Robert Reiner, Ph.D., BCN, BCB, is the Executive Director and founder of Behavioral Associates
and has been practicing psychology since 1981. Dr. Reiner is well known
for his work in treating anxiety and phobias through biofeedback and
virtual reality therapy. He has had great success in treating clients
who have a fear of flying which was documented on an episode of the National Geographic Show.
Dr. Reiner can frequently be seen in the news and media and is often
makes appearances on major news networks for his expert opinion. He
currently serves on the faculty for the Department of Psychiatry at New
York University Medical Center and is a guest lecturer at the University
of Pennsylvania psychology department.
SZ: You’ve been a practicing psychologist for thirty-five years. When did you begin to incorporate Virtual Reality into your practice and why?
RR: When I was a psychology graduate student I remember when the curriculum turned to Joseph Wolpe and Systematic Desensitization it seemed like a great theory and made complete sense from a Behavioral and Learning Theory perspective. I also thought very few clients would develop vivid imagery or sufficient imagery around something they fear because it’s something they have spent their whole life avoiding. For example, if you have a fear of flying you’re not going to generate good imagery about being in an airplane. This was in the 70’s and I remember thinking that if something like Virtual Reality ever became available it would not only confirm Wolpe’s theory but also revolutionize the profession because the process forces the client to confront what they are afraid of.
In 1999 I was watching CNN and sure enough it had happened. The technology had finally become available. I started making a lot of phone calls and as luck would have it there was a big conference two weeks away on Virtual Reality. I attended the conference and met the major player’s and I was trying to find out what system to buy. There was an American Company called Virtually Better that cost 15k in 1999 money. There was also a company out of Spain called, Previ, that was piggy backing on the Virtually Better research. They were selling their system for 2k. I initially bought the Previ but tech support was a challenge. I sold it back to them and bought the Virtually Better system which I have used until recently.
SZ: You foresaw the future and got on board.
RR: Yeah, I always knew it would work. I suspected that the use of V.R. would force the client to face what they are afraid of and it turned out the quality of the V.R. didn’t have to be that good for it to work. You just had to activate part of the clients autonomic system, not the whole thing. The early graphics were very cartoonish. But we were getting success rates of about sixty percent which is respectable. I’ve always been a biofeedback person. I was doing biofeedback as a graduate student. I tore my left trapezious muscle and someone turned me on to EMG biofeedback and I was hooked.
When I interned at NYU Medical Facility, Bellevue Hospital, they built a lab for me. I had all these stand alone machines, we didn’t have the computers that are available today. I combined Heart Rate Variability, (HRV) and Galvanic Skin Response (GSR) and our success rate became over ninety percent. It made sense because the very nature of HRV is that it disables the bodies Fight or Flight response. The goal is to pair something like fear of flying with something that’s so relaxing it can put you to sleep. This process has been a major game changer in my career.
SZ: A client comes to see you for treatment of fear of flying. What would be the treatment steps?
RR: At Behavioral Associates we see about six to one clients who have
a fear of flying. That’s what we are known for but we work with clients
with all sorts of phobias. Basically a client comes in and during the
first session I will hook them up to a bunch of biofeedback sensors and I
will show them the V.R. equipment and program only because one, the
client wants to see it and what we will be doing, and two, I want to see
if their body registers a response to the GSR device. It they don’t
register a reaction then there’s a problem, V.R. isn’t going to work.
SZ: If someone is on medication it can dampen their systems response.
RR: Even if someone is taking tranquilizers they can still have a panic attack. Medication for the most part will not block a panic attack unless you are unconscious. If the client is just a nervous flyer but not a phobic person medication can make them less uncomfortable but nothing is going to block a panic attack. It’s like a tsunami and will roar right through. The first session informs me and the client whether they are a candidate for V.R. The next step is teaching the client HRV and that usually takes about 3-4 weeks on average.
SZ: With assignments at home?
RR: Yes. I can have them use a metronome or even a harmonica is good. I play the blues harmonica and I have them pull out their smart phone and use the voice recorder of me playing the harmonica at their optimal breath rate. Ninety-five percent of the populations optimal breath rate is six breaths per minute. I make it clear to the client they need to practice everyday. It is easy to spot how much a person has practiced and that is a big motivator. I ask the client to e-mail me each day and let me know their experience, when they practiced, and for how long which helps them feel like they are on top of things. I reinforce that the more they practice the exercise the more they will get out of it and the quicker they will be flying. If they aren’t practicing it will be obvious.
Usually within 3-4 weeks they get it. I know they have gotten it when I can turn off the monitors and the client is able to self regulate. That’s a critical step. After the client has a grasp on HRV we start pairing the breathing with V.R., fear of flying. One of the early V.R. scenes is of them being at the airport gate waiting to board. Some of the programs go much further back having the client packing for the trip at home. During this process I make it very clear to the client how important it is that they do not behave protectively. This means to the extent that a person acts like a phobic person which is in actions like calling turbulence.com a website for the weather.
Turbulence is probably the thing people fear the most. It doesn’t matter if I explain to them that turbulence cannot bring a plane down anymore than if there is a hurricane and you have a wine cork floating in the ocean, the cork will not sink to the bottom of the ocean. It may get rocked around quite a bit but it’s not going anywhere.
