Bringing Exposure Therapy for Animal Phobias to Real-Life Context With Augmented Reality
Phase: NA
Conditions: Phobias Snakes, Phobias Spiders
Sponsor: Wayne State University

 
 
 
 
 
 
 
 
 
 
 
 
 
Bringing Exposure Therapy to Real Life Context  
with Augmented Reality and Telepsychiatry 
 
Study Protocol 
 
NCT03649347 
 
Document Date: September 22, 2020 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

Software  
The software was developed in collaboration with the AR industry and connects the clinician’s 
computer to the AR headset via Local Access Network (LAN). It provides the clinician with a 
3D visual of the surfaces surrounding the participant, obtained from the AR device mapping of 
the environment. The clinician can use the keyboard to adjust their view of the map 360º to have 
a better view of any surface. A simple drop-down menu allows the clinician to choose a 
hologram and a sub-type of the feared object (wolf, jumping, black widow); furthermore, the 
feared object’s color (brown, white, yellow), size, direction of motion, and speed of motion are 
all clinician-directed manipulations offered. Five unique spider webs are available to place on 
and between surfaces. At any time, the program can be paused with a single click such that all 
objects disappear for as long as the clinician sees fit.  
 
The software outputs the number of spiders in the environment, the number of spiders in the 
participant’s field of view, the largest spider, and the distance to the closest spider at any 
moment. Participant’s subjective units of distress (see measures below) can be directly entered 
into the software during the session. A short video demonstrating the software can be seen here: 
https://drive.google.com/file/d/1qrHNVjLlVOM8NIguuCtMFnc2fr9IjIkY/view  
 
Device  
Microsoft ® HoloLens, a holographic AR device, was utilized. This device was selected for its 
accurate spatial mapping, a preferred feature for realistic positioning of virtual object on real 
surfaces. This device is wireless, and operates through LAN connections, granting participants 
the ability to move and interact freely with the environment and the augmented objects.  
 
Participants  
Participants were designated to single session ARET or no treatment control based on the order 
of enrollment (block designation ABAB; parallel trial design). Inclusion criteria included: 1) 
current untreated arachnophobia, 2) adults of any sex between the ages of 18 and 45, and 3) 
willing and able to give written informed consent. Exclusion criteria included: 1) current or 
previous diagnosis of a psychotic disorder, 2) presence of a substance use disorder within the 
past six months, 3) current use of psychotropic medications, 4) history of seizure, head trauma, 
or neurological disease, or 5) an uncorrected visual impairment. All participants provided written 
informed consent and all study procedures were approved by the Wayne State University 
Institutional Review Board (IRB# 107517B3F). All research activities occurred at an office 
clinic at Wayne State University in urban Detroit.  
 
We initially aimed to recruit n=15 individuals per group as part of NCT03649347 Bringing 
Exposure Therapy to Real-Life Context with Augmented Reality (ARET). This clinical trial is to 
test the feasibility and efficacy of a novel augmented reality software for the treatment of spider 
and snake phobias. The sample size of 15 per group, 30 total was chosen for arachnophobia as a 
pilot feasibility and efficacy trial of the software. This sample size was chosen based on samples 
found in previous studies for pilot feasibility and efficacy testing of VR and AR platforms (14-
20). A priori power analyses were not conducted, however post hoc power analyses were 
conducted and are reported in the results section. Recruitment and study sessions ran within the 
year 2019. 
 

 
Procedure 
 
Treatment group 
Prior to the treatment, principles of exposure therapy, using the AR device, and process of the 
treatment were explained. Participants were told they would be informed of each new level of 
exposure and would not be surprised or tricked without prompt. They were informed that 
towards the end of the treatment, if they agreed (which all did), placement and motion of the 
objects would not be prompted. 
 
For potentiating contextualization of safety learning, exposure therapy took place in two 
different looking clinic offices. Initially participants were in a bright, windowed office, sitting on 
a chair in one corner. A small, augmented wolf spider was placed on the floor at the point most 
distant from the participant. Then a small, augmented jumping spider was presented, followed by 
a small black widow. At each stage, when the participant reached SUDs of below 4, they would 
advance to the next level with a larger augmented spider, or to the types of augmented spiders or 
colors (yellow, brown, white) the participant found scarier. Then augmented spiders were 
moved horizontally, then slowly toward the participant. Gradually the number, speed of motion, 
proximity to the participant, and the size of the augmented spiders increased; augmented spiders 
were also placed, or crawled on the walls or the ceiling, or on a clinical assistant present in the 
room. Participants were encouraged to walk towards the augmented spiders, sit next to them, and 
do the same while the augmented spiders were moving. When participants could hold their hand 
very close to a moving spider with SUDs below 4, this stage was concluded. 
 
Next the participants moved to a darker, windowless office. The same process was repeated. At 
this stage, participants were also encouraged to walk through an augmented spider web placed on 
an open doorway, with augmented spiders on it. Ultimately, the participant would be walking 
around the room, surrounded by tens of augmented spiders crawling around without prompt. 
 
At SUDs below 4, the clinician left the room, and communicated with the participant via 
telecom. This was to allow the participants to feel comfortable with the feared objects on their 
own, assuring sense of control and autonomy. This stage usually took less than ten minutes until 
participants found it comfortable to walk around the room and touch the moving augmented 
spiders of various size. Treatment ended when the SUDs were below 4. 
 
After the post-treatment BAT, participants were reminded of the principles of exposure therapy 
and advised to practice at home. 
 
Control group 
After filling out the questionnaires, the participants did the BAT. They returned one week, and 
then one month later for repeating the questionnaires and the BAT.