The goal of this project is to design an exposure therapy experience through the use of virtual reality as part of a remote treatment service. By investigating ways to implement the interaction between the patient and the therapist in the VR environment, the focus is to maximize the learning outcome of the exposure. In the VR experience, the aim is not only to recreate experiences introduced in the real world, but also to reach beyond the limitations of reality.

“Fear reduction within exposure therapy is an index of performance but not of learning and long term outcome”

— Michele Craske

Problem definition

Phobias, such as agoraphobia and acrophobia, are anxiety disorders. Phobias impose the patient to overreact compared to the scale of a threat in a situation. Their symptoms involve rapid heartbeat, a distorted perception of time, trembling and increased prespiration. Common ways to treat patients with certain phobias are psychotherapy, medication and cognitive behavioral therapy. Additionally, exposure therapy is used in many cases, when the conditions of the phobia can be reproduced. This method involves the gradual change of the individual’s perception of the potential danger ahead and trains the patient to react in a certain pattern to overcome the fear. However, in many cases, the fear returns after a certain period of time. Therefore a number of strategies supplied to the patients through long term treatment seems to be beneficial for the learning outcome of exposure therapy.

Since 1994, virtual reality has been used as a medium to provide exposure therapy. There are a few services that provide the technology and equipment to therapists, to treat patients at their clinical space. Today, with the use of VR on smartphones patients can be treated remotely, as the cost and performance of the equipment makes exposure therapy more accessible. The rise of tele-therapy and patient support programs confirms that a service for remote treatment of phobias would work. The focus of this thesis was how to create the appropriate conditions in remote therapy, to maximize the effect of exposure therapy remotely.

Problem statement

User Research

In total I met with five individuals, in semi- structured interviews, to understand the perspective of the phobic individual. Four of them had arachnophobia, one had ornithophobia and one had a more ‘poetic’ form of monophobia. This led me to choose aracnophobia as the topic I wanted to approach. Three of the interviewees were open to participate in follow up testing and be exposed to feared cues. Through the interviews, I gathered information about the manifestation of their phobia, the fear cues and their current defend mechanisms.

The people I interviewed were all on a different level of arachnophobia. This means that their level of tolerance with the object of fear differed. This allowed me to direct the focus of the interviews based on their concerns and identify three categories of users. The ‘target’, the ‘advanced’ and the ‘cured’ user.
I later held a workshop with all the phobic individuals, a number of designers, one of which is familiar with virtual reality, to include the perspective of the technical expert.
I asked them about their expectations of the service and to visualize potential moments where remote treatment with exposure can fail.
I captured their preferences towards the therapist and how to establish trust between them. They agreed that they were seeking for a professional friend, someone who cares and listens with genuine interest.
Additionally, they wanted to be reminded of their past achievements, to gain motivation and stay engaged.

Experience Principles

Through desk research and speaking to experts in clinical psychology and exposure treatment, I gathered the benefits and challenges of my project scope. In an approach to solve the biggest challenge in the treatment of phobias, the return of fear, I created a number of Experience Principles. These derive from a lecture of Michelle Craske (Ph.D.,Professor of Psychology, Psychiatry and Biobehavioral Sciences and Director of the Anxiety and Depression Research Center in UCLA) at Karolinska University in 2014. Her lecture was about exposure strategies, to maximize the outcome of treatment and create a long-lasting effect. Combining the learnings from her lecture with what I read in the literature available regarding exposure therapy, remote treatment and virtual reality, the Experience Principles led the process and experience design.


I created low fidelity prototypes with a low level of challenge. This would help the users stay emotionally stable and give feedback on everything that is not a fear cue. Following one of my target user’s experience in her exposure treatment, I recreated a number of scenes that borrow the same principles of exposure progress.

I tested the prototypes on a Daydream headset with the three individuals with arachnophobia. Every session was recorded and lasted a bit over an hour. Accessing the prototypes though the Daydream gallery made the experience easy to navigate. The prototypes that were shown were selected based on the responses of the users. There was no introduction to the content or instructions further than the ones the Daydream demo provides. The goal was to capture their reactions to the experience as if that was the real exposure session.

A ‘short’ compilation of my prototypes that you can watch with VR glasses (e.g. a Google Cardboard). This compilation shows how the therapist’s intervention can be implemented during exposure.

Footage from a 360 camera was used for the prototypes

I created interactions in Unity to explore how different elements affect the experience.

Prototyping objectives

Development Process

Based on the principles, I created scenarios of virtual stages, appropriate for different levels of exposure. Starting from a less challenging setting, where the user has a more passive role, the stages gradually become more challenging. The interactions between the user and the virtual reality environment change and the user is immersed in more surprising encounters with the fear cues. Through VR, the transition from one stage to the other happens effortlessly. Depending on the level of challenge required, the technology enables the therapist to customize the next exposure session and encourage patients to step out of their comfort zone in a safe and controlled setting. Similarly, the therapist’s presence in the VR environment becomes more saturated when the level of challenge increases.

Three experience stages that describe the overtime progression of the treatment

I started to work in Unity, by importing a scene from the Asset store. In order to build for mobile devices, I had to make the scene lighter in size. I combined meshes and ‘baked’ the lights before exporting. However, the VR application was still lagging. I started working on a new terrain and used the tools imported with the scene, in an attempt to create a new, lighter version. The process was time-consuming and a bit too technical for what I wanted to achieve. For that reason, I decided to do some explorations in Google Tilt Brush, a sketching tool for VR devices. During my ideation process, I discovered three distinct areas, where the user has different behaviors and interactions with the environment. They can all be used at different levels of the treatment. Later, I mapped all the suggested stages with the Experience Principles, to push the concepts further and achieve the optimal exposure experience.

Starting to work with a scene in Unity felt too technical and inappropriate for ideation purposes.

I sketched in Tilt Brush to explore potential stages for VR experiences.

Rocky Land
The Hike
Great desert
Three stages came up from the explorations in Tilt Brush. They are suitable for different levels of the treatment, with ‘Great Desert’ being the very last experience for the patient. Additional documentation provides evidence on how all conceived stages are guided by the Experience Priniciples.

Experience Journey

Designing a service to improve mental health requires an understanding of the overall customer experience. For this purpose I created an experience map, that describes the phases of engagement with the service, the service interactions and the touchpoints. This map should be read as an element of ideation rather than a blueprint. Together with a high-level user journey, it helped me map out the scope of the project and understand how I can apply the experience principles.

Service artefacts

The homepage provides an assessment for first time users

Column two

Resources and Progress Report are also accessible on the mobile phone

The website and the mobile application are points of interaction through the experience. They provide access to the patient’s profile, progress report and resources. The application is the portal of communication with the therapist and the virtual experience, both for real-time treatment and home assignments with pre-recorded support and instructions.

A preview of my demo as a starting point. The app still needs to be optimized for the mobile, so it might appear slow. If you choose to watch it on your phone, keep in mind that the quality also depends on the phone’s screen definition.