapist in this process is of high

importance. It does not need to be a constant pres-

ence, but one-off checkups. The progress made by

the patient needs to be analysed, and with those con-

clusions, the therapist decides which level of anxiety

intensity the patient plays at home. The therapist has

access to the patient progress by a data base. When

the patient logs in, a code provided by the therapist

is inserted and that data is saved and can be accessed

later by the therapist.

Figure 8: Login and game options.

A Controlled Virtual Reality Exposure Therapy Application for Smartphones

299

The patient must play at least once every session

for the therapist to evaluate the progress. The physio-

logical signals such as the heart rate and galvanic skin

response will also target that evaluation.

During the development of the presented work,

meetings with psychologists clariﬁed the patients

point of view and how to help and not overexpose

them to the anxiety source. The therapist must be

able to evaluate the situation step by step so the ex-

posure remains controlled. So, to facilitate and help

keep track of the patient progress, he has access to

the scores of each mini-game and the total time of

play of each patient. It is then possible to know how

many times throughout the time-off sessions the pa-

tient played and the difﬁculty they faced.

6 PRELIMINAR VALIDATION

6.1 Game / Usability Analysis

The game was tested by 10 individuals. At the end

of each test, the individuals ﬁlled a User Experi-

ence Questionnaire (UEQ), a Flow Short Scale Ques-

tionnaire and an open answer questionnaire to obtain

some information about the individuals.

The UEQ is frequently used to measure the user

experience with a certain product. It evaluates the

user experience in six different categories: attractive-

ness, perspicuity, efﬁciency, dependability, stimula-

tion and novelty. If a category is above 0.8 it has a

positive evaluation and above 1.5 is considered and

excellent result. The results are presented in ﬁgure

9. It presents the average classiﬁcation of each cat-

egory and its standard deviation. The attractiveness,

efﬁciency, stimulation and novelty categories were all

classiﬁed as excellent, although with a high standard

deviation due to the sample size. The perspicuity and

dependability had slightly lower scores with 1.225

and 1.375 respectively.

Perspicuity refers to how easy it is to get famil-

iar with the application and how easy it is to use it.

The application is a virtual reality serious game and

in the open answer questionnaire most of the individ-

uals lack of experience with VR so, being an VR ”Es-

cape Room” game it was expected some difﬁculties

in interacting with the environment at ﬁrst try. De-

pendability refers to how in control of the interaction

the user feels. The serious game is a compilation of

puzzles and codes, so the fact that some individuals

felt they did not had control of the situation is not far

from the reality.

The Flow Short Scale Questionnaire evaluates

three aspects of the application on a scale of 1 to 7:

Figure 9: UEQ Questionnaire Results.

ﬂow, anxiety level and challenge level. Flow level in-

dicates if the user is feeling engaged while playing the

game and if he feels like the activity is intrinsically in-

teresting and takes pleasure and enjoyment while in-

volved with it. Anxiety level translates to how much

anxiety the users felt while playing the game and chal-

lenge level to how challenging it was with 1 being too

easy and 7 too hard.

The results with the average and standard devia-

tion of each category are presented in table 1. The

challenge level was considered to be close to perfect

(with 4 being a perfectly adequate challenge level).

The anxiety level was not high but it presented a rel-

atively high standard deviation. In the open answer

questionnaire three individuals said to have anxiety

problems such as anticipation anxiety. This may ex-

plain why such high standard deviation. A ﬂow level

of 5.04 indicates the users mostly enjoyed playing the

game but some aspects could be improved such as

adding descriptions of how the mini games are played

and maybe a scene without any game to allow the user

to get to know the VR environment.

Table 1: Flow Short Scale Questionnaire Results.

Average Stardard Deviation

Flow 5.04 0.527

Anxiety 3.867 1.124

Challenge 3.9 0.568

7 CONCLUSION

Exposure therapy is one of the best behavioural ther-

apy techniques as it allows the user to explore the dis-

order in a safe and controlled way. This paper we pre-

sented a serious game for that purpose, that explores

VR to expand the range of disorders that the treatment

can reach and allow the patients to train at home and

expose themselves to the anxiety source according to

their therapist recommendations.

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300

This type of application can be the starting point

for many people to learn how to manage their anxi-

ety and live life in a much better state of mind. As

the chosen game design can be so multifaceted, the

opportunities are endless. Not only can different dis-

orders like arachnophobia, PTS, OCD and ADHD be

improved, but the therapist can adequate the game to

each patient depending on the presented disorders and

the best anxiety intensity levels for each one.

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