New posts in ‘Overcoming Anxiety and Panic’ blog on PsychologyToday.com

Check out Dr. McMahon’s new posts in her Psychology Today blog, “Overcoming Anxiety and Panic” for practical, effective ways to reduce anxiety, worry, panic, and fears: 

• How to Effectively Talk Back to Worries and Fears https://www.psychologytoday.com/intl/blog/overcoming-anxiety-and-panic/202312/how-to-effectively-talk-back-to-worries-and-fears 

• Practical Tips on Changing Anxious Thoughts https://www.psychologytoday.com/intl/blog/overcoming-anxiety-and-panic/202309/practical-tips-on-changing-anxious-thoughts 

• Listening to Worries Can Actually Make You Less Anxious https://www.psychologytoday.com/intl/blog/overcoming-anxiety-and-panic/202309/listening-to-worries-can-actually-make-you-less-anxious 

•  9 Steps to Keep Worry From Hijacking Your Brain https://www.psychologytoday.com/intl/blog/overcoming-anxiety-and-panic/202307/9-steps-to-keep-worry-from-hijacking-your-brain 

• 5 Signs that Worry Is Not Helpful – PsychologyToday.com named this an Essential Read in the areas of Anxiety, Stress, & CBT. https://www.psychologytoday.com/intl/blog/overcoming-anxiety-and-panic/202306/5-signs-that-worry-is-not-helpful

• 3 Ways to Tell if Worry Is Helpful https://www.psychologytoday.com/us/blog/overcoming-anxiety-and-panic/202305/3-ways-to-tell-if-worry-is-helpful 

• 6 Steps to Overcome a Fear of Needles https://www.psychologytoday.com/intl/blog/overcoming-anxiety-and-panic/202306/6-steps-to-overcome-a-fear-of-needles

New 'Overcoming Anxiety and Panic' blog featured on PsychologyToday.com

Psychology Today featured a post in my new blog as an 'essential read'!

My 'Overcoming Anxiety and Panic' blog launched recently on PsychologyToday.com with three posts, including one PT selected as an 'Essential Read': “5 Signs That Your Worry Is Not Helpful”. The other posts are “3 Ways to Tell if Worry Is Helpful” and "6 Steps to Overcome a Fear of Needles".

I am working on additional posts coming covering practical steps for people with anxiety and panic, as well as information on virtual reality therapy for anxiety issues. Stay informed by signing up for my e-mail list on www.elizabeth-mcmahon.com

What Is the Best Anxiety Treatment?

Anxiety can be treated with psychotherapy, medication, or both. Lifestyle changes, including diet, can help reduce anxiety triggers and improve resilience but lifestyle changes alone are not treatments.

The best treatment for anxiety depends on a number of factors including the specific anxiety issues, any coexisting medical or psychological issues, and the person’s preferences. Before any treatment, a diagnostic evaluation by a qualified professional is recommended to determine if symptoms are due to an anxiety condition or something physical.

Research and experience show that most people get the best results from treating anxiety or panic attacks and fears without medicine. Psychotherapy using cognitive behavioral therapy (CBT) is considered to be the best practice treatment for anxiety, even if you are taking anti-anxiety medication. Virtual reality can help with cognitive behavioral therapy, as explained below.

A large study found that although people taking medication for panic got faster symptom relief initially, they did less well in the long term. Those treated with medication had more ongoing fear of panic and their panic attacks were more likely to return after they stopped taking the medicine [1]. Other studies show that taking a medicine makes relapse and return of fear more likely [2, 3].

In certain situations, medications may be the best option. For example, someone who needs an emergency MRI but is too anxious to go into the machine may benefit from a fast-acting anti-anxiety medication such as alprazolam (Xanax).

Cognitive Behavioral Therapy for Anxiety

Cognitive behavioral therapy (CBT) is a psychotherapy technique that helps people change their thoughts and beliefs (cognition) as well as their actions (behavior).

CBT for anxiety includes information and exercises that helps you:

• Understand the causes of anxiety and the anxiety cycle.

• Identify your personal anxiety cycle including fears, triggers, and panic actions.

• Reduce your triggers.

• Challenge your fears and change your thinking.

• Change your actions and resume a normal life.

• Learn additional techniques for increasing your resilience and dealing with possible recurrences.

Virtual Reality Therapy for Anxiety

Virtual reality (VR) technology enables a user to feel like they are ‘inside’ a 3-dimensional virtual environment. This illusion is created by a VR headset that contains a computer graphic display, lenses, sensors, and speakers. The headset tracks the user’s location and head position to adjust the 3-D graphics in real-time and create the appearance of being within the virtual environment.

Conceptual view of a VR headset that uses a smartphone to create 3D virtual environments

For VR therapy, the client wears a VR headset and experiences the virtual environment. The therapist does not use a headset, but they can monitor and control what the client is seeing on their workstation. 