SZ: Preconceived fears of what’s going to happen in the absence of reality?
RR: Not necessarily because some of these people actually do fly but they are just miserable when they fly. Most of them had a bad flight. The plane hit an air pocket and dropped a thousand feet and they were nervous to begin with. So they just stop flying. I explain to them that when they do fly they have to work at a muscular skeletal level on acting as if they are relaxed even if their stomach is turning somersaults. Staying relaxed at a muscular skeletal level is really important because the brain is monitoring muscular skeletal activity. The brain notices if the client is acting nervous then it must be dangerous. That’s why phobias become progressively worse over time.
But at this stage of treatment which is usually session five I expose them to V.R. and pairing the V.R. with breath. That’s usually a challenge because the client gets really anxious as our systems are pretty realistic. When the client is wearing the V.R. goggles they can’t see their breath rate. The early V.R. screens are easy and gradually becomes tougher. After the fifth session it takes about twenty more sessions before the client is ready to fly. It will then be another five to ten more sessions before treatment is complete.
The biggest issue we have that I still am working on the solution to is I know when the client is ready to fly but they have no successful experience to draw upon and they can’t possibly be aware of the affect of the counter-conditioning. They have to take my word for it. Most people get through it, but some people just run off the plane they are that scared. But I warn them. So I tell them I’m not insulted. I know it’s terrifying for them and they have no positive experiences yet to draw upon, but when they do the breathing it typically works out.
SZ: But they are not yet able to sit long enough to get through the experience?
RR: Right, it’s tough because they are most afraid of fear of flying
and they are also afraid that they’ve wasted all this money. There is an
article written by a client who came to see me to overcome her fear of flying. The article gives a snapshot of her experience.
There are two kinds of reinforcement, positive and negative. Negative reinforcement is a tough sell because it’s the termination of an averse stimulus. Where as positive reinforcement is getting something really good like a great dessert or a vacation something that’s an easy sell. Telling someone they are going to come here and I am going to make them miserable but then I’m going to stop it is not an easy sell. It’s like hitting myself in the head with a hammer because it feels good to stop.
SZ: A lot of this is about your relationship with the client. Trust in you overrides some of the unknown fears. That’s a huge part of the gap between the treatment and the client making it through the journey.
RR: I agree with you. I think you need all your therapy skills.
SZ: Also personality, possessing the interpersonal skills so the client believes what you taught them and can walk that unknown path drawing on that training.
RR: You know those classes where people go to the airport and they explain the physics of flying? This is not talk therapy. It’s not the system that you are working with. It’s the unconscious stuff that you can’t control. It all happens below the radar. We are working with the limbic system.
SZ: How do your clients describe their experience using V.R. as part of their treatment for fear of flying?
RR: They like it. It works and they know it’s realistic. They feel immersed in it and think it’s cool.
SZ: Dr. Reiner thanks so much for taking the time out of your very busy schedule to talk with me about V.R. and it’s uses.
SZ: You’ve been a practicing psychologist for thirty-five years. When did you begin to incorporate Virtual Reality into your practice and why?
RR: When I was a psychology graduate student I remember when the curriculum turned to Joseph Wolpe and Systematic Desensitization it seemed like a great theory and made complete sense from a Behavioral and Learning Theory perspective. I also thought very few clients would develop vivid imagery or sufficient imagery around something they fear because it’s something they have spent their whole life avoiding. For example, if you have a fear of flying you’re not going to generate good imagery about being in an airplane. This was in the 70’s and I remember thinking that if something like Virtual Reality ever became available it would not only confirm Wolpe’s theory but also revolutionize the profession because the process forces the client to confront what they are afraid of.
In 1999 I was watching CNN and sure enough it had happened. The technology had finally become available. I started making a lot of phone calls and as luck would have it there was a big conference two weeks away on Virtual Reality. I attended the conference and met the major player’s and I was trying to find out what system to buy. There was an American Company called Virtually Better that cost 15k in 1999 money. There was also a company out of Spain called, Previ, that was piggy backing on the Virtually Better research. They were selling their system for 2k. I initially bought the Previ but tech support was a challenge. I sold it back to them and bought the Virtually Better system which I have used until recently.
SZ: You foresaw the future and got on board.
RR: Yeah, I always knew it would work. I suspected that the use of V.R. would force the client to face what they are afraid of and it turned out the quality of the V.R. didn’t have to be that good for it to work. You just had to activate part of the clients autonomic system, not the whole thing. The early graphics were very cartoonish. But we were getting success rates of about sixty percent which is respectable. I’ve always been a biofeedback person. I was doing biofeedback as a graduate student. I tore my left trapezious muscle and someone turned me on to EMG biofeedback and I was hooked.
When I interned at NYU Medical Facility, Bellevue Hospital, they built a lab for me. I had all these stand alone machines, we didn’t have the computers that are available today. I combined Heart Rate Variability, (HRV) and Galvanic Skin Response (GSR) and our success rate became over ninety percent. It made sense because the very nature of HRV is that it disables the bodies Fight or Flight response. The goal is to pair something like fear of flying with something that’s so relaxing it can put you to sleep. This process has been a major game changer in my career.
