Developing a Virtual Reality Training Tool for Exposure Therapy: Simulated Exposure Trainer (SET)
Phase: NA
Conditions: Low-immersion (Mobile Device), High-immersion (Head Mounted Display)
Sponsor: Bradley Hospital

 
 
 
 
 
 
Study Protocol & Analytic Plan:  
 
Developing a Virtual Reality Training Tool for Exposure 
Therapy: Simulated Exposure Trainer (SET-VR) 
 
 
Protocol Version 1 – June 2022 
IRB Approval Date: 6.27.22 
 
ClinicalTrials ID: NCT06706245 
 
 
 

Protocol: Developing the Simulated Exposure Trainer (SET-VR) 
 
RESEARCH OBJECTIVES:  
Exposure-based cognitive-behavioral therapy (CBT) is highly efficacious and a front-line treatment for anxiety 
disorders and obsessive-compulsive disorder8-13. Despite clear efficacy, exposure therapy remains one of the 
least utilized EBPs to treat anxiety3-5. Even among providers with specialized training in exposure, less than half 
report use with anxious patients1. This suggests our current training paradigms for exposure therapy require a 
shift, incorporating innovative theory-driven approaches capable of addressing barriers to dissemination. 
Effective therapist training capable of changing therapist behavior is a core component in the 
dissemination of EBPs14,15. Experiential activities (e.g., role-play) are more likely to produce a change in therapist 
practice as compared to passively delivered didactic instruction16. Virtual training environments are well-
equipped to overcome issues related to representativeness, replicability, individualization, standardization and 
economic scalability, all of which limit the efficacy and reach of role playing and other (non-technological) 
experiential training tasks. To our knowledge, virtual reality (VR) has yet to be leveraged as an experiential 
training strategy for promoting the delivery of psychotherapeutic strategies. VR platforms have strong support 
for their efficacy in treating patient anxiety. Accordingly, VEs may be especially successful in promoting 
“exposure to exposure” during the training of exposure therapists. 
This study will develop SET™ utilizing simulated interactions with an anxious VP to target and reduce 
therapist negative beliefs about exposure. SET™ will be developed to be delivered via two media methods: Head 
Mounted Display (HMD; hypothesized as high-immersion) and a web-based (WB; via laptop or mobile device; 
hypothesized as low-immersion). The goal is to test which platform provides an ideal balance of usability, target 
engagement (i.e., negative belief change), and scalability.  
 
SUBJECT RECRUITMENT: 
Study setting. Study procedures will take place at Bradley Hospital.  
 
Participants. Training trial clinicians (N=40) will be recruited from local mental health agencies as well as private 
practice. Trial clinicians will be naïve to exposure therapy and will self-select for the training.  
 
METHOD AND PROCEDURES: 
Overview. This study will develop SET™ based upon clinically-derived anxious behaviors by creating VP 
animations and learner interaction features to target and reduce therapist negative beliefs about exposure. An 
experimental therapeutics framework will be applied to a brief training trial to demonstrate initial engagement of 
our learning target (i.e., therapist negative beliefs about exposure). 
 
Training Trial to Test Learning Target Engagement.  
Training Trial Overview. Therapists seeking exposure training (N=40) will be recruited to complete a 
training workshop in exchange for continuing education credits (CEs) and monetary compensation. Therapists 
will be randomly assigned to interact with one of the SET™ delivery methods (i.e., HMD or WB). All therapists 
will receive the same 4-hour didactic instruction in exposure therapy followed by experiential VR training (2 
hours) with the assigned delivery method. Our learning target (negative beliefs) measure will be given at multiple 
timepoints to isolate the specific, incremental effect of the experiential component on our beliefs target (see 
Table 1). The two conditions will operate as a tandem case-series analysis that evaluates whether therapists in 
both conditions reach an a-priori target engagement benchmark.  
Training Trial Outcome Measures. Therapist Negative Beliefs about Exposure Scale (TBES)2. The 
TBES assesses the extent to which therapists endorse 21 negative beliefs about exposure therapy. The TBES 
is the primary outcome measure for assessing target engagement. Exposure Knowledge.6 We have condensed 
the original 49 multi-choice item measure by selecting 12 multiple-choice items that best fit the didactic content 
of our training. Exposure Self-Efficacy.6 This is a 27-item measure of therapists’ confidence in delivering 
exposure therapy. This measure has demonstrated high internal consistency and predictive validity in 
determining the frequency of self-reported clinical use of exposure therapy.  
 
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Deacon BJ, Farrell NR, Kemp JJ, et al. Assessing therapist reservations about exposure therapy for anxiety disorders: The Therapist 
Beliefs about Exposure Scale. J Anxiety Disord. 2013;27(8):772-780. doi:10.1016/j.janxdis.2013.04.006  
 
 

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Chorpita BF, Daleiden EL, Ebesutani C, et al. Evidence‐based treatments for children and adolescents: An updated review of 
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Analytic Plan 
 
Statistical analyses were carried out using SAS version 9.4 1M7 (The SAS Institute, Cary NC). Knowledge, 
Self Efficacy, and TBES were assessed longitudinally and analyzed via binomial Generalized Estimating 
Equations (GEE). SUS, VPE, and TARS were only assessed at the conclusion of the study and were analyzed 
using a binomial generalized linear model. Both sets of analyses used the binomial distribution to constrain the 
model space to the range of the measures being used. The scores were first shifted to have a minimum score 
of zero by subtracting the minimum score possible. This was used as the binomial number of “successes”, and 
the range of the score was used as the number of “trials”. Classical sandwich estimation was then used to better 
incorporate any differences in empirical variances and covariances. Both raw and adjusted (where appropriate) 
p-values were presented as well as unadjusted 95% confidence intervals. For GEEs, 16 different hypotheses 
were tested using orthogonal linear estimates: a) changes from baseline conditions in each condition (8 total), 
b) high- and low-immersion training conditions compared at each time point cross sectionally (4), and as c) 
condition comparisons in changes from baseline for each follow-up (4). The Holm test was used to calculate 
adjusted p-values maintaining familywise alpha at 0.05 across all 16 hypothesis tests in GEEs. For all other 
models, only one hypothesis was tested comparing the conditions.