Therapist workstation display enables the therapist to monitor and control the client’s virtual environment

Virtual reality therapy uses VR technology to enhance several parts of cognitive behavioral therapy, including diagnosis, skills training, reward/relaxation, and relapse prevention. The most powerful use of VR in therapy is for the ‘exposure’ portion of therapy. 

During the exposure portion of therapy, the client repeatedly faces activities and situations that cause anxiety while practicing new ways of thinking and acting which they have learned earlier in therapy. Exposure to virtual environments, controlled by the therapists, is much more realistic and efficient than alternate ways of doing of exposure such as imagining the situation (imaginal exposure) or facing the situation in real life (called in vivo exposure). 

About the Author

Dr. McMahon has specialized in brief effective treatment for anxiety-related issues for over 40 years and teaches continuing education courses for therapists. She has been using VR with clients since 2010 and has written a textbook on VR therapy for anxiety. Her qualifications include 32 years at Kaiser Permanente Medical Group where in addition to helping hundreds of clients, she coauthored best practice guidelines for anxiety treatment and trained post-doctoral psychologists. See About Dr. McMahon for more information.

Call Dr. McMahon at 1-415-625-3565 for more information or to arrange an appointment.

Medication Note

If you take medication for anxiety, continue taking it as directed until you receive new instructions from your health care provider. Certain anti-anxiety medications must be discontinued gradually to avoid problems.

References

[1] Barlow, B. H., Gorman, J. M., Shear, M. K., & Woods, S. W. (2000). Cognitive-behavioral therapy, imipramine, or their combination for panic disorder: A randomized controlled trial. JAMA, 283(19): 2529-2536.

[2] Marks, L., Sinson, R. P., Basoglu, M., Kuch, K., Noshirvani, H., O’Sullivan, G., et al. (1993). Alprazolam and exposure alone and combined in panic disorder with agoraphobia: A controlled study in London and Toronto. British Journal of Psychiatry, 162, 776-787.

[3] Powers, M. B., Smits, J. A., Whitley, D., Bystritsky, A., & Telch, M. J. (2008) The effect of attributional processes concerning medication taking on return of fear. Journal of Consulting and Clinical Psychology, 76(3), 478-490.

Virtual Reality: Curing Phobias, Creating Empathy, Taking Over the Market

By: Adesuwa Agbonile

SAN FRANCISCO—A couple decades ago, if you were deathly afraid of public speaking, the best advice someone could offer you was to get in front of a crowd – maybe imagine them in their underwear. Afraid of planes? Book weekly flights – when you touch down safely enough times, you’ll get over it.

The problem is, people who are terrified of public speaking typically don’t want to get in front of large crowds, no matter how much good it might do them. People afraid of flying don’t have the will—or the funds—to take a flight once a week.

But what if you could face your fears in a world where you’re sure you’ll never be hurt? What if you could strap on a headset that made your mind and body believe you were on a plane, when in reality, you’re sitting safely on your psychologist’s couch?

That’s exactly the kind of service psychologist Elizabeth McMahon offers. For nearly ten years, she’s been using virtual reality (VR) to help patients overcome their phobias.

Due to its unique qualities, VR is increasingly being used by psychologists like McMahon and researchers for a host of reasons – curing phobias, treating mental illness, instilling empathy. But its rapid rate of growth also opens the door to negative ramifications, like addiction, or teaching prejudice.

McMahon jumped on the technology right at its outset because of its unique advantages. It’s immersive enough to make patients believe what they’re seeing is real, but it’s not actually real, and easily controllable.

“You can do it in the office, it’s easier on the patient, you can individualize it,” McMahon said. “It sounded great.”

McMahon spends the first couple sessions with her patients discussing their phobias and brainstorming strategies to help them cope with their fears.

Then, after she’s determined that they’re ready, she slips an Android smartphone into a VR headset, McMahon helps her patients adjust the headset straps over their heads, and when they peer into the lenses, they are transported into an alternate reality.

Scared of heights? McMahon can put you on top of a tall New York City building. Flying? Put on a headset, and suddenly you’re on a plane – the turbulence is provided by McMahon, who stands behind her patient’s chair and shakes it. Just like that - sliding into another reality becomes as simple as a phone buckled into a headset, pressed to your face.

There’s no official data showing how many health practitioners use VR, but Limbix—a leading VR startup that sells software and equipment to health practitioners, including McMahon—has more than 10,000 customers using their products to help patients. Those numbers keep growing, and it’s easier than ever for patients themselves to access VR outside of a session.

Stanford freshman Shreya Venkat, who struggles with medical problems that cause her heart rate to rapidly increase, sometimes uses a meditation virtual reality module to lower her heartrate. Through the headset is a calming fantasy world; harp music plays through the speakers, glowing lanterns bob in and out of sight.

