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The effect of virtual reality exposure
therapy on focus of attention,
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self‑criticism, and interpretation bias

in university students with social
anxiety
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DOI:
10.4103/jehp.jehp_1742_22 Monir Ghasempeyvandi, Hajar Torkan1

Abstract:
BACKGROUND: The present research aims to investigate the effectiveness of virtual reality exposure
therapy on the focus of attention, self‑criticism, and interpretation bias among university students
with social anxiety.
MATERIALS AND METHODS: The present research was conducted using quasi‑experimental
research with pre‑test and post‑test control group design. The participants were university students
aged between 10 and 30 years old who had visited Isfahan counseling centers in 1399 HS. Among
53 patients referred to the counseling centers, 30 were randomly selected by convenience sampling
and then assigned to an experimental group (15 individuals) and a control group (15 individuals).
The experimental group received eight sessions of 30‑minute and face‑to‑face virtual reality‑based
interventions. In contrast, the control group remained on the waiting list. A structured clinical interview
and Social Phobia Inventory (SPIN) were used to select and screen students, and the Focus of
Attention Questionnaire (FAQ), Levels of Self‑Criticism Scale (LOSC), and revised interpretation
Master of Clinical bias inventory were applied for the pre‑test and the post‑test. Then, all the data were analyzed by
Psychology, Department a statistical analysis of covariance.
of Psychology, Faculty RESULTS: The results showed that virtual reality exposure therapy significantly reduces the symptoms
of Psychology and of the focus of attention, self‑criticism, and interpretation bias in the experimental group compared
Education, Islamic to the control group. (P < 0/01).
Azad University,
CONCLUSION: The research showed that virtual reality exposure therapy reduced the symptoms
Isfahan (Khorasgan)
of social anxiety. Therefore, this method can be applied to reduce some symptoms of social anxiety
Branch, Isfahan,
in university students.
Iran, 1Department of
Psychology, Faculty Keywords:
of Psychology and Exposure therapy, focus of attention, interpretation bias, self‑criticism, social anxiety, virtual reality
Education, Islamic
Azad University,
Isfahan (Khorasgan)
Branch, Isfahan, Iran
Introduction that students are dealing with nowadays.
Social anxiety is one of the most important
Address for
correspondence:
Monir Ghasempeyvandi,
T he development of students’ cognition,
emotion, and behavior is critical during
university. Interpersonal communication
psychological issues that affect student’s
life and education.[1] Several studies have
shown that university students’ moderate
Master of Clinical
with others is essential for students’ and severe social anxiety reaches 22.4%.[2]
Psychology, Department
of Psychology, Faculty education, life, and career. However,
of Psychology and interpersonal communication problems Moreover, university students’ different
Education, Islamic have become a common psychological issue levels of social anxiety affect their social
Azad University, performance. [3] The fear and avoidance
Isfahan (Khorasgan)
This is an open access journal, and articles are
Branch, Isfahan, Iran. distributed under the terms of the Creative Commons
E‑mail: gh.p_monir@ Attribution‑NonCommercial‑ShareAlike 4.0 License, which How to cite this article: Ghasempeyvandi M,
yahoo.com allows others to remix, tweak, and build upon the work Torkan H. The effect of virtual reality exposure
non‑commercially, as long as appropriate credit is given and therapy on focus of attention, self-criticism, and
Received: 05‑12‑2022 interpretation bias in university students with social
the new creations are licensed under the identical terms.
Accepted: 02‑02‑2023 anxiety. J Edu Health Promot 2023;12:310.
Published: 29-09-2023 For reprints contact: [email protected]

