The effect of using Virtual Reality in combination with cognitive behavioral therapy to treat driving anxiety after motor vehicle crashes

Participants randomised to the intervention group will receive an 8-week manualised Cognitive Behavioural Therapy program for driving anxiety, delivered individually by a Clinical Psychologist. Participants in both the intervention and control groups will attend one 1-hour CBT session per week for 8 weeks. The CBT component will be the same in both groups and will include psychoeducation, self-monitoring using a cognitive-behavioural emotion model, flexible thinking/cognitive restructuring, and preparation for exposure-based practice. The exposure component of treatment will occur outside the weekly CBT sessions and will be individualised for each participant and typically be 30 minutes to 1 hour per day. During the CBT sessions, the Clinical Psychologist will work with each participant to identify their specific driving-related fears, avoidance behaviours, and treatment goals. A personalised exposure hierarchy will then be developed, ranking feared driving situations from least to most distressing using Subjective Units of Distress Scale ratings. This hierarchy will guide the participant’s between-session exposure tasks and will be reviewed and adjusted during the weekly CBT sessions according to progress, tolerance, safety, and clinical need. The difference between groups relates to the mode of exposure practice completed between sessions. Participants in the control group will complete real-world driving exposure only. Participants in the intervention group will complete both real-world driving exposure and Virtual Reality Exposure Therapy. VRET will involve use of an immersive VR headset to complete simulated driving exposure scenarios relevant to the participant’s personalised exposure hierarchy, such as particular road types, traffic conditions, weather conditions, lighting conditions, or driving situations. VRET is intended to supplement, not replace, real-world exposure. For participants in the intervention group who attend online sessions, the VR headset will be posted to them before the commencement of the exposure phase, with instructions for setup and use provided by the Clinical Psychologist. For participants attending in person, the VR headset will be provided at the commencement of Session 3, when the exposure phase begins. Sessions 1 and 2 will focus on psychoeducation, self-monitoring, flexible thinking, and preparation for exposure, so the headset is not required before this point. The intervention is individualised within the manualised CBT framework. All participants receive the same core CBT program, but the specific exposure tasks are tailored to each participant’s fear profile. For example, a participant whose anxiety relates to roundabouts may complete graded exposure to roundabout scenarios, while a participant whose anxiety relates to night driving may complete exposure tasks involving low-light or night-time driving conditions. The purpose of individualisation is to ensure that exposure practice targets the participant’s own anxiety-provoking situations while maintaining consistency in the therapeutic framework. Participants in the intervention group will also complete a prescribed home-based VRET program between weekly CBT sessions. This will involve using the VR headset at home to complete clinician-prescribed exposure scenarios based on the participant’s personalised hierarchy. The home VRET program will be conservative and will focus on scenarios that have been prepared for, or comfortably achieved, during therapist-guided planning. Participants will be asked to complete at least one home VRET exposure session per day during the exposure phase, with the exact duration and frequency adjusted by the Clinical Psychologist according to the participant’s progress, tolerance, and practical circumstances. Adherence to the home VRET program will be monitored through an online VR/video management system, which allows the Clinical Psychologist to prescribe specific VR scenarios and review participant engagement with the assigned content. Participants may also be asked to record completion of exposure tasks and distress ratings to support review in the next weekly CBT session. Treatment fidelity will be supported through psychologist-completed checklists documenting delivery of the CBT protocol and, for the intervention group, prescription and review of VRET exposure tasks.