“I stepped out of my world, and I was in this other place,” she said. “I was more relaxed mentally. I felt good.”

As she was talking, her voice slowed down. For a second, her eyes glazed over. “I’m thinking about it now,” she said. “I want to do it again.”

This is the magic of VR – even looking at the crudest animation through a headset can make you feel like you’re somewhere entirely different.

At first, McMahon’s VR animation was cartoonish. “If you went up to the roof of a building and looked up at the sky, you could see the seam,” she said.

But even then, the experience was shockingly realistic.

“[Patients] would be saying: I feel like I’m going to fall,” McMahon said. “It was emotionally convincing and compelling, it was physiologically compelling.”

Now, animation is becoming more sophisticated and headsets are becoming more accessible. Ten years ago, McMahon’s VR setup was thousands of dollars, now headsets like the Samsung Gear VR and the Google Daydream both retail at about $100. The recently released Oculus Go, marketed as “the easiest way to jump into virtual reality”, is $200. For $15 dollars, consumers can buy a Google Cardboard, a piece of cardboard with two plastic magnifying lenses that folds into a box you can put a phone into.

The worlds VR are creating are easier than ever to step into, and harder to distinguish from real life. On an Oculus forum, one user posted a comment on a message board titled: ‘I feel like I’m in VR when I’m not’.

“When I look at my hands, I feel like they’re not really my hands, like they’re the Rift hands,” the user said. Underneath the post, there were dozens of comments from other users, affirming that they often felt the same way.

That feeling people get in VR of really being somewhere is called presence – a phenomenon where a person is aware that the simulation they’re in is virtual, but they behave as if it’s real. A person who is on top of a building in VR will be cautious about stepping forward, lest they step off the edge; even though they know they’re not on the top of a building.

Early research (www.researchgate.net/publication/221182454_Embodied_Social_Presence_Theory) into presence suggests that the phenomenon has to do with the active interaction VR allows – so when you turn your head, what you see in front of you changes. And while the neuroscience behind why that interaction translates to VR feeling real is fuzzy, it’s certain that presence is a powerful force.

It’s this feeling of presence that McMahon manipulates to help her patients with phobias. People react to VR like it’s real life, but because it’s virtual, McMahon can walk them through the experience, offering advice and skills that alleviate their fears. The immersive experience is “enough to trigger the fear, so you can learn from it and learn to tolerate it; but not to big that it gets you scared,” McMahon said.

And presence has far broader implications than alleviating flying anxiety.

At Stanford, researchers like Jeremey Bailenson are using VR as a tool to increase empathy. Subjects put on a headset and look into a virtual mirror – suddenly, they’re a black man, or a homeless person. They can—literally—spend a day in that person’s shoes, and experience how they interact with society.

“I think it's greatest impact is going to be increasing global learning,” said Elise Ogle, a researcher at Bailenson’s lab. “Giving people the ability to walk a mile in someone else's shoes. This can increase the connection we feel with others, if done right.”

The hope is that exposing people to these kinds of narratives will increase their empathy and spur social change.

“One time I had a participant tell me at the end of a study, "That has completely changed the way I look at the world."” Ogle said.

Oculus Go has a new feature called Venues, where users can put on a headset and be transported to a sports game, live concert, or stand-up show. The feature also allows people to interact with others virtually at the event. Apps like Fearless VR are letting people use VR to tackle phobias without the help of a psychologist. YouTube, Netflix and Hulu are beginning to offer streaming services on VR platforms. Facebook 360 lets people experience immersive videos.

These features all manipulate VR’s ability to create presence to offer viewers the most immersive experience that they could hope for, without really being there. For McMahon, this means that she can help her patients better. But she’s also aware of the negative effects this technology could have.

“Any technology that has power, that power can be used to heal but it can also cause harm. If you can use VR to create empathy, couldn’t you also use it for propaganda and to dehumanize the other person?” said McMahon. “If you can use it to make you feel safe, you can use it to make you feel like you’re in an environment that’s terrifying.”

McMahon is especially worried about this in the field of VR for therapy – according to her, VR is a useful tool in helping combat phobias and anxiety. But just like all tools, if VR is used in the wrong way without proper training and instruction, it can do more harm than good.

There is danger in stepping into a world that feels real but is constructed. And with the technology at the cusp of commercialization, not much time has been invested research about how VR can affect people in the long term, and how the tool should be regulated – if at all.

“There’s going to be a big rush to market in advance of actual research,” McMahon said.

Regardless, McMahon plans to keep on using VR as a tool for positive good. And in years to come, our real realities and our virtual ones are sure to become even more blurred. When McMahon got on a plane after trying an airplane VR module, the first thought that popped into her head was: “this is just like VR.”

© 2017 by Adesuwa Agbonile, based on a Stanford University class project.