Investigating the effectiveness of ailurophobia treatment using virtual reality technique compared to metacognitive therapy: a randomized clinical trial

Abstract

Background

Fear of cats as a specific phobia disorder can cause disruption in some aspects of the affected people’s lives. On the other hand, due to the fact that the two approaches of metacognitive treatment and behavioral therapy methods such as virtual reality are considered common treatment methods in anxiety disorders; It seems that it is necessary to examine the two approaches based on the effectiveness, durability and cost-benefit issue to present and introduce to therapists.

Methods

The present study was a Randomized Clinical Trial study that was conducted on 28 patients with Ailurophobia. Based on simple random sampling, the participants were allocated in two groups: metacognitive intervention and virtual reality intervention. In order to collect data, demographic information questionnaire, cat anxiety questionnaire and researcher-made cat fear questionnaire were used. Data analysis was done with SPSS version 22 software and statistical tests of chi-square, t, analysis of variance. An alpha level of less than 0.05 was considered as a significant level.

Results

The results of the study showed that there was a statistically significant difference between the average anxiety score in the two groups of virtual reality and metacognitive therapy (P˂0.001). So that in the virtual reality group, the anxiety score was significantly reduced. Also, other results of the study indicated that the mean score of the fear of cats scale was significantly lower in the virtual reality group than in the metacognitive therapy group (P˂0.001).

Conclusions

Although both treatment approaches based on virtual reality and metacognition are effective in reducing the level of anxiety and fear of cats in patients with Ailurophobia; However, the effectiveness and continuity of treatment in people receiving virtual reality treatment are more significant.

IRCT registration number

IRCT20230105057057N1. Registration date: 2023-03-04.

Registry

Iranian Registry of Clinical Trials.

Background

A specific phobia is characterized by a “specific and persistent fear that is excessive or irrational, caused by the presence or anticipation of a specific object or situation” [1]. It becomes significant in the daily functioning of the affected person at home, work or school and in relationships [2]. Five types of specific phobias involving animals. Environment; blood, injection or injury; Situations such as airplanes, driving, and closed spaces [3] and other fears such as choking, vomiting, certain noises, or types of people are less common [4].

In the core of specific phobia, unrealistic beliefs about threat and danger are common to all fears, so that the cognitive behavioral models of specific phobias show that beliefs about threat by avoiding the fearful situation is a recurring process in affected patients [5, 6]. Some phobias can develop following a traumatic experience [7], but not all people who experience a traumatic event develop a phobia [8, 9]. Among motor vehicle accident survivors, there may be an increased risk of travel anxiety, characterized by negative beliefs about the inherent risk of travel and anticipation of travel anxiety or distress [10]. Fear of cats is called ailurophobia, which is derived from the Greek root alurios meaning cat and phobia meaning fear. Of course, in the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders¹, there is no special name for fear of cats, but in general, specific phobias are mentioned, which include fear of cats. A specific phobia Marked fear or anxiety about a specific object or situation (e.g., flying, heights, animals (such as Ailurophobia, describes fear of cats) receiving an injection, seeing blood). The phobic object or situation almost always provokes immediate fear or anxiety and is actively avoided or endured with intense fear or anxiety.

The fear or anxiety is out of proportion to the actual danger posed by the specific object or situation and to the sociocultural context and is persistent, typically lasting for 6 months or more; it causes clinically significant distress or impairment in social, occupational, or other important areas of functioning. The disturbance is not better explained by the symptoms of another mental disorder, associated with panic-like symptoms or other incapacitating symptoms (as in agoraphobia); objects or situations related to obsessions (as in obsessive-compulsive disorder); reminders of traumatic events (as in posttraumatic stress disorder); separation from home or attachment figures (as in separation anxiety disorder); or social situations (as in social anxiety disorder) [11].

