Using Virtual Reality and Other Computer Technologies to Implement Cognitive-Behavior Therapy for the Treatment of Anxiety Disorders in Youth

  • Lynn D. Miller
  • Cidalia Silva
  • Stéphane Bouchard
  • Claude Bélanger
  • Terry Taucer-Samson
Part of the Autism and Child Psychopathology Series book series (ACPS)


Among the therapeutic strategies used in the treatment of anxiety, behavioral approaches featuring exposure to aversive stimuli occupy a central role. Research on the effectiveness of cognitive-behavior therapy (CBT) in the treatment of anxiety disorders generally places exposure at the heart of therapeutic change. In fact, these studies have shown their empirical effectiveness in adults as well as children (Barrett, 2009; Carr, 2009; Cartwright-Hatton et al., 2004). Despite their proven effectiveness, exposures can present significant challenges to the therapist as well as the client (see Bouchard et al., 2004; Davis et al., 2009).


Anxiety Disorder Virtual Reality Social Anxiety Virtual Environment Head Mount Display 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.



This project was supported in part by the financial support of the Canada Research Chairs program awarded to the third author, Canadian Foundation for Innovation awarded to the first and third author, and Cyberpsychology and Schools, and the Myrne Nevison Research Professorship awarded to the first author. Portions of this chapter were inspired by a book chapter in French from Silva, Bouchard, and Bélanger (written for Turgeon, in press).