© 2023 Journal of Education and Health Promotion | Published by Wolters Kluwer - Medknow 1
 Ghasempeyvandi and Torkan: The effect of virtual reality exposure therapy on social anxiety

of social occasions and crowds often lead to severe exposure therapy’s effectiveness in various anxiety
psychological impairment and other psychological disorders. Cognitive behavior therapy is considered
disorders, such as depression and compulsion, the gold standard in the psychotherapeutic treatment
which seriously affect the healthy development of of anxiety disorders. In particular, exposure to social
personality.[4] Interpretation bias is a critical variable occasions has been reported to effectively reduce social
among patients with social anxiety—the tendency anxiety and overcome social avoidance.[16] Virtual reality
toward the negative interpretation of ambiguous exposure therapy is an alternative behavioral therapy
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social situations.[5] Interpretation bias is considered a and has shown initial clinical effectiveness in reducing
metacognitive phenomenon resulting from aberrant anxiety symptoms. Moreover, it can significantly affect
information processing.[6] People with social anxiety the assessment and treatment of mental disorders.[17]
tend to make biased interpretations in social situations.
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For instance, they would probably interpret facial Virtual reality exposure therapy simulates real‑life
expressions as negative rather than neutral or positive.[7] occasions for the patients, such as anxiety and fear.
As mentioned, when confronting new social occasions, Virtual reality exposure scenarios are very much like
they tend to interpret them threateningly due to their real‑life situations, and it is possible to adjust situational
prejudice. Also, they have experienced various negative factors such as the patient’s exposure levels and control
consequences, including increased anxiety and physical the reaction of others involved in the scenario.[18] Virtual
symptoms on social occasions. Moreover, they selectively reality exposure therapy can challenge the boundaries
recall the negative aspects of social occasions. of everyday surrounding by providing a unique ability
to stimulate environments.[19] Virtual reality treatment
According to these findings, some researchers believe involves repeated exposure and allows therapists to
that interpretation bias is critical in maintaining and practice with patients repeatedly, making training more
perpetuating social anxiety disorder.[8] Self‑criticism straightforward and accessible.[20]
is robustly associated with anxiety, and it is
considered one of its factors. Excessive self‑criticism Besides, there is also the ability to control stimuli.
is shown to be associated with a broad spectrum Because therapists can observe what really happens in
of psychological disorders, which can cause anger, the real world and overcome the limitations of imaginal
anxiety, social avoidance, delinquency, personality exposure, such as patients’ inability to create mental
disorders, interpersonal issues, and, ultimately, social images, this allows therapists to guide patients while
maladjustment.[9] Self‑criticism is considered a form of observing and supporting them. Therefore, virtual
self‑harm behavior that leads to stress and weakness. It reality exposure therapy is a valuable tool for mental
is defined as having high expectations for themselves health treatments by providing an exciting physiological
when trying to achieve goals. Self‑critical individuals and emotional experience for patients.[21] Thus, in a safe
experience vulnerability when facing obstacles and environment, patients can be exposed to others’ negative
setbacks on their way to success and their goals. They reactions to help them learn that such situations are not
are prone to depression, extreme humiliation, guilt, dangerous. Therapists can also guide patients through
unworthiness, and failure when they fail to reach high challenging moments, even dealing with the public
standards.[10] ridicule they fear the most.[22] For the effectiveness of
virtual reality exposure therapy, it is essential that the
Studies show self‑criticism is robustly associated with patients feel that they are actually in the real world,
social anxiety disorder, and individuals with social and they have to be immersed in the environment. The
anxiety show high levels of self‑criticism.[11] One of the more virtual reality imitates reality in terms of graphic
cognitive components closely related to social anxiety clarity, different types of scenarios, and their dynamic
is the focus of attention.[12] Self‑focused attention is a adaptation to the patient’s behavior, the more effective
type of cognitive processing that maintains negative it will be.[23]
emotions. [13] Self‑focused attention is defined as
an awareness of self‑referent, internally generated The results of the previous meta‑analysis on the
information that stands in contrast to an awareness effectiveness of virtual reality exposure therapy for
of externally generated information derived through anxiety disorders showed that virtual reality exposure
sensory receptors. When individuals with social anxiety therapy significantly reduces anxiety symptoms.[24]
disorder enter a social occasion, they focus on detailed Zainal et al.[25] (2021) showed that virtual reality exposure
monitoring and observations of themselves.[14] It is not therapy significantly reduced social anxiety disorder
helpful since being aware of internal information, such symptom severity. Therefore, the current research
as emotions, increases anxiety and mental images, completes the previous studies, which is in line with
which individuals may take as confirmation of their them, and it seeks to investigate the effectiveness of
negative beliefs.[15] Many years of empirical work indicate virtual reality exposure therapy on social anxiety

