Chapter XIII Fear of Flying and Virtual Environments: An Introductory Review

Transcription

1 221 Chapter XIII Fear of Flying and Virtual Environments: An Introductory Review Giovanni Vincenti Gruppo Vincenti S.r.l., Italy Abstract Fear of flying is a common problem that many people have to face. As varied as the causes may be, all kinds of fears have many aspects in common. Much is known to us about fear, and the fields of psychology and psychiatry teach us that many times we can conquer fears simply by exposing the subject to the dreaded object. Human-Computer Interaction has branched even in this direction, including the treatment of phobias. With the help of Virtual Reality researchers around the world have recreated using a computer the way that psychologists and psychiatrists cure fears, adding a twist. Many times patients are supposed to go the extra mile and expose themselves, little by little, to what they are afraid of. Virtual Reality brings this type of exposure directly to the patient, with the comfort that such fear can be stopped at any time, since it is only a computer simulation. The most successful studies have been performed on arachnophobia, or the fear of spiders. There are also studies that deal with the fear of heights and the fear of public speaking. Some studies have also been performed on addressing the fear of flying using a virtual environment. This work is a review of such methods, and an explanation of the principles behind the motivation for these studies. Copyright 2009, IGI Global, distributing in print or electronic forms without written permission of IGI Global is prohibited.

2 Introduction Computers play a significant role in most aspects of our lives nowadays. We use computers when we drive to work, they help us perform our jobs better and more accurately, and sometimes they even help us fall in love by letting us talk to old friends and make new ones through chat programs. Some people share their whole lives on a computer, recording nearly every move they make on a web log, an on-line diary (Wijnia, 2005). As this invention takes more of a dominant part in our lives, we adapt more and more to having this powerful tool around. Especially, children are growing up using computers as their teachers, playgrounds and friends (Subrahmanyam et al., 2000). The same computers help our lives not only in health, but also when we are sick. Computers help hospitals keep track of patients, but they are also used as a diagnostic tool, allowing doctors to reach conclusions on tough cases or request the help of colleagues located on the other side of the world (Shortliffe et al., 2001). In these cases, computers serve as passive tools that increase the quality of work. Human-Computer Interaction The field of Human-Computer Interaction (HCI) is a rather new addition to the world of computer science. The potential that HCI has is great, when we explore in a bit more detail all the applications and repercussions that these concepts bring to the world of computing (Shneiderman, 1998). The branch of HCI that deals with Direct Manipulation and Virtual Environments, as discussed in Shneiderman (1998), is most relevant to this discussion. Virtual Environments (VE) and Virtual Reality (VR) are closely tied with informatics applied to the fields of medicine and psychology. Hodges et al. (2001) report that some of the applications of VR that are more widely used are the ones that interact with humans cognitive and physical (manipulation) aspects, besides its application to entertainment. If we apply these concepts to medical informatics, the role of computers towards patients becomes more active. Hodges et al. (2001) explore the application of VR to curing psychological and physical disorders, such as fears. This team of researchers applied concepts of HCI to the treatment of patients who suffer of many types of phobias, such as fear of height, or acrophobia, fear of spiders, or arachnophobia, and fear of public speaking. In this chapter we will explore a few, but we will concentrate especially on the fear of flying. Virtual Reality and Virtual Environments Anyone who has created a program to supply the demands of a customer knows about scope creep. When the project starts, the future users usually list an endless sequence of features they would like to see included in their new work tool. As they test the application, they say that it would be nice if this program could also do this or if it could do that. Scope creep does not only mean that users are asking for more, it also means that programmers will have to provide greater functionality. This very concept is the driving motor that pushed developers to create programs that users could not only observe, but could interact with at multiple levels. Although the distinction between VR and VE is not well agreed-upon, most resources seem to point to the idea that VR is the field that addresses the creation of VEs that make users believe they are immersed in real environments. Shneiderman (1998) introduces the concepts of VR and VE using an example that is extremely effective. As a team of people start the creation of a building, the people who are commissioning such work will get a good idea of what things will look like from the sketches and diagrams. Should the same drawings be reproduced on a computer screen, 222