  1. Anderson, P., Jacobs, C., & Rothbaum, B. O. (2004). Computer-supported cognitive behavioral treatment of anxiety disorders. Journal of Clinical Psychology, 60(3), 253–267. doi: 10.1002/jclp.10262.PubMedCrossRefGoogle Scholar
  2. Annenberg School for Communication. (2008). Annual Internet Survey by the Center for the Digital Future. Los Angeles: University of Southern California, Center for the Digital Future.Google Scholar
  3. Barak, A., Hen, L., Boniel-Nissim, M., & Shapira, N. (2008). A comprehensive review and a meta-analysis of the effectiveness of internet-based psychotherapeutic interventions. Journal of Technology in Human Services, 26(2/4), 109–160. doi: 10.1080/15228830802094429.CrossRefGoogle Scholar
  4. Barrett, P. (2009). Prevention of child and youth anxiety and anxiety disorders. In M. M. Antony & M. B. Stein (Eds.). Oxford handbook of anxiety and related disorders (pp. 497–511). New York: Oxford University Press.Google Scholar
  5. Bee, H., & Boyd, D. (2007). The Lifecycle: Human Psychological Development. (3rd ed.). Québec: ERPI.Google Scholar
  6. Borzekowski, D., & Rickert, V. (2001). Adolescent cybersurfing for health information: A new resource that crosses barriers. Archives of Pediatrics and Adolescent Medicine, 155(7), 813–817. Retrieved from Accessed 26 Feb. 2012.PubMedGoogle Scholar
  7. Botella, C., Garcia-Palacios, A., Baños, R., & Quero, S. (2009). Cybertherapy: Advantages, limitations, and ethical issues. PsychNology Journal, 7(1), 77–100. Retrieved from Accessed 26 Feb. 2012.Google Scholar
  8. Bouchard, S., St-Jacques, J., Robillard, G., Côté, S., & Renaud, P. (2003). Efficacy of exposure in virtual reality for the treatment of spider phobia: Preliminary results. Journal De Therapie Comportementole et Cognitive, 13(3), 107–112.Google Scholar
  9. Bouchard, S., Mendlowitz, S. L., Coles, M. E., & Franklin, M. (2004). Considerations in the use of exposure with children. Cognitive and Behavioral Practice, 11(2), 56–65.CrossRefGoogle Scholar
  10. Bouchard, S., St-Jacques, J., Robillard, G., & Renaud, P. (2007). Efficacy of exposure in virtual reality for the treatment of spider phobia in children: A pilot study. Journal De Therapie Comportementole et Cognitive, 17(3), 101–108. doi: 10.1016/S1155–1704(07)73238-X.CrossRefGoogle Scholar
  11. Bouchard, S., St-Jacques, J., Robillard, G., & Renaud, P. (2008). Anxiety increases the sense of presence in virtual reality. Presence: Teleoperators and Virtual Environments, 4(1), 376–391.CrossRefGoogle Scholar
  12. Bouchard, S., St-Jacques, J., Renaud, P., & Wiederhold, B. K. (2009). Side effects of immersions in virtual reality for anxious people. Journal of Cybertherapy and Rehabilitation, 2(2), 127–137. Retrieved from Accessed 26 Feb. 2012.Google Scholar
  13. Bussière, P., & Gluszynski, T. (2004). The impact of computer use on reading achievement of 15-year-olds. Learning Policy Directorate, Strategic Policy and Planning Branch Human Resources and Skills Development Canada.Google Scholar
  14. Carr, A. (2009). What works with children, adolescents and adults? A review of research on the effectiveness of psychotherapy. New York: Routledge/Taylor & Francis Group.Google Scholar
  15. Cartwright-Hatton, S., Roberts, C., Chitsabesan, P., Fothergill, C., & Harrington, R. (2004). Systematic review of the efficacy of cognitive behavior therapies for childhood and adolescent anxiety disorders. British Journal of Clinical Psychology, 43(4), 421–436. doi: 10.1348/0144665042388928.PubMedCrossRefGoogle Scholar
  16. Cheng, K. (1999). Gen Y pops and shops online. Adweek Eastern Edition, 40(41), 68. Retrieved from Accessed 26 Feb. 2012.Google Scholar
  17. Côté, S., & Bouchard, S. (2008). Virtual reality exposure for phobias: A critical review. Journal of Cybertherapy and Rehabilitation, 1(1), 75–91. Retrieved from Accessed 26 Feb. 2012.Google Scholar
  18. Cunningham, M., & Wuthrich, V. (2008). Examination of barriers to treatment and user preferences with computer-based therapy using the Cool Teens CD for adolescent anxiety. E-Journal of Applied Psychology, 4(2), 12–17. Retrieved from Accessed 26 Feb. 2012.Google Scholar
  19. Cunningham, M., Rapee, R., & Lyneham, H. (2006). Feedback to a prototype self-help computer program for anxiety disorders in adolescents. Australian e-Journal for the Advancement of Mental Health, 5(3), 1–9. Retrieved from Accessed 26 Feb. 2012.Google Scholar
  20. Cunningham, M., Wuthrich, V., Rapee, R., Lyneham, H., Schniering, C., & Hudson, J. (2009). The Cool Teens CD-ROM for anxiety disorders in adolescents: A pilot case series. European Child & Adolescent Psychiatry, 18(2), 125–129. doi: 10.1007/s00787–008-0703-y.CrossRefGoogle Scholar