2 Journal of Education and Health Promotion | Volume 12 | September 2023

 Ghasempeyvandi and Torkan: The effect of virtual reality exposure therapy on social anxiety

variables, including the focus of attention, self‑criticism, with positive, negative, and neutral connotations. The
and interpretation bias. According to our review, no interviewee must rate them on a scale of 1 to 3. After
research has been conducted on the mentioned variables, the occurrence of the scenario, whatever comes to the
so further clinical research in this field would greatly interviewee’s mind immediately must be given a scale
help. The current research is the first regarding the of 1 and 0 for whatever comes to last their mind, and the
effectiveness of virtual reality exposure therapy on the remaining option is given a scale of 2. Both versions of the
focus of attention, self‑criticism, and interpretation bias questionnaire have high internal consistency; the alpha
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in individuals with social anxiety disorder. Therefore, coefficient of the self‑relevant equals 0.85, and the other
the current research attempts to show whether virtual relevant version equals 0.88, both with good ecological
reality exposure therapy significantly affects the focus validity.[26] In a study, the internal consistency of both
of attention, self‑criticism, and interpretation bias in the self‑and‑relevant versions was reported as 0.83 and
nYQp/IlQrHD3i3D0OdRyi7TvSFl4Cf3VC1y0abggQZXdtwnfKZBYtws= on 11/09/2024

university students with social anxiety. 0.79, respectively, using Cronbach’s alpha method.[27]
In the present study, the calculated Cronbach’s alpha
Materials and Methods coefficient for the entire questionnaire was equal to 0.81.

Study design and setting Display, headset, and social phobia treatment
The current research was conducted using application based on virtual reality technology
quasi‑experimental research with pre‑test and post‑test In this research, a three‑dimentional application based
control group design. The statistical population consisted on virtual reality technology was used for exposure
of 53 university students. They were aged between 18 therapy; It is called Speech Trainer and made by the
and 30 with social anxiety symptoms. They also visited Stream companies. The therapy consisted of eight
Isfahan counseling centers in 1399 HS. sessions lasting from 10 to 20 minutes. In a simulated
environment, the participant started observing and
Study participants and sampling presenting a text in the presence of the audience. In
Due to the pandemic COVID_19, 30 eligible university order to make it happen, they were given a virtual reality
students were selected by convenience sampling, then (VR) headset, a microphone to hear the reflection of their
randomly assigned to two groups (15 individuals each), voice, and two remote controls; one as a laser pointer and
15 people in the experimental group and 15 people in the other as a microphone [Table 1].
the control group. Both groups were pre‑tested, and the
experimental group received virtual reality exposure Levels of self‑criticism scale
therapy. However, the control group did not receive any This questionnaire was designed by Thompson and
treatments; then post‑test was conducted. Zuroff (2004) to measure Comparative Self‑Criticism
and Internalized Self‑Criticism. It is a 22‑item self‑report
Eligibility and inclusion criteria questionnaire on a scale of 7, ranging from 0 (strongly
Participants must be university students aged between disagree) to 6 (strongly agree)[28] Another research
19 and 30 with no multiple acute psychiatric. They must reported an appropriate internal consistency (Cronbach’s
be diagnosed with social anxiety disorder, confirmed by Alpha = 0.90) for this scale.[29] In Iran, the validity
a clinical psychologist. and reliability of self‑criticism were calculated using
Cronbach’s alpha. The calculated value for the
Exclusion criteria comparative and internalized self‑criticism was reported
Participants must have one psychotic disorder or the full as 0.87 and 0.55, respectively.[30] The reliability of the
criteria of other mental disorders. present questionnaire was calculated using Cronbach’s
alpha, which equals 0.84.
Statistical analysis was performed by using the SPSS‑25
software and the Covariance method. Social phobia inventory
This questionnaire was first developed in 2000 by Connor
Data Gathering Tools and Techniques et al.[31] to measure social anxiety. It is a 17‑item self‑report
questionnaire composed of three subscales: Fear (six
Revised interpretation bias inventory items), avoidance (seven items), and physiological
The revised interpretation bias inventory was applied in symptoms (four items), and each item is measured on a
the present research. The questionnaire has two versions, 5‑point Likert scale. The subscale scores are obtained by
the self‑relevant version (22 items) and the other relevant summing the scores of its items. The test‑retest validity
version (22 items). Each version comes with subscales of this scale in individuals diagnosed with social phobia
of ambiguous social situations or scenarios (15 items) is 0.78 to 0.89, and its internal consistency is reported in
and ambiguous non‑social situations or scenarios (7 normal individuals as 0.94. In another research on an
items). Each item includes three interpretive options Iranian sample, the reliability of this scale was obtained
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 Ghasempeyvandi and Torkan: The effect of virtual reality exposure therapy on social anxiety