3 they will get a much more vivid representation of what is going to be built. An even more realistic representation would come from substituting a projector to the computer monitor. Such projector would display the image of the new building onto a wall, giving to the observers a much more impressive display. The next step is the creation of controls that allows the commissioners to zoom in, move the point of view around the building, and perhaps even change the height of the observation point. This level of exploration is not that far from connecting the controls to a treadmill, where observers can actually walk around the scene, which is now projected through a head-mounted display, instead of a projector. What the commissioners are now experiencing is a virtual environment. Looking at vs Being in Many fields and applications are sufficiently satisfied by letting users look at something, as explained in Shneiderman (1998), but some may benefit greatly from allowing them to be in the situation that they would otherwise have to imagine. Some of the most common simulators replicate the behaviors of airplanes (Shneiderman, 1998). These simulations are built using the same components that are also used to build the real airplanes, giving them a realistic feel. The pilots are exposed to scenarios from all around the world, thanks to high quality displays that replace the windows. They are also given a sense of motion through elaborate hydraulic systems. The cost of such simulators can be quite high, but their value is far greater than anything else (Shneiderman, 1998). A pilot can train for any type of occurrence using one of these simulators, while staying safe within a confined environment. These pilots can fail certain maneuvers over and over, until they finally understand the dynamics of the situation. They will not have destroyed any planes, but, more importantly, they will be alive and they will walk away from the simulator with the knowledge of what to do in those emergencies. A Recipe for Success In order to create a successful VE, Shneiderman (1998) says that it is important to integrate multiple technologies. These technologies include visual displays, head-position and hand-position sensing devices, force feedback, sound input and output, if possible, the recreation of other sensations, and finally the use of cooperative and competitive VR. All these aspects enhance the realism that the VE brings to the users, submerging their senses even deeper. What is Fear As we will see shortly, such immersion of the senses is necessary to bring healing to the person who has a hard time at dealing with phobic episodes. Before we get any deeper into the adaptation of VR to clinical purposes, we should review briefly the beast that we are trying to eradicate. Fear is a debilitating factor that many people have to confront over and over, sometimes on a daily basis. Whatever the fear may be, the person who is victim to this dormant enemy can be truly impaired from functioning properly. For this reason, fears need to be addressed to their core. Taking care of the symptoms may not be enough. Fear belongs to the group of Obsessive-Compulsive Disorders (OCD), as described in Jenike (2001). Even though fear is well documented in the reactions that the body encompasses, there is no one source where all fears come from (Jenike, 2001). We can distinguish between two categories of reactions (Richmond, 2005). The first deals with the body, and a person may show any of the fol- 223

4 lowing symptoms: muscle tension, tremors, heavy breathing, heart palpitations, sweating, weakness and dizziness among the most common (Richmond, 2005). The second category of reactions deals with psychological responses. The symptoms that accompany a fear attack are: impaired memory, narrowed perceptions, poor judgment, negative expectancies and perseverative thinking (Richmond, 2005). In this particular work we will observe the fear of flying a bit more closely, but all fears have these common symptoms. One Output from Many Inputs Every fear addresses multiple weak points of the person that may lead to the reactions that we just presented. Fear of flying, for example, can be triggered by a single factor, or a combination of multiple reasons. Usually fear of flying can be associated with any of these problems: fear of heights, enclosed spaces, crowded conditions, not feeling in control, being in a machine which functions in ways that the subject ignores (Richmond, 2005). Exposure Therapy The most common remedy for all types of fear is well agreed upon, and that is exposure therapy (Jenike, 2001; Richmond, 2005; Hodges et al., 2001). Such exposure can be sudden, but in most cases, when the treatment to a phobia is coordinated by a specialist, it is administered in increasing doses. Curing fear of flying usually starts from meetings with a psychologist to learn how to deal with anxiety, and then slowly the person is introduced to the object of fear (Hodges et al., 2001). The first exposures may be limited to just a trip to the airport, seeing and hearing planes take off and land, eventually the patient will then be able to enter a stationary airplane. The most effective part of the cure would be a flight after such slow habituation to this feared environment (Hodges et al., 2001). Exposure is then the silver bullet that may destroy fears. But can a computer really replace the exposure to the real thing, the object, or the situation, that is feared? We will explore some well-known phobias, and the changes that can be seen in a person after they take part in sessions where they were treated using computers. Virtual Environments Applied to Clinical Settings As the power of computers increases and people ask that programs do more and more, the market now has a wide variety of applications that perform every function imaginable and some that can t even be imagined possible. Medicine is one of the fields that benefit the most from these technological advancements. The field of medical informatics is deeply involved with the field of computer science to bring to doctors and patients the best possible applications. Many times doctors and patients turn to a computer screen to compromise between the highly technical jargon that every caregiver is used to and the poor medical vocabulary that the average person possesses. As the doctor explains the images that both see, the patient may feel relieved by understanding better the matters discussed. Computers as Passive or Active Tools The visualization aspect of medical informatics is just one side of a diamond that is extremely multifaceted. Szekely and Satava (1999) give a brief introduction to the role that VR has come to play in daily practices in hospitals around the world. VR has dramatically changed the way many doctors prepare for surgery. Surgeons used to review anatomy books and operating procedures before VR took over with tools that allow the user to walk through a complete surgery. Such tools are not used only to perform preparations for surgeries, 224