SZ: A client comes to see you for treatment of fear of flying. What would be the treatment steps?
It begins with breath
Client is hooked up to sensors and V.R. to see if they are candidates for treatment
People think they have to get really immersed in V.R. for it to be
effective but that’s not true. All that has to happen is that the
autonomic system fires and you measure that with GSR or Electrodermal
activity (EDR). We also collect baseline data on their breathing
habits. Almost all these clients hyperventilate when they become
anxious.
RR: Even if someone is taking tranquilizers they can still have a panic attack. Medication for the most part will not block a panic attack unless you are unconscious. If the client is just a nervous flyer but not a phobic person medication can make them less uncomfortable but nothing is going to block a panic attack. It’s like a tsunami and will roar right through. The first session informs me and the client whether they are a candidate for V.R. The next step is teaching the client HRV and that usually takes about 3-4 weeks on average.
SZ: With assignments at home?
RR: Yes. I can have them use a metronome or even a harmonica is good. I play the blues harmonica and I have them pull out their smart phone and use the voice recorder of me playing the harmonica at their optimal breath rate. Ninety-five percent of the populations optimal breath rate is six breaths per minute. I make it clear to the client they need to practice everyday. It is easy to spot how much a person has practiced and that is a big motivator. I ask the client to e-mail me each day and let me know their experience, when they practiced, and for how long which helps them feel like they are on top of things. I reinforce that the more they practice the exercise the more they will get out of it and the quicker they will be flying. If they aren’t practicing it will be obvious.
Usually within 3-4 weeks they get it. I know they have gotten it when I can turn off the monitors and the client is able to self regulate. That’s a critical step. After the client has a grasp on HRV we start pairing the breathing with V.R., fear of flying. One of the early V.R. scenes is of them being at the airport gate waiting to board. Some of the programs go much further back having the client packing for the trip at home. During this process I make it very clear to the client how important it is that they do not behave protectively. This means to the extent that a person acts like a phobic person which is in actions like calling turbulence.com a website for the weather.
Turbulence is probably the thing people fear the most. It doesn’t matter if I explain to them that turbulence cannot bring a plane down anymore than if there is a hurricane and you have a wine cork floating in the ocean, the cork will not sink to the bottom of the ocean. It may get rocked around quite a bit but it’s not going anywhere.
SZ: Preconceived fears of what’s going to happen in the absence of reality?
RR: Not necessarily because some of these people actually do fly but they are just miserable when they fly. Most of them had a bad flight. The plane hit an air pocket and dropped a thousand feet and they were nervous to begin with. So they just stop flying. I explain to them that when they do fly they have to work at a muscular skeletal level on acting as if they are relaxed even if their stomach is turning somersaults. Staying relaxed at a muscular skeletal level is really important because the brain is monitoring muscular skeletal activity. The brain notices if the client is acting nervous then it must be dangerous. That’s why phobias become progressively worse over time.
But at this stage of treatment which is usually session five I expose them to V.R. and pairing the V.R. with breath. That’s usually a challenge because the client gets really anxious as our systems are pretty realistic. When the client is wearing the V.R. goggles they can’t see their breath rate. The early V.R. screens are easy and gradually becomes tougher. After the fifth session it takes about twenty more sessions before the client is ready to fly. It will then be another five to ten more sessions before treatment is complete.
The biggest issue we have that I still am working on the solution to is I know when the client is ready to fly but they have no successful experience to draw upon and they can’t possibly be aware of the affect of the counter-conditioning. They have to take my word for it. Most people get through it, but some people just run off the plane they are that scared. But I warn them. So I tell them I’m not insulted. I know it’s terrifying for them and they have no positive experiences yet to draw upon, but when they do the breathing it typically works out.
SZ: But they are not yet able to sit long enough to get through the experience?
V.R. brings realistic experiences to client
There are two kinds of reinforcement, positive and negative. Negative reinforcement is a tough sell because it’s the termination of an averse stimulus. Where as positive reinforcement is getting something really good like a great dessert or a vacation something that’s an easy sell. Telling someone they are going to come here and I am going to make them miserable but then I’m going to stop it is not an easy sell. It’s like hitting myself in the head with a hammer because it feels good to stop.
SZ: A lot of this is about your relationship with the client. Trust in you overrides some of the unknown fears. That’s a huge part of the gap between the treatment and the client making it through the journey.
RR: I agree with you. I think you need all your therapy skills.
SZ: Also personality, possessing the interpersonal skills so the client believes what you taught them and can walk that unknown path drawing on that training.
RR: You know those classes where people go to the airport and they explain the physics of flying? This is not talk therapy. It’s not the system that you are working with. It’s the unconscious stuff that you can’t control. It all happens below the radar. We are working with the limbic system.
SZ: How do your clients describe their experience using V.R. as part of their treatment for fear of flying?
RR: They like it. It works and they know it’s realistic. They feel immersed in it and think it’s cool.
Specializes in helping clients overcome fear of flying with biofeedback and V.R.
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