Isr J Psychiatry Relat Sci Vol 44 No.

1 (2007) 2932

Virtual-Reality-Assisted Treatment of Flight Phobia

Helene S. Wallach, PhD,1,2 and Margalit Bar-Zvi, MD3
1

Tsfat College, Tsfat, Israel

Department of Behavioral Studies, Emek Yezreel College, Emek Yezreel, Israel
3 Psychiatric Outpatient Clinic, Ziv Hospital Tsfat, Israel
2

Abstract: Background: Flight phobia is a common and debilitating specific phobia. Recently, an effective technology,
called Virtual Reality (VR), has been developed for the treatment of various anxiety disorders including flight phobia.
Method: This article reports the results of a pilot study consisting of four subjects treated for Flight Phobia using Virtual Reality. Results: All four subjects flew post-treatment. They experienced a significant reduction in fear of flying on
two measures anxiety about flying and global rating of fear of flying. Limitations: Due to the small sample size, the
lack of a control group, and the lack of objective measures, caution must be exercised in interpreting the results. Conclusions: The use of Virtual Reality psychotherapy is relatively new worldwide, as well as in Israel. This study suggests
the utility of implementing this technology in Israel.

This paper will focus on a specific phobia fear of

flying (1). Approximately 10%-25% of the population suffer from this specific phobia. The discomfort
created by the phobia ranges from a mild annoyance
to a major disturbance. In addition, approximately
20% of those who fly depend on sedatives or alcohol
during flights (2, 3).
The combination of cognitive and behavior therapy (CBT) has been found to be the treatment of
choice for phobias (4). This combination is superior
to all other psychotherapeutic approaches, in the
percentages of people improving, degree of improvement as well as long-term effects in follow-up
studies.

Virtual Reality
Virtual reality (VR) is defined as a situation in which
the information arriving through the senses is fed
from a computer. The more senses involved, and the
higher the degree of accuracy in the presentation, the
higher the sense of immersion, and thus it becomes
harder for the client to discriminate between the
real and the virtual reality. The use of VR in therapy is relatively new. Its advantage is opening up an
alternative to in-vivo exposure and increasing generalization (5).
In VR therapy for flight phobia, the client re-

ceives visual, audio and tactile (vibrations) input

from the program. The therapist monitors the clients SUD level and thus can reduce the fear of the
environment level, if needed.

Advantage Using VR Therapy

Research has repeatedly found that exposure in-vivo
is superior to exposure in imagination, although it is
both costly as well as difficult to control the elements. For example, for flight phobia we need to rent
an airplane and perform multiple takeoffs and landings. This entails traveling to an airport which in
most cases is far from the clinic, thus increasing time
and cost, the high costs in renting a plane and paying
a pilot. An additional problem with in-vivo exposure
is encountering people the client knows and thus exposing the fact s/he is in therapy.
The advantages of VR therapy over imaginal
therapy are for people who have difficulty imagining
situations vividly, or for those who avoid staying in
the imagined fearful situation. In addition, with VR
the therapist has full knowledge of and control over
the exposure.

Research Using VR for Flight Phobia

VR therapy has been used for specific phobias (6).

Address for Correspondence: Dr. Helene S. Wallach, Department of Behavioral Studies, Emek Yezreel College, Emek
Yezreel 19300, Israel. E-mail: helenwa@Yahoo.com, helenew@yvc.ac.il

30

VIRTUAL-REALITY TREATMENT OF FLIGHT PHOBIA

Four controlled studies combining VR and CBT

have found VR an effective tool for flight phobia (2,
711). However, in one study the post-treatment effect was lost by follow-up (7), in another only twothirds of the patients actually flew by follow-up (8),
and in the third no differences were found between
the treatment and waitlist group on actual flying
rates (9). Only one study found significant differences both post-treatment and in follow-up (2, 10,
11).
The present study proposed to examine the utility
of virtual reality psychotherapy for flight phobia in
an Israeli population. The hypothesis was that VR
psychotherapy will reduce fear of flight ratings.

Method
Subjects
Four subjects (three women and one man), who met
DSM-IV-TR criteria for specific phobia flight participated in this study.

Measures
1. Flight anxiety situations questionnaire (FAS).
This questionnaire includes 31 questions relating
various flight situations and asks the subject to
rate the level of anxiety he/she feels in each, on a
five-point Likert scale ranging from 1 (no anxiety) to 5 (overwhelming anxiety).
2. Flight anxiety modality questionnaire (FAM).
This questionnaire includes 23 questions relating
to expression of fear during flying. Each question
is rated on a five-point Likert scale ranging from
1 (not at all) to 5 (very intensely).
Both questionnaires (12) are used by the Valk
Institute and were translated into Hebrew by
Galit Rosenberg. Both have high reliability in
their original language and after translation to
Hebrew.
3. Questionnaire on attitudes toward flying (QAF)
(12). This questionnaire assesses history of fear of
flying, previous treatment and attitudes towards
flying. It contains 36 questions rating the level of
fear in different flying situations on a Likert scale
ranging from 011. Test retest reliability was .92
and split half reliability was .99.
4. After treatment, subjects flew accompanied by a

research assistant on a short flight (30 minutes),

waited at the airport for a couple of hours and
flew back. They rated their anxiety using SUDS
(0100) at various points from entrance to the
terminal until leaving the plane at the end of the
flight.