5 Fear of Flying and Virtual Environments but they are also used by students as a learning ground for anatomical, physiological and pathological notions. Diagnosis is, of course, another aspect of medicine that benefits greatly from these advancements (Shortliffe et al., 2001). The uses that Szekely and Satava (1999) list in their article are primarily passive uses, the computer serves as a tool, and not as an active element of a therapy. This is where VR shows all its strengths. Hodges et al. (2001) describe three applications that were deeply affected by VR. These three clinical applications are the treatment of anxiety disorders, such as phobias, pain distraction and ankle rehabilitation. We will explore in depth only the first application. Defining Metrics Conducting a scientific experiment to find a clear physiological correlation between the pre-exposure and the post-exposure anxiety conditions of a patient who undergoes exposure therapy is hard, as Hellstrom and Ost (1996) report. Their study investigated the physiological changes that a subject experiences before coming into contact with the object feared. They were monitoring the diastolic blood pressure of the subject before exposure to VR treatment and then they compared it with the post-exposure reading. The subjects analyzed were tested for a variety of fears, as to establish a common denominator that could be used as a baseline for further studies. There were four tests in this experiment, two related to phobia of spiders, one related to blood phobia, and the fourth related to phobia of needles. The results were inconclusive about the hypothesis that diastolic blood pressure can be used as a metric when analyzing the effect of VR exposure treatment. For this reason, the majority of researchers base their findings on subjective reports coming from the patient, or the observation of the modification of the person s behavior when facing the feared object. The First Experiments The mid to late 90s are the years that are most prolific for studies on VR applied to the treatment of phobias. We can see through the work of various groups that this alternate approach to exposure therapy is actually worthy of notice. The first study, a classic that is mentioned in various sources, is the work of Hodges et al. (1995) that worked on acrophobia, or the fear of heights. Participants were exposed to virtual footbridges, balconies and glass elevators. Results from this experiment laid the ground for what was coming next. The researchers were actually able to note that the changes made in the participants were not just an effect of short-term habituation, but it changed how they felt about heights perhaps permanently. Seven out of 10 subjects exposed themselves to what was the dreaded situation in real-life, without being prompted to do so (Hodges et al., 1995). A second publication that is worthy of notice is the one that reports the case study on a single subject about the treatment of claustrophobia, or the fear of enclosed spaces (Botella et al., 1998). In this work, the patient was exposed to a graded exposure method by means of a VE. At every step the perception of the VE was getting smaller around the subject. The patient was originally scheduled to receive only six exposures. After the final exposure, she had to undergo a medical test unrelated to the study that placed her in a small enclosed environment. She reported a little stress, but overall she was extremely satisfied with the outcome. At that point, the researchers decided to administer two more exposure sessions to achieve overlearning (Botella et al., 1998). Attacking Arachnophobia at Multiple Levels An extremely successful study was conducted by Hoffman et al. (2003). As we stated earlier, 225