  21. Davis III, T. E., Ollendick, T. H., & Öst, L. G. (2009). Intensive treatment of specific phobias in children and adolescents. Cognitive and Behavioral Practice, 16, 294–303.CrossRefGoogle Scholar
  22. Dewis, L. M., Kirkby, K. C., Martin, F., Daniels, B. A., Gilroy, L. J., & Menzies, R. G. (2001). Computer-aided vicarious exposure versus live graded exposure for spider phobia in children. Journal of Behavior Therapy and Experimental Psychiatry, 32, 17–27. doi: 10.1016/S0005–7916(01)00019–2.PubMedCrossRefGoogle Scholar
  23. Doré, F., & Bouchard, S. (2006). Using virtual reality to treat social anxiety disorder in adolescents. Annual Review of Cybertherapy and Telemedicine, 4, 205–206 (Interactive Media Institute ISSN 1554–8716).Google Scholar
  24. Flanagan, M. B., May, J. G., & Dobie, T. G. (2004). The role of vection, eye movements and postural instability in the etiology of motion sickness. Journal of Vestibular Research: Equilibrium and Orientation, 14(4), 335–346. Retrieved from Accessed 26 Feb. 2012.Google Scholar
  25. Gilroy, L. J., Kirkby, K. C., Daniels, B. A., Menzies, R. G., & Montgomery, I. M. (2000). Controlled comparison of computer-aided vicarious exposure versus live exposure in the treatment of spider phobia. Behavior Therapy, 31(4), 733–744. doi: 10.1016/S0005–7894(00)80041–6.CrossRefGoogle Scholar
  26. Gilroy, L. J., Kirkby, K. C., Daniels, B. A., Menzies, R. G., & Montgomery, I. M. (2003). Long-term follow-up of computer-aided vicarious exposure versus live graded exposure in the treatment of spider phobia. Behavior Therapy, 34(1), 65–76. doi: 10.1016/S0005–7894(03)80022–9.CrossRefGoogle Scholar
  27. Glantz, K., Rizzo, A., & Graap, K. (2003). Virtual reality for psychotherapy: Current reality and future possibilities. Psychotherapy: Theory, Research, Practice, Training, 40(1/2), 55–67. doi: 10.1037/0033–3204.40.1–2.55.CrossRefGoogle Scholar
  28. Gould, M. S., Munfakh, J. L. H., Lubell, K., Kleinman, M., & Parker, S. (2002). Seeking help from the Internet during adolescence. Journal of the American Academy of Child and Adolescent Psychiatry, 41(10), 1182–1189. doi: 10.1097/01.CHI.0000020280.43550.C9.PubMedCrossRefGoogle Scholar
  29. Gray, N. J., Klein, J. D., Noyce, P. R., Sesselberg, T. S., & Cantrill, J. A. (2005). Health information-seeking behavior in adolescence: The place of the Internet. Social Science & Medicine, 60(7), 1467–1478. doi: 10.1016/j.socscimed.2004.08.010.CrossRefGoogle Scholar
  30. Griffiths, K. M., & Christensen, H. (2006). A review of randomised controlled trials of internet interventions for mental disorders and related conditions. Clinical Psychology, 10, 16–29. doi: 10.1080/13284200500378696.CrossRefGoogle Scholar
  31. Gutiérrez-Maldonado, J., Magallón-Neri, E., Rus-Calafell, M., & Peñaloza-Salazar, C. (2009). Virtual reality exposure therapy for school phobia. Anuario de Psicología, 40(2), 223–236.Google Scholar
  32. Harris, K., & Reid, D. (2005). The influence of virtual reality play on children’s motivation. Canadian Journal of Occupational Therapy, 72(1), 21–29. Retrieved from Accessed 26 Feb. 2012.Google Scholar
  33. Howarth, P. A., & Hodder, S. G. (2008). Characteristics of habituation to motion in a virtual environment. Displays, 29(2), 117–123. doi: 10.1016/j.displa.2007.09.009.CrossRefGoogle Scholar
  34. Jones, S., & Fox, S. (2009). Generations Online in 2009, Pew Internet & American Life Project. Washington: Pew Research Center.Google Scholar
  35. Kendall, P., & Hedtke, K. (2006). Cognitive-behavioral therapy for anxious children: Therapist manual (3rd ed.). Ardmore: Workbook Publishing.Google Scholar
  36. Kendall, P. C., Robin, J. A., Hedtke, K. A., Suveg, C., Flannery-Schroeder, E., & Gosch, E. (2005). Considering CBT with anxious youth? Think exposures. Cognitive and Behavioral Practice, 12, 136–150.CrossRefGoogle Scholar
  37. Kennedy, R. S., Lane, N. E., Berbaum, K. S., & Lilienthal, M. G. (1993). Simulator Sickness Questionnaire: An enhanced method for quantifying simulator sickness. International Journal of Aviation Psychology, 3(3), 203–220.CrossRefGoogle Scholar
  38. Khanna, M., & Kendall, P. (2008). Computer-assisted CBT for child anxiety: The Coping Cat CD-Rom. Cognitive and Behavioral Practice, 15, 159–165. doi: 10.1016/j.cbpra.2008.02.002.CrossRefGoogle Scholar
  39. Khanna, M., & Kendall, P. C. (2010). Computer-assisted cognitive behavioral therapy for child anxiety: Results of a randomized clinical trial. Journal of Consulting and Clinical Psychology, 78(5), 737–745. doi: 10.1037/a0019739.PubMedCrossRefGoogle Scholar