Procedure
Subjects were recruited through advertisements in
local newspapers. They were interviewed by a psychiatrist (the second author). Exclusion criteria
were: psychotic disorders, psychoactive substance
abuse and seizures. Only those who suffered from
flight phobia were included. All subjects filled out
the questionnaires. Following treatment they flew
with the research assistant on a short (30 minutes)
domestic flight, waited at the terminal for several
hours and flew back. They received eight sessions
of treatment administered according to a protocol
(13).
Treatment: Subjects were taught relaxation, built an
anxiety hierarchy, and performed virtual reality exposure for eight sessions lasting 45 minutes each session. Patients started in a stationary airplane and
progressed through the stages only when their SUDS
level was below 30.

Results
The three fear of flight measures taken before treatment were compared to those taken after treatment
(see Table 1). The difference in the flight anxiety modality questionnaire (FAM) was not significant
(t[3]=1.30, p=0.14). Therefore, VR therapy did not
help patients reduce their expression of fear during
flying.
Two questionnaires were used for the level of fear
during flying situations. On one no significant difference was found, yet on the other there was a significant difference. The difference for the
questionnaire on attitudes toward flying (QAF) was
not significant (t[2]=1.45, p=0.14). The difference
for the flight anxiety situations questionnaire (FAS)
was significant (t[3]=3.59, p=0.02).
Comparing the SUD level on the two post-treatment flights approached significance (t[3]=2.10,
p=0.06).

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HELENE S. WALLACH AND MARGALIT BAR-ZVI

Table 1. Scores on Fear of Flight Measures (Pre- and Post-Scores)

Time
N

FAM
M

SD

FAS
M

6.02

3 226.67 60.14

4 26.70 13.63

85.75* 10.63

3 173.67 63.09

4 20.34 17.03

4 62.00 15.34

4 112.75*

Post

4 48.25

SD

SUDa
M

SD

Pre

9.50

QAF
M

SD

a SUD pre = first flight after treatment, from Rosh Pina to Tel Aviv; post = second flight after treatment, from Tel Aviv to Rosh Pina.

* p0.05

Lastly, rated global fear towards flying, pre-treatment, was compared to average SUD level in posttreatment flight (see Table 2). This yielded a significant difference (t[2]=3.75, p=0.03).

* p0.05

trol groups, to perform blind SUDs ratings on

flights, as well as follow-up.
It is also important to compare VR therapy to
CBT, as well as comparing VR therapy alone to VR
with cognitive elements, to discover whether cognitive elements are necessary for the success of VR exposure therapy for flight phobics.
This pilot study points to the utility of using a
short (eight session) therapy in virtual reality for fear
of flying. As pointed out earlier, VR enables the patient to benefit from an effective therapy at a lower
cost and without the disadvantages of lack of anonymity and lack of control over external forces.

Discussion

Acknowledgements

The present study was conducted to assess VR treatment for flight phobia on an Israeli population. All
measures were reduced from pre- to post-treatment.
One of two measures of fear of flying was reduced
significantly from pre- to post-treatment, while the
difference in the other was not significant. An additional measure of expression of fear during flying
was reduced, but again not significantly. The comparison of a global rating of fear of flying to the average SUD level rated during an actual flight posttreatment was also significant. Lastly, this study
compared two post-treatment flights, performed
one after the other with a short delay of 23 hours between them, and found a close to significant result.
Therefore, the fear of flight continues to be reduced
with continued exposure made possible by VR treatment.
The major limitations of this study are its small
sample size, the lack of a control group and objective
measures and the lack of a follow-up. It is important
to perform this study again with a large number of
subjects, randomly assigned to treatment and con-

The authors wish to thank Daniela Shriki, Tsachi

Minerbo, Rachael Markovitz and Arik Cohen who
assisted in running the research.
This research project was made possible by the
aid of a generous research grant, 4731, by the Chief
Scientist of the Israeli Ministry of Health.

Table 2. Comparing Level of Felt Fear Prior to Treatment

to Average SUD Level on Post-Flight
Measure

SD

Felt fear prior to treatment

70.00*

10.00

Average SUD level during posttreatment flight

15.55*

17.24

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Ministr y of Justice
The Public Defender Office

Invitation for Offers to be included in Pool of Expert

Psychiatrists, Psychologists and Clinical Criminologists
The Public Defender Office requests offers from physicians specializing in psychiatry who
are duly licensed to practice in Israel, and from psychologists and clinical criminologists,
who are interested in being appointed on its behalf to provide advice and expert opinions
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The Public Defender Office will order services, from time to time and as necessary, from
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work performed will be paid in accordance with the provisions of section 7 of the Public
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Interested persons are requested to respond in writing no later than 30/5/07 attaching
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