6 Shneiderman (1998) says that an effective VE must include simulations of several aspects of an environment. Most studies only report of exposing the person to a VE with a head-mounted display and perhaps with sound. This takes care of only two of the senses. Hoffman et al. (2003) take this matter further and decide to simulate tactile cues. They investigated different exposure therapies where subjects were exposed to no treatment, subjects were exposed to a standard VE (without tactile cues) and finally subjects exposed to VE and tactile cues. This study concluded that both VE exposure therapies are more effective than no therapy, showing that their VE is suitable for exposure therapy. Moreover, they linked a higher decrease in the symptoms of phobia displayed by the subjects that received exposure therapy with tactile cues (Hoffman et al, 2003). Post-Traumatic Stress Disorders Fear does not come only from an object or a situation, but also from memories, as explained in Foa and Kozak (1986). Such phobias can be classified under the name of Post-Traumatic Stress Disorders (PTSD). Consequently, studies were conducted to investigate if VE approaches to exposure therapy can help in the habituation of a person to memories of a harmful situation. Especially two teams of researchers stress such aspect. Weiss et al. (1992) led a study on patients with PTSD from the Vietnam War. This study does not show VE as an effective exposure therapy for curing PTSD in post-war patients, but it is reported that this tool is a very effective one when a psychologist is walking the subject through memories. The second team of researchers investigated the usefulness of VE for exposure therapy in a PTSD patient after a terroristic attack, the attack to the Twin Towers on September 11th, 2001 (Difede and Hoffman, 2002). The subject already sought help with traditional image exposure therapy, but this approach was ineffective. Difede and Hoffman (2002) created a VE where the patient was exposed to planes flying over the towers, planes crashing, sounds imitating explosions, and the images of people falling from the windows. Such exposure therapy was reported by the subject to be effective. As specified by the researchers, this report analyzes only one subject and it should not be generalized. The outcome though seems promising for a larger scale testing. Fear of Flying and Virtual Environments So far we have analyzed many aspects that relate to the field of HCI: psychology, physiology and perhaps even medicine. We have explored what VR is with Shneiderman s work (1998). We have also explored a bit what fear is, and some of the responses that we get from being afraid of something (Jenike, 2001). We have merged the fields of HCI and cognitive psychology by reviewing some work that was done in this direction (Hellstrom and Ost, 1996, Hodges et al, 1995, Botella et al., 1998, Hoffman et al., 2003, Weiss et al., 1992, Difede and Hoffman, 2002). We can now focus on the analysis of the fear of flying. Quantifying the Fear of Flying Hodges et al. (1996a) say that, as an estimate, 10 to 25 percent of the population suffers from a fear of flying. Moreover, they report of a survey that was conducted by the Boeing Airplane Company that affirms that 25 million adults in the United States are fearful about flying (Hodges et al., 1996a). It was not specified if any of these people do fly, it was clearly stated though that 20 percent of those who do fly depend on alcohol or sedatives during flight to mitigate the symptoms of their phobia (Hodges et al., 1996a). In this article the authors cite the work of Roberts (1989), which affirms that in 1989 the airline industry had an 226

7 Fear of Flying and Virtual Environments estimated annual revenue loss of $1.6 billion dollars because of people s fear of flying. Although more recent estimates are not available, Osborne (2001) speculates about the cost of a higher fear of flying after the episodes of September 11th, Steps to Recovery (That Become Obstacles) Just like every other phobia we have analyzed so far, exposure is one of the best ways to break down the physical and psychological responses. Hodges et al. (1996a) outline the steps to recovery: therapists, sessions that describe accurately the functioning of a plane, and an actual plane for exposure therapy. They also outline some of the reasons why people do not want to go through a program that would help them. Therapists take time, and meeting a therapist may be expensive. Most people won t push themselves to do something unless they really have to, and the fear of being on an airplane keeps them from flying, but also from seeking help. They also feel that they put themselves at risk. There are also expenses associated with the final stages of the exposure therapy, which will, most likely, involve a round trip flight. Fear of Flying: A Case Study For these many reasons, Hodges et al. (1996b) proposed the solution of using VR to manage some of the issues that may lead people to desist from taking action against their fears. In their article they write about the VE that they developed, and that they feel would replace in vivo (in real life) exposure therapy. They created a VE that matched the scale of a real Boeing 747 airplane. They modeled the interior of the cabin as well as the outside of the airplane because the key to a stationary simulator is making the person feel as if they were inside the real environment. In order to fully do so, the investigators also created all the items that a person would see through the window, such as runways, airports and clouds. Figure 1. State diagram (Hodges et al., 1996b) 227

8 Figure 1 shows the state diagram representing an airplane. Such diagram outlines the possibilities that were explored during the simulation within Hodges et al. (1996b). The subject was not only exposed to a head-mounted display, but sound was also accompanying the experience. The subject was exposed to this therapy for six sessions. Each time the simulation was composed of a different series of events, based on the state diagram in Figure 1. The researchers were trying to recreate an environment that would be as similar to the real environment as possible. As there is no metric that assesses such gap, they were not able to verify this aspect. Upon completing the six exposures, the subject was then able to complete a round trip flight on a real airplane. The subject reported that she was much less afraid after VR exposure therapy. She took questionnaires that classified her fears on a scale from 1 to 10, where a 1 indicates calm when flying and 10 indicated a debilitating effect of the phobia. Before exposure her score was 8, and after the treatment her level lowered to 4. Clinically, her tests showed a great improvement as well. She said that she still felt some of the physical and psychological symptoms of fear, but she just had to think of the simulation, and then she would calm down. She even reported of being able to stay calm during 10 minutes of turbulence (Hodges et al., 1996b). Fear of Flying: An Experiment Given this promising start, Rothbaum et al. (2000) used a similar setup to recreate a VE that would be used to treat more subjects. In this case, the researchers were able to work with 45 people. The participants were divided among three groups of fifteen each. The first group, the control group, was given the Wait List treatment, where they were exposed to an airport, and sight and sound of flying planes, but they did not get exposed to a real flight. The second group was given exposure to a real airplane and real flights. Finally, the third group was given the VE exposure treatment. All groups were to undergo an 8-session procedure. The first four sessions were the same for everyone, and it consisted of counseling sessions with a therapist. Then each of the groups took their own route. The results this time left no doubt in the matter of VE exposure accommodating only one person s fears, or if it would also help others. Rothbaum et al. (2000) write: In this controlled trial comparing [VR exposure] therapy, [in-vivo exposure] therapy, and a [wait-list] control for treatment of FOF, VRE and SE were shown to be equally effective both in decreases in symptoms as measured by standardized questionnaires and by the number of participants to actually fly on a real airplane following treatment. Moreover, they report that [anxiety] ratings during the actual flight indicated that [VR exposure]-treated patients were as comfortable as [in-vivo exposure]-treated patients (Rothbaum et al., 2000). These results are in line with the hypothesis that was proposed by this team of researchers and many others before them. Lasting Effects? Rothbaum et al. (2000) did not stop at a post-exposure assessment. They wanted to ensure that the effects of this method were not only to be attributed to a temporary habituation of the person to the idea of flight, but were persistent changes that would stay with them. For this reason, they did not conclude their first experiment until six months after the eight sessions were over. In assessing the response that the participants had to the treatment, they found that the gains observed were maintained at the six month follow-up (Rothbaum et al., 2000). In addition to this first follow-up, Rothbaum et al. (2002) also performed a second follow-up 228