  40. Klinger, K., Bouchard, S., Légeron, P., Roy, S., Lauer, F., Chemin, I., et al. (2005). Virtual reality therapy versus cognitive behavior therapy for social phobia: A preliminary controlled study. CyberPsychology & Behavior, 8(1), 76–88. doi: 10.1089/cpb.2005.8.76.CrossRefGoogle Scholar
  41. Lamson, R. J. (1997). Virtual therapy. Montreal: Polytechnic International Press.Google Scholar
  42. Lawson, B. D., Graeber, D. A., Mead, A. M., & Muth, E. R. (2002). Signs and symptoms of human syndromes associated with synthetic experience. In K. M. Stanney (Eds.), Handbook of virtual environments: Design, implementation, and applications (pp. 589–618). Mahwah: IEA.Google Scholar
  43. Lévesque, R. (2007). Adolescents, media and the law: What developmental science reveals and free speech requires. New York: Oxford University Press.Google Scholar
  44. Lombard, M., & Ditton, T. (1997). At the heart of it all: The concept of presence. Journal of Computer-Mediated Communication, 3(2). Retrieved from Accessed 26 Feb. 2012.Google Scholar
  45. Marcelli, D., & Braconnier, A. (2008). Adolescence and psychopathology. Issy-les-Moulineaux: Masson.Google Scholar
  46. March, S., Spence, S., & Donovan, C. (2009) The efficacy of an Internet-based cognitive-behavioral therapy intervention for child anxiety disorders. Journal of Pediatric Psychology, 34(5), 474–487. doi: 10.1093/jpepsy/jsn099.PubMedCrossRefGoogle Scholar
  47. McCrindle, M. (2006). New generations at work: Attracting, recruiting, retraining & training generation Y: McCrindle Research. Retrieved from: Accessed 26 Feb. 2012.Google Scholar
  48. Nelissen, I., Muris, P., & Merckelbach, H. (1995). Computerized exposure and in vivo exposure treatments of spider fear in children: Two case reports. Journal of Behavior Therapy and Experimental Psychiatry, 26(2), 153–156. doi: 10.1016/0005–7916(95)00002-H.PubMedCrossRefGoogle Scholar
  49. Nichols, S. (1999). Physical ergonomics of virtual environment use. Applied Ergonomics, 30(1), 79–90. doi: 10.1016/S0003–6870(98)00045–3.PubMedCrossRefGoogle Scholar
  50. Peattie, S. (2007). The Internet as a medium for communicating with teenagers. Social Marketing Quarterly, 13(2), 21–46. doi: 10.1080/15245000701326343.CrossRefGoogle Scholar
  51. Pouget, F. (2008) Defining Generation Y. Retrieved from Accessed 26 Feb. 2012.Google Scholar
  52. Pratt, D. R., Zyda, M., & Kelleher, K. (1995). Virtual reality: In the mind of the beholder. IEEE Computer, 28(7), 17–19. doi: 10.1109/MC.1995.10085.Google Scholar
  53. Price, M., & Anderson, P. (2007). The role of presence in virtual reality exposure therapy. Journal of Anxiety Disorders, 21(5), 742–751. doi: 10.1016/j.janxdis.2006.11.002.PubMedCrossRefGoogle Scholar
  54. Rickwood, D., Deane, F., & Wilson, C. (2007). When and how do young people seek professional help for mental health problems? Medical Journal of Australia, 187, 35–39. Retrieved from Accessed 26 Feb. 2012.Google Scholar
  55. Riva, G., Mantovani, F., Capideville, C., Preziosa, A., Morganti, F., Villani, D., et al. (2007). Affective interactions using virtual reality: The link between presence and emotions. CyberPsychology & Behavior, 10(1), 45–56. doi: 10.1089/cpb.2006.9993.CrossRefGoogle Scholar
  56. Rothbaum, B. O., Hodges, L. F., Kooper, R., Opdyke, D., Williford, J. S., North, M., et al. (1995). Virtual reality graded exposure in the treatment of acrophobia: A case report. Behavior Therapy, 26(3), 547–554.Google Scholar
  57. Robillard, G., Bouchard, S., Renaud, P., & Cournoyer, L. G. (2002). Validation of two French-Canadian measures in virtual reality: Immersive Tendencies Questionnaire and Presence Questionnaire. Poster session presented at the 25th Meeting of the Quebec Society for the Research in Psychology. Trois-Rivières, 1–2 Nov 2002.Google Scholar
  58. Robillard, G., Bouchard, S., Fournier, T., & Renaud, P. (2003). Anxiety and presence during VR immersion: A comparative study of the reactions of phobic and non-phobic participants in therapeutic virtual environments derived from computer games. CyberPsychology & Behavior, 6(5), 467–476. doi: 10.1089/109493103769710497.CrossRefGoogle Scholar
  59. Santor, D. A., Kususmakar, V., Poulin, C., & Leblanc, J. (2007). Facilitating help seeking behavior and referrals for mental health difficulties in school aged boys and girls: A school-based intervention. Journal of Youth and Adolescence, 36, 741–752. doi: 10.1007/s10964–006-9092-z.CrossRefGoogle Scholar
  60. Sharples, S., Cobb, S., Moody, A., & Wilson, J. (2008). Virtual reality induced symptoms and effects (VRISE): Comparison of head mounted display (HMD), desktop and projection display systems. Displays, 29(2), 58–69. doi: 10.1016/j.displa.2007.09.005.CrossRefGoogle Scholar
