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What are you afraid of? Everybody is afraid of something. But when fear becomes extreme, with full or partial avoidance of specific objects or situations, it becomes a phobia.
If your life is disrupted by a phobia, treatment that integrates virtual reality (VR) is now available in Israel. A clinic in Herzliya Pituah (www.fearless.org.il on the web, with offices at 6 Rehov Hamada) offers phobics 3-D goggles that will gradually expose them to what terrifies them, complete with sounds to make patients feel they are really facing the object of their phobia.
Dr. Yehuda Sasson, a psychiatrist on leave from Sheba Medical Center, where he was deputy chief of psychiatry, claims his "Fearless" clinic is the only place and the country offering virtual reality treatment for phobias.
Unlike post-traumatic stress disorder (PTSD), which is triggered by a traumatic event and has to be treated quickly or it can lead to lifelong suffering, Sasson says phobias can be treated any time, although the passage of many years makes it more difficult to alleviate. If the phobia results from a traumatic event, it generalizes into other things and is more complex.
SASSON, WHO studied medicine at Tel Aviv University's Sackler School of Medicine and pursued his specialty in Beersheba's Soroka University Medical Center and at Sheba, admits to having had a phobia himself:
"I was afraid of making public appearances." But Sasson says he was successfully treated years ago (before the advent of VR), and now appears routinely in a variety of situations.
For years, before the availability of VR equipment, he has been treating anxiety, obsessive-compulsive disorder (OCD) and phobias in adults but not childen (because of insurance limitations).
There are hundreds of phobias - irrational fears - connected to anything from seeing cats and riding elevators to mall shopping, driving or taking a bath. For aviophobics, being on a plane may result in panic attacks, nausea, shaking and hyperventilation.
Most fears are natural and protective, says Sasson in an interview; being afraid of wild animals or fire can protect your life. But if fear is exaggerated, it paralyzes and reduces functioning.
AROUND ONE in five people - of every ethnic group, age, faith and background and of both sexes - suffer from some kind of phobia, says Sasson. The most common, found in 13 percent to 17%, is related to appearing, speaking, eating or drinking in public. The next in frequency is flight (aviophobia or aerophobia) and height phobias (which include a fear of bridges), followed by claustrophobia (an abnormal fear of being in enclosed or narrow places such as elevators).
Next in line are object phobias, which includes a wide range of things or creatures, from cats and dogs to snakes and insects. Many people suffer from technophobia - an irrational fear of computers.
"There is not an object, I believe, for which someone doesn't have a phobia, although when I come to think of it, I haven't heard of anyone with a cellphone phobia. But there are people who don't touch money because they regard it as 'filthy,' though that is more an obsession-compulsion."
Israelis suffer from the same phobias as people in other parts of the world, says the Fearless psychiatrist, but "they may have a bit more aviation phobia because of years of terror attacks. People can develop phobias of places where terror attacks occurred."
Sasson recalls the case of an Orthodox man who suffered from a phobia that prevented him from being able to lead prayer services. "This was before the age of VR. We helped him deal with his anxieties using cognitive behavior therapy [a form of psychotherapy that emphasizes the role of thinking in how we feel and what we do] and he gradually felt comfortable praying in front of a congregation."
A century ago, height and aviation phobias were very rare, as there were few buildings tall enough and few people took airplanes. Today, the variety of phobias has changed, he says. Well-publicized events, such as the recent collapse of a hefty bridge in the US or the flimsy Maccabiah bridge over the Yarkon a decade ago, can arouse phobias. When someone is fearful of elevators but has no choice but to use one because of the height of a building, he will probably close his eyes, go in and pray.
In the past, psychologists and psychiatrists have exposed phobia patients to objects such as cats, or taken them up elevators in a gradual process. This is called in-vivo exposure. Taking patients on planes is a much more complicated - and expensive - process that required renting a plane and performing several takeoffs and landings. Another problem is that patients may encounter friends and acquaintances who will learn of their phobia and therapy.
But this is avoided by VR. Getting patients inured to objects or situations that cause them anxiety is private and much simplified with VR, in which information arrives through the senses, just as it does in normal life, but from a computer. This leads to a feeling of alternate reality or "immersion," and the more the senses are involved and the greater the degree of accuracy in the presentation, the more difficult it is for a patient to discriminate between the "real" situation and the "virtual" reality.