9 Fear of Flying and Virtual Environments with the participants that were assigned to the VR exposure group as well as the ones assigned to the standard exposure. Although the researchers were not able to get in touch with everyone, they were able to base their observations on 24 people. As a further affirmation that this method does have lasting effects, it was reported that 92% of VR exposed participants and 91% of standard exposure participants had flown on a plane since the end of the sessions described in Rothbaum et al. (2000). These findings show that not only VR exposure is as effective as standard exposure therapy in the short term, but they also have lasting effects. Conclusion The world of Virtual Reality is a branch of computer science, and especially Human-Computer Interaction, that is undergoing constant development and improvement. Applications range from simple interfaces that allow children to play games more interactively to curing fears that a person may have carried within for years. We explored many different phobias and their treatments, both with in-vivo exposure and exposure by means of a virtual environment. We put special emphasis on the cure of fear of flying, reviewing not only a case study that seemed promising, but also a full experiment with three groups of subjects. The outcomes of these experiments were very clear when we compare the effects of exposure to a virtual environment with those of a standard exposure therapy. Moreover, the fact that a virtual reality exposure has lasting effects comparable to the ones of standard exposure therapy suggest that this approach leverages on the same inputs that make the in-vivo exposure so successful, leaving us with a cheaper and safer alternative for curing phobias. References Botella, C., Banos, R., Perpina, C., Villa, H., Alcaniz, M. & Rey, A. (1998). Virtual Reality Treatment of Claustrophobia: a Case Report. Behaviour Research and Therapy, 36(2), Difede J. & Hoffman, H. (2002). Virtual Reality Exposure Therapy for World Trade Center Post-traumatic Stress Disorder: A Case Report. CyberPsychology and Behavior, 5(6), Foa, E. & Kozak, M. (1986). Emotional Processing of Fear: Exposure to Corrective Information. Psychological Bulletin, 99(1), Hellstrom, K. & Ost, L. (1996). Prediction of Outcome in the Treatment of Specific Phobia. A Cross-Validation Study. Behaviour Research and Therapy, 34(5), Hodges, L., Kooper, R., Meyer, T., Rothbaum, B., Opdyke, D., degraaff, J., Williford, J. & North, M. (1995). Virtual Environments for Treating the Fear of Heights. IEEE Computer, 28(7), Hodges, L., Watson, B., Kessler, G., Rothbaum, B. & Opdyke, D. (1996a). Virtually Conquering Fear of Flying. IEEE Computer Graphics and Applications, 16 (6), Hodges, L., Rothbaum, B., Watson, B., Kessler, G. & Opdyke, D. (1996b). A Virtual Airplane for Fear of Flying Therapy. Proc. VRAIS 96, IEEE Virtual Reality Annual Symposium, Hodges, L., Anderson, P, Burdea, G., Hoffman, H. & Rothbaum, B. (2001). Treating Psychological and Physical Disorders with VR. IEEE Computer Graphics and Applications, 21(6), Hoffman, H., Garcia-Palacios, A., Carlin, A., Furness III, T. & Botella-Arbona, C. (2003). Interfaces that Heal: Coupling Real and Virtual Objects to Treat Spider Phobia. International Journal of Human-Computer Interaction, 16(2),

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