Specific fear is present in one tenth of the world’s population, and many have problems in this field, which has caused disruption in some aspects of their lives; Therefore, psychotherapy is very important in such disorders [12, 13]. People with ailerophobia have different fears, for example, looking at a cat, thinking about meeting him, calling him, seeing a cat in the dark or staring into a cat’s eyes, seeing a picture of a cat on TV, even cat-shaped toys. There are different treatment methods such as behavioral representation, exposure, cognitive-behavioral therapy and family therapy [14, 15].

Most of the treatments for panic disorders have paid more attention to the content of thought and avoidance behaviors such as cognitive-behavioral therapy², cognitive therapy and behavioral therapy [16], the aim is to stop negative cycles by breaking down things that make patients feel bad, anxious or scared. By making problems more manageable, it can help them change their negative thought patterns and improve the way them feel [17]. Metacognitive therapy appeared especially in order to eliminate cognitive-behavioral deficits [18]. The metacognitive model was first proposed by Wells and Matthews (1994) and then modified by Wells (1997–2000). Metacognition refers to the beliefs and processes that are used to evaluate, adjust, review and revise thought. Metacognitive beliefs such as the need to control thought and the importance of thoughts are specially categorized in the group of beliefs related to thinking [19].

Metacognitive therapy³ emerged in order to solve the shortcomings of cognitive-behavioral therapy. According to Wells, cognitive therapy, considering the opinion that negative thoughts in emotional disorders result from the activity of dysfunctional beliefs, emphasizes more on the origin of the content of thoughts, but on how these thoughts are formed or what is the mechanism of these thoughts. It highlights the inefficient, no attempt has been made [20]. Therefore, in order to understand thinking processes, it is necessary to emphasize the individual’s beliefs about thinking, individual strategies about controlling attention, and also the type of metacognitive beliefs. What is emphasized in MCT are factors that control thinking and change the state of mind, not challenges with thoughts and cognitive errors or long-term and repeated exposure to beliefs about trauma or physical symptoms [21]. The theoretical and therapeutic perspective of metacognition emphasizes negative beliefs and thoughts as the result of metacognitive control of cognition and states how metacognition is effective in the continuity and change of cognition. MCT offers levels of intervention that focus on challenging the content of thinking and negative beliefs that are present in the traditional cognitive representation; It does not emphasize and tries to change the metacognitions that increase repetitive negative thoughts in an inconsistent way or increase general negative beliefs [22].

The metacognitive approach is based on the belief that people are caught in the trap of emotional discomfort because their metacognition leads to a pattern of responding to internal experiences that perpetuates negative emotions and strengthens negative beliefs in these people. This approach is called cognitive-attentional syndrome. which includes worry, rumination, fixed attention and self-regulation strategies with maladaptive coping behaviors [19]. MCT is an emerging approach, instead of focusing on the content of the patient’s thoughts, emphasizes reducing unhelpful cognitive processes and facilitating metacognitive processing and works on the fundamental theory (executive function model of self-regulation). It can be considered a treatment that patients empower in identifying dysfunctional thinking and coping patterns that cause chronic emotional disturbances. Also, MCT helps patients to change these patterns and correct meta-beliefs about their thoughts and feelings [23].

MCT may have an advantage over CBT in improving aspects of executive function, including attention. MCT’s emphasis on attentional training and flexible control of thinking may have a beneficial effect on neuropsychological functioning, consistent with the purported mechanism of action [24].

Metacognition refers to the information that each person has about their cognitive system, and it includes the memory processes of the person, and research has shown that the person’s awareness of his cognitive activities or processes has a great role and effect on learning [25]. So far, three classes or categories have been identified in metacognitive knowledge. These classes are:

• a) A person’s knowledge of his cognitive system: this category is the first category in the cognitive system that should be taken into account and refers to the person’s knowledge about what he should know about learning and information processing. Knowing about memory abilities and correctly estimating these abilities can help a person in acquiring, maintaining and using what he has learned correctly, note that our cognitive system can include the three stages of memory (sensory memory, short-term memory, long-term memory) or control processes [26].