Table 1: A Summary of Virtual Reality Therapy the internal consistency coefficient for the subscales of
Sessions Protocols self‑focused attention and other‑focused attention was
Session Content of Sessions reported as 0.75 and 0.86, respectively.[34] The reliability
1 acquaintance interview; conducting the pre‑tests, making of the present questionnaire was calculated using
the participant familiar with the concept of social anxiety,
Cronbach’s alpha, which was 0.82.
therapy procedures, tools, and equipment; simulating a
public place for the participant using VR (as the audience
in a conference hall is observing them) Ethical considerations
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2 Leaving the participant in a virtual conference hall under According to the ethical principles in the research, the
constant observation by the audience, then discussing participants were assured that their information would
anxiety triggers during the presentation. be confidential, and an informed consent form was
3 Rehearsal of the second session: Leaving the participant
given to all the participants. This research has achieved
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in a virtual conference hall under constant observation by

the audience, then discussing anxiety triggers during the the code of ethics from the Islamic Azad University
presentation of Isfahan (Khorasgan) under the number IR.IAU.
4 Leaving the participant in a conference hall under constant KHUISF.1399.215.
observation by the audience; then they are asked to read
a text for the audience loud and clear. Findings
5 Rehearsal of the fourth session: Leaving the participant in
Table 2 shows the demographic characteristics of the
a conference hall as they are under constant observation
by the audience; then they are asked to read a text for the research sample.
audience loud and clear
6 Leaving the participant in a seminar hall as they are under According to the Chi‑square test results, there is no
constant observation by the audience, then they are asked significant difference in the distribution of variables of
to make a speech from a provided text while making eye education, age, and level in the two groups (P < 0.05).
contact with the audience
Descriptive indices related to the research variables are
7 Rehearsal of the sixth session: Leaving the participant in a
seminar hall as they are under constant observation by the
presented in Table 3 by type of test and group. First, the
audience, then they are asked to make a speech from a assumptions of this test were examined.
provided text while making eye contact with the audience
8 We continue the practice of being in a virtual conference Multivariate analysis of covariance (MANCOVA) was
hall, under constant observation by the audience, and used to investigate the effectiveness of virtual reality of
presenting a new provided text in a more extended period exposure therapy with the scales of focus of attention,
than the previous ones while making more prolonged eye
contact with the audience. The post‑tests will be taken
self‑criticism, and interpretation bias in patients with
from the participant using the same tools as the pre‑test social anxiety disorder.
