Specific phobias are incredibly common. According to estimates, around 3‒15% of people will develop one in their lifetime, the majority of whom won’t seek treatment. Phobias can manifest around a huge number of stimuli, such as lightning, dentists, and — most commonly — animals such as spiders.
Although exposure therapy is well established and is very effective at reducing fear and anxiety in those with specific phobias, not many end up accessing treatment. Unsurprisingly, the certainty of being exposed to terrifying things doesn’t entice many people. Even those who do make it into a therapeutic setting are also quite likely to drop out due to the extreme fear caused by these controlled exposures.
However, modern technology may help us to sidestep these issues entirely. Anja Zimmer and team at the University of Basel and Saarland University believe that the solution may lie in augmented reality.
Though exposure therapy using virtual reality (VR) technology has been shown by several studies over the last decade to be effective and well tolerated, its rollout has been somewhat underwhelming. Practically speaking, many clinicians cite concerns about motion sickness, costs, or trouble using the hardware. This means that, although VR headsets are now relatively accessible, only the minority of clinicians have chosen to offer this approach as an option.
Augmented reality (AR) is a close relative of VR. Instead of donning a bulky headset, users are able to open their phone cameras and view on-screen virtual objects overlaid on their surroundings in real time. Not only is programming AR experiences much less time intensive (and therefore more cost effective) than doing so in VR, but users are also able to see their own bodies through the camera lens, creating a greater level of engagement with the virtual objects.
These qualities make it a potentially good choice for a new method of delivering exposure therapy. So, in order to test the efficacy of exposure therapy administered via AR, the team designed Phobys, a smartphone based AR app designed to reduce fear of spiders.
Over the course of six 30-minute sessions administered within two weeks, users are able to work through nine short levels of virtual spider exposure. These involve tasks such as looking at the virtual spider, approaching and “collecting” them (like in a video game), superimposing spiders onto their hand, and even walking through groups of spiders. After each level, users give a rating of how fearful and disgusted they felt on a scale of 0 to 10; once a rating of 4 is achieved, they can advance to the next level. Perhaps most endearingly, if users get close enough to a spider in the ninth and final level, a kiss sound is triggered and hearts float across the screen. Gamification elements such as this are widely recognised to improve uptake, and are used throughout the levels.
In this study, published in the Journal of Anxiety Disorders, 33 participants (18 diagnosed with arachnophobia) used the Phobys app as recommended. Before and after using the app, they provided responses to several measures of fear: subjective fear ratings when approaching a real spider (a Behavioural Approach Test), the Fear of Spiders Questionnaire (FSQ), and the Spider Phobia Beliefs Questionnaire (SBQ), as well as a measure of disgust. They were also asked to rate how much they felt that their fears had reduced, post-intervention. A further 33 (17 diagnosed with arachnophobia) participants received no intervention, in order to provide control data.
Analyses of these measures revealed that use of Phobys led to significantly lower subjective levels of fear when approaching real spiders, when compared to controls. Those who had used the AR app were also able to progress further in a Behavioural Approach Test with spiders than those who had received no intervention. The story was similar across all measures — app users subjectively felt less disgusted, scored lower on the FSQ and SBQ, and estimated higher levels of fear reduction than those assigned to the control group.
Since this intervention was completed at home, there were varying levels of uptake. The majority of participants did more than one session (lasting 30 minutes), though some used it for upwards of two hours. Data analysis showed that after an average of only 90 minutes of training with the app, clinically significant improvements in fear were seen — however, the authors note that due to the design of this study, they can’t rule out a contribution from placebo to this effect. That is, users might have expected an improvement from using the app, so they got a short-term boost from using it that’s not necessarily reflective of long-term fear reduction.
Improvements in fear and disgust were seen regardless of whether or not participants crossed the DSM-5 threshold for a specific phobia, meaning that an AR approach may be suitable for all levels of spider fear requiring exposure therapy. Whether AR exposure will work for other types of specific phobia, though, is still somewhat unclear. For example, while spiders can neatly and convincingly be superimposed into environments, larger animals, or even more elaborate experiences such as dental visits, may be tricky to condense into such a small and neat format. Further explorations of whether users are more comfortable with fear stimuli in the long term are also needed. Even so, this study indicates new and highly accessible avenues for exposure therapy.
Emma L. Barratt (@E_Barratt) is a staff writer at BPS Research Digest