• b) The person’s knowledge of the assignment: Knowledge about the assignment includes knowledge about the nature, type, quality, and manner of the assignment that one person is supposed to deal with, such as knowing the time, number, and manner of questions in an exam. The first step is to inform the person about the purpose of learning. Since the inefficiency of the memory is more than anything related to the lack of attention at the beginning of the work, if the material is carefully selected at the beginning of the processing, it recalls will also be disrupted. For processing information correctly, the learner must be able to gain awareness of his abilities in that field.

• c) A person’s knowledge of strategy: the patient can know when and where to deviate from strategy [22, 27].

In this regard, the results of a study conducted by Safi Khani et al. (2020) showed that treatments based on metacognition had a significant effect on anxiety disorders such as social anxiety [28]. In addition to treatment based on metacognition, in recent years, research has shown that exposure therapy in a virtual reality environment is probably as effective as treatment in a natural environment [29]. Virtual reality⁴ is a human effort to remove the boundaries between real space and virtual space. VR is a set of computer technologies that provides a relationship with the computer world, especially it can provide a convincing relationship for user to imagine that he is actually present in a three-dimensional computer world. A virtual environment is a virtual reality application that allows users to move and interact with a 3D computer environment in the present time [30].

The Base of VR can be attributed to the 1860s when 360-degree paintings appeared under the name of panorama. Virtual reality includes stimulation in real time by multiple sensory channels, which include visual, auditory, and tactile aspects [31]. The person placed in a virtual environment similar to what is considered anxiety-provoking in the real world, except that this environment has not dangers of the real environment. The virtual situation has the ability to control and repeat and grade the level of anxiety and has an interactive feature, by emphasizing the graphic environment, a person not only creates the feeling of being in a physical environment, but also provides conditions to interact with the environment [32].

Notably, mental health is a representative field that can use VR to diagnose and treat various mental illnesses. There are many psychological barriers to medication-assisted treatment due to the social stigma associated with mental disorders and the burden of medications. In addition, psychotherapy has limitations due to the lack of counseling professionals and high cost. Therefore, in this situation, logistics and economics of VR treatment encourage patients to adopt a regimen based on virtual reality. Virtual reality therapy provides a realistic and immersive environment tailored to the individual’s needs and enables repeated, continuous and systematic training. Objective measurement of data facilitates their recovery and evaluation [33].

In the field of virtual reality treatment, the most studied area is related to anxiety disorders, and several meta-analyses have been reported on the effectiveness of VR intervention on the evaluation and treatment of various anxiety disorders [34]. Traditionally, exposure therapy has been the most effective treatment for anxiety disorders. However, direct exposure to fearful people/situations may intensify the patient’s anxiety and lead to a possible inhibition of treatment or complete abandonment of treatment [35]. Additionally, may be limits to the number of times a patient is exposed to the actual source of fear due to anxiety or phobia symptoms. During virtual reality therapy, patients can more safely experience the anxiety-inducing virtual environment and measurements of objective bio signal data, such as changes in heart rate and galvanic skin reflex, can be obtained using wearable devices during VR training [32].

Virtual reality has advantages such as spending less time, being safe, less side risks and less costs, and it can be done in the therapist’s office and the patient accepts it easily. Meta-analysis studies confirm the effectiveness of VR for the treatment of specific phobias [30]. Also, the results of a study conducted in Malaysia showed that the use of current reality-based treatments in specific phobia disorder such as fear of dentistry is also effective [36].

However, durability of VR therapeutic effect is not known and Although metacognition has significant functions in the treatment of anxiety disorders, it seems that it is necessary to review the two approaches based on the level of effectiveness, durability and the issue of cost-benefit to present and introduce to therapists.