A SMALL local study on VR to treat flight phobia was published recently in the Israel Journal of Psychiatry and Related Sciences. Dr. Helene Wallach of Safed College and Jezreel Valley College and Dr. Margalit Bar-Zvi of the Ziv Hospital's psychiatric outpatient clinic studied three women and one man with flight phobia who were recruited through newspaper ads and interviewed by Bar-Zvi.
The subjects were taught relaxation, and underwent eight sessions of VR, starting in a "stationary" plane and progressing through the stages to a "moving" aircraft only when their anxiety levels had been reduced. The treatment's success was tested by two actual short flights of half an hour each at the conclusion of the treatment. The authors concluded from the pilot study, which was based on a very small sample of patients, that a short VR therapy for fear of flying can be effective, and cheaper than conventional therapy, without the disadvantages of lack of anonymity and lack of control over external forces.
Psychoactive medications are not recommended for treating phobias.
VR treatment for this problem has been available for a while in the US and Europe. But although there have been several Israeli attempts to offer VR therapy for phobias - including that of Prof. Marilyn Safir at the University of Haifa's Center for the Study of Psychological Stress and Dr. Anthony Naftali at Haifa's Bnei Zion Hospital and Mount Carmel Psychotherapy Institute - Sasson claims his Fearless clinic is the only one in the country to give VR treatment combined with cognitive behavioral therapy. "We don't advertise very much," he says. "People learn about us from word of mouth."
It doesn't take long for patients to admit their phobias, as "most already know what causes their irrational fear. Initially, we train them to relax with breathing exercises. Then we use the computer program for gradual exposure to the object or situation to which they are phobic. We don't check their blood pressure, but we do speak to them and observe the effects. They generally sweat, their pulse quickens and their muscles become tense. They don't cry or scream, but they are anxious. We do it gradually, in small doses."
Sasson says he can often predict which patients will most benefit from VR treatment which covers flight, elevators, high places, bridges, closed places and appearing before the public. Sasson said he has not yet encountered cabinet ministers or MKs, but "we are ready for them."
Sasson purchased a program from the University of Atlanta in the US and uses it, along with 3D goggles, videos, a head tracker and other equipment. Each 50-minute session costs NIS 600, and people need anywhere from six to 12 sessions, depending on the phobia.
"The average is usually six for height phobias and 10 to 12 for aviophobia and fear of appearing in public," explains Sasson. "We have a 90% success rate; the remaining 10% usually have other problems as well that makes treatment more complicated. We offer additional free treatment if the sessions are not successful," he says, "but failures are unusual."
The program is modifiable, so the psychiatrist can change scenes to suit subjects' reactions.
"We don't use biofeedback, as US research has found that it doesn't add much to the treatment's success."
VR treatment of phobias is not included in the basket of health services provided by the health funds. "I wish it were," comments Sasson, "as we could help a lot more people. We are in negotiations with all the health funds, which today cover only cognitive behavior therapy for phobias."
Ironically, although the VR program used at Fearless comes from the US, VR headsets were actually invented by a Jerusalem Post editor, Gershom Gale.
The former Canadian immigrant to Israel held the earliest US patent for a virtual reality headset, but never profited from it because powerful international companies ignored the patent, and he lacked the money to invest in lawyers who would represent him.
Gale, who has been physically disabled for decades after a road accident and is now confined to a wheelchair, thought of putting a liquid-crystal display in front of each eye, combined with synchronized "three-dimensional sound" and a gamut of synthetic smells that would together put a user into another world. He was awarded US Patent No. 4,952,024 in August, 1990, after spending $12,000 on the project.
Commenting on the use of VR to treat Israeli phobics, Gale said: "I'm delighted to see the VR concept being used here, and for such a good purpose - doubly so, considering it's by an Israeli company. Now that my 1990 patent has expired, I think we can expect to see mass marketing efforts by such corporate giants as Sony, which has taken out several international VR patents in recent years that cite mine as 'prior art.'
"It will take a company the size of Sony to introduce and popularize the medium that I remain convinced will replace television."