  61. Skinner, H., Biscope, S., Poland, B., & Goldberg, E. (2003). How adolescents use technology for health information: Implications for health professionals from focus group studies. Journal of Medical Internet Research, 5(4), e32. doi: 10.2196/jmir.5.4.e32.PubMedCrossRefGoogle Scholar
  62. Slater, M. (1999). Measuring presence: A response to the Witmer and Singer presence questionnaire. Presence: Teleoperators and Virtual Environments, 8(5), 560–565.CrossRefGoogle Scholar
  63. Spence, S. H., Holmes, J. M., Donovan, C. L., & Kenardy, J. A. (2006a). BRAVE for Teenagers—ONLINE: An internet based program for adolescents with anxiety. Brisbane: School of Psychology, University of Queensland.Google Scholar
  64. Spence, S. H., Holmes, J. M., March, S., & Lipp, O. V. (2006b). The feasibility and outcome of clinic plus Internet delivery of cognitive-behavior therapy for childhood anxiety. Journal of Consulting and Clinical Psychology, 74(3), 614–621. doi: 10.1037/0022–006X.74.3.614.CrossRefGoogle Scholar
  65. Spence, S. H., Donovan, C. L., March, S., Gamble, A., Anderson, R., Prosser, S., et al. (2008). Online CBT in the treatment of child and adolescent anxiety disorders: Issues in the development of BRAVE-ONLINE and two case illustrations. Behavioral and Cognitive Psychotherapy, 36(4), 411–430. doi: 10.1017/S135246580800444X.CrossRefGoogle Scholar
  66. St-Jacques, J., & Bouchard, S. (2005). Clinical applications of virtual reality and cybersickness. Poster presented at the 10th Cybertherapy Conference 2005, 7–10 June 2005, Basel (Switzerland).Google Scholar
  67. St-Jacques, J., Bouchard, S., & Bélanger, C. (2007). Virtual reality use with children and youth: A review of the literature. Revue Quebecoise de Psychologie, 28(2), 93–110.Google Scholar
  68. St-Jacques, J., Bouchard S., & Bélanger, C. (2010). Is virtual reality effective to motivate and raise interest in phobic children toward therapy? A clinical trial study of in vivo with in virtuo versus in vivo only treatment exposure. Journal of Clinical Psychiatry, 71(7), 924–931. doi: 10.4088/08m04822blu.PubMedCrossRefGoogle Scholar
  69. Stephens, T., & Joubert, N. (2001). The economic burden of mental health problems in Canada. Chronic Diseases in Canada , 22(1), 18–23. Retrieved from–1/d_e.html. Accessed 26 Feb. 2012.Google Scholar
  70. Subrahmayam, K., & Greenfield, P. (2008). Online communication and adolescent relationships. The Future of Children, 18(1), 119–146. Retrieved from Accessed 26 Feb. 2012.CrossRefGoogle Scholar
  71. Turgeon, L. (in press). Cognitive-behavioural intervention with children and youth: Manual for therapists.Google Scholar
  72. Wallach, H., Safir, M., & Bar-Zvi, M. (2009). Virtual reality cognitive behavior therapy for public speaking anxiety: A randomized clinical trial. Behavior Modification, 33(3), 314–338. doi: 10.1177/0145445509331926.PubMedCrossRefGoogle Scholar
  73. Webb, M., Burns, J., & Collin, P. (2008). Providing online support for young people with mental health difficulties: Challenges and opportunities explored. Early Intervention in Psychiatry, 2(2), 108–113. doi: 10.1111/j.1751–7893.2008.00066.x.PubMedCrossRefGoogle Scholar
  74. Wiederhold, B. K., & Wiederhold, M. D. (2005). Virtual reality therapy for anxiety disorders: Advances in evaluation and treatment. Washington: American Psychological Association.CrossRefGoogle Scholar
  75. Wiederhold, B. K., Gevirtz, R., & Wiederhold, M. D. (1998). Fear of flying: A case report using virtual reality therapy with physiological monitoring. CyberPsychology and Behavior, 1(2), 97–104.CrossRefGoogle Scholar
  76. Witmer, B., & Singer, M. (1998). Measuring presence in virtual environments: A presence questionnaire. Presence: Teleoperators and Virtual Environments, 7(3), 225–240. doi: 10.1162/105474698565686.CrossRefGoogle Scholar

Copyright information

© Springer Science+Business Media, LLC 2012

Authors and Affiliations

  • Lynn D. Miller
    • 1
  • Cidalia Silva
    • 2
  • Stéphane Bouchard
    • 3
  • Claude Bélanger
    • 4
  • Terry Taucer-Samson
    • 5
  1. 1.Department of Educational and Counseling Psychology and Special EducationUniversity of British ColumbiaVancouverCanada
  2. 2.Psychology Department, Cyberpsychology LaboratoryUniversité du Québec en OutaouaisGatineauCanada
  3. 3.Department of Psychoeducation and Psychology, Cyberpsychology LaboratoryUniversité du Québec en OutaouaisGatineauCanada
  4. 4.Douglas Institute of Mental Health, Department of PsychologyUniversité du Québec à MontréalMontrealCanada
  5. 5.Ecole Une Autre LangueCannesFrance

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