immediately after this session.
(Adapted from North, North, and Koble’s Virtual Reality Therapy Protocol) Table 4 shows the normality of data distribution for
all variables in both groups, including the pre‑test and
by Cronbach’s alpha and reported as 0.94 and the post‑test stages. Besides, in Levene’s test, the variable
test‑retest coefficient of 0.96.[32] In the mentioned research, F is not significant for all variables. Therefore, this
Cronbach’s alpha coefficient for the whole questionnaire assumption that the variances are equal is tenable. The
was found to be 0.86. assumption of homogeneity of the variance‑covariance
matrices for the variables is fulfilled. The results of the
Focus of attention questionnaire multivariate analysis of covariance (MANCOVA) on the
This questionnaire was developed by Woody, Chambless, post‑test stage after controlling the effects of the pre‑test
and Glass to assess the focus of attention of individuals have been presented in Table 5.
with social anxiety in social situations. The FQA
is a self‑report measure and consists of five‑item The multivariate analysis of covariance results showed
a significant difference between the mean of focus of
subscales to assess self‑focused attention (FAQ inter) and
attention, self‑criticism, and interpretation bias in the
other‑focused attention (FAQ extern). Each item is indicated
experimental and control groups. The results indicate
on a 5‑point Likert scale (1 = not at all to 5 = the whole
the effectiveness of virtual reality exposure therapy
time). Participants respond to each item based on their
compared to the control group.
perception of the previous social attractions. The score
of each subscale is obtained by summing the scores of Discussion
all five items. The Cronbach’s alpha coefficient for the
subscales of self‑focused attention and other‑focused The present study was designed to determine the effect of
attention was reported to be 0.76 and 0.72, respectively. virtual reality exposure therapy on the attention of focus,
The construct validity of this scale using principal self‑criticism, and interpretation bias. The results of this
component analysis was investigated by Woody et al.[33]; investigation indicated that virtual reality exposure
they also confirmed the two‑factor structure. In Iran, therapy significantly affects the focus of attention,
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 Ghasempeyvandi and Torkan: The effect of virtual reality exposure therapy on social anxiety

Table 2: Frequency distribution table and percentage frequency of the research groups
Variable Virtual Reality Exposure Therapy Control Group
Frequency Frequency % Frequency Frequency %
Education
BA student 8 53/3 10 66/7
MA student 7 46/7 5 33/3
Total 15 100 15 100
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Chi‑Square 0/56
Significance P=0/98
Age
Up to 20 3 20 2 13/3
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21 to 25 8 53/3 9 60
26 to 30 4 26/7 4 26/7
Total 15 100 15 100
Chi‑Square 6/87
Significance P=0/81
Social Anxiety Levels
Moderate 6 40 7 46/7
Severe 6 40 5 33/3
Very severe 3 20 3 20
Total 15 100 15 100
Chi‑Square 0/17
Significance P=0/92

Table 3: Mean and standard deviations for the two the patients so that they can evaluate their limitations
groups of the research variables and performance. Hence, they will undoubtedly
Variable Stage Control Group Virtual Reality experience less self‑criticism and anxiety during the
Exposure Therapy
extinction process in the following sessions. Excessive
M SD M SD
and constant interpretation bias as a cognitive deficit
Focus of Pre‑test 33/27 3/22 33/80 2/57
attention
can result in cognitive disorders. Individuals with
Post‑test 33/33 1/57 29/80 3/84
social anxiety tend to interpret new social occasions
Self‑criticism Pre‑test 77 13/92 81/67 16/05
Post‑test 76/93 13/87 73/07 13/51
as negative and threatening. Virtual reality exposure
Interpretation Pre‑test 87/67 9/79 93/54 8/28 therapy creates a simulated social setting that reduces
bias Post‑test 91/73 3/90 87/53 8/54 attention bias toward threats, negative self‑evaluations,
and interpretation bias. As a result, virtual reality
exposure therapy reduces interpretation bias and
self‑criticism, and interpretation bias in university
ineffective judgments of individuals towards themselves.
students with social anxiety disorder. Although
Moreover, virtual reality exposure therapy has increased
extensive research has been carried out, no studies have
other‑focused attention in university students with social
specifically covered the mentioned criteria. However,
anxiety when confronting new situations and interacting
the present findings are consistent with those of Fodor
socially. In virtual reality exposure therapy, individuals
et al.[24] and Zainal et al.,[25] indicating that virtual reality
exposure therapy has a promising effect on the treating with social anxiety are more involved with external and
social anxiety disorder. other‑focused attention than internal and self‑focused.
In other words, virtual reality exposure therapy is more
The results imply that virtual reality exposure therapy focused on individuals and interactions in a social setting
helps them build courage and bravery to confront their rather than the symptoms of the individuals.
weaknesses and failures. It also improves self‑acceptance
and a healthy sense of self‑worth. Social anxiety Limitations and recommendation
leads to negative self‑evaluations and, consequently, The current investigation was limited to 18–30 university
rumination and self‑criticism. As a result, it makes students with social anxiety disorder, and the findings
individuals with social anxiety more vulnerable. They cannot be transferred to the whole society. The most
constantly feel anxious about being scrutinized and important limitation lies in the fact that it was not feasible
losing self‑control; then, they feel guilty for having to tailor a virtual reality exposure therapy (VRET) movie
such emotions and continue with the rumination.[35] specifically for individuals. Future studies should
Deliberate and long‑term exposure in a safe environment therefore concentrate on individuals with social anxiety
provides a virtual world and a safe environment for with no age limit. In addition, it is recommended to
Journal of Education and Health Promotion | Volume 12 | September 2023 5
 Ghasempeyvandi and Torkan: The effect of virtual reality exposure therapy on social anxiety

Table 4: The results of the Shapiro‑Wilk and Levene’s test on research variables at the general level
Number Variable Shapiro‑Wilk Test Leven’s Test MBox Test
Statistics Significance Statistics Significance Statistics Significance
1 Focus of attention (Pre‑test) 0/96 0/39 ‑ ‑ 46/55 0/06
2 Focus of attention (Post‑test) 0/92 0/021 2/94 0/1
3 Self‑criticism (Pre‑test) 0/94 0/08 ‑ ‑
4 Self‑criticism (Post‑test) 0/96 0/39 1/35 0/25
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5 Interpretation bias (Pre‑test) 0/96 0/35 ‑ ‑

6 Interpretation bias (Post‑test) 0/95 0/29 6/46 0/02

Table 5: Results of the Multivariate Analysis of Covariance (MANCOVA) on the Post‑Test Stage after Controlling
nYQp/IlQrHD3i3D0OdRyi7TvSFl4Cf3VC1y0abggQZXdtwnfKZBYtws= on 11/09/2024

the Effects of the Pre‑Test

Variable Resource of Sum of Degree of Mean Coefficient Significance Eta Power of
Changes Squares Freedom Square F Level Squared a Test
Focus of Pre‑test effect 163/87 1 163/87 57/86 0/001 0/71 1
attention Group Membership 91/15 1 91/85 32/18 0/001 0/57 1
Error 67/98 24 2/83 ‑ ‑ ‑ ‑
Total 335/37 29 ‑ ‑ ‑ ‑ ‑
Self‑Criticism Pre‑test effect 4014/45 1 401/454 486/54 0/001 0/95 1
Group Membership 306/72 1 306/72 37/17 0/001 0/61 1
Error 198/03 24 8/25 ‑ ‑ ‑ ‑
Total 5360 29 ‑ ‑ ‑ ‑ ‑
Interpretation Pre‑test effect 923/69 1 923/69 104/12 0/001 0/81 1
Bias Group Membership 76/07 1 76/07 8/57 0/007 0/26 0/80
Error 212/91 24 8/87 ‑ ‑ ‑ ‑
Total 1366/976 29 ‑ ‑ ‑ ‑ ‑

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