Materials and methods

This research is a Randomized Clinical Trial, which was conducted with the aim of investigating the effectiveness of Ailurophobia treatment using virtual reality technique compared to metacognitive therapy. This study was evaluated and approved by Research Ethics Committees of School of Medicine- Mashhad University of Medical Sciences. Approval ID: IR.MUMS.MEDICAL.REC.1399.549. IRCT registration number: IRCT20230105057057N1Registration date: 2023-03-04. All patients with Ailurophobia referred to the outpatient clinic of Ibn Sina Hospital and psychiatry and psychology clinics in Mashhad and met the conditions for inclusion in the study. First, the samples were selected based on having the conditions for entering the study and based on the purpose, and after obtaining written informed consent, they were randomly divided into two VR (14 people) and MCT (14 people) groups. Sampling was done based on the envelope method, so that envelopes were prepared by a member of the research team and random numbers with the help of Randomaize.com, printed and placed inside the envelope. The envelopes were closed and their contents could not be seen from outside. Then, the purpose of the study was explained to the person who meets the stated conditions, and if the person wishes, he signed the informed consent form and took an envelope and then opened it, and based on the contents of the envelope, the person was placed in one of the intervention groups. The samples included 28 patients suffering from Ailurophobia who referred to the outpatient clinic of Ibn Sina Hospital and psychiatry and psychology clinics in Mashhad.

Tools

The data collection tool includes two questionnaires that will be examined below:

Kettle anxiety test (1957)

Kettle’s anxiety test, which was developed by Kettle in 1957, can complement clinical diagnosis and provide an objective result for research purposes. This questionnaire has forty items and can be answered within five minutes on average. The anxiety scale can be used in both sexes at all ages after 14–15 years and maximum culture, current scale is not only specific to a primary diagnosis, but is also used to diagnose the patient’s development chart. In this questionnaire, each question is scored between 0 and 2. Alignment scores are placed on a ten-point scale and People whose scores are 0–3 are calm and comfortable people, scores between 4 and 6 show a degree of anxiety and scores are between 7 and 8 have anxiety disorders, and finally people whose scores are between 9 and 10 They are very anxious. This questionnaire has three levels: first level is hidden anxiety, which has questions 1–20, second level is obvious anxiety which has 20–40 questions, and finally the third level, which is the sum of two levels and measures general anxiety. This scale has high reliability and validity: The validity of scale that is retested reaches at least /07 meantime Cronbach’s alpha coefficient is /09, and reliability is /08 with the retest method. This questionnaire can accurately measure the physiological aspects of anxiety according to its visible complications. This questionnaire has been validated in Persian language since the beginning of 2017 with the cooperation of a group of psychology students of Tehran University [37].

Ailurophobia questionnaire

The component questionnaire was constructed based on diagnostic and statistical guide criteria of mental disorders for phobia and was taken from the patient as a pre-test and post-test so that the results of clinical interventions are meaningful and at the end, this questionnaire will be attached based on Likert (yes - between these two - no) designed. This questionnaire consists of ten propositions, the purpose of which is to measure the fear of cats and obvious that the person who gets a high score in this questionnaire has a higher fear (upper limit of the score is 20) and the lower limit is zero; (0–5) is a slight fear of cats, and a score between [5,6,7,8,9,10] is moderately afraid of cats, and a score between [10,11,12,13,14,15] means severe fear of cats.

A score between [15,16,17,18,19,20] must solve the problem with a specialist. The author’s Ailurophobia test questionnaire includes questions that measure how a person encounters and how much he avoids dealing with cats, and also checks how much of his necessary activities he will give up to avoid encountering cats. In this context Askari Ghale (2019) designed a 10-item ailurophobia questionnaire in Persian that Cronbach’s alpha of the questionnaire was equal to 0.87 and we used it [38, 39].

Data execution and analysis method

After the project was approved and approved by the Ethics Committee of Mashhad University of Medical Sciences, the researcher started the study while introducing himself and stating the objectives of the research and obtaining informed consent from the participants. Necessary information regarding the right to withdraw from the study and confidentiality of information was provided. After the approval of the psychiatric assistant for the diagnosis of the patient, patients were divided into 2 groups of 14 people between the ages of 18 and 45, male and female. Each group was treated during 8 sessions of 45 min in 8 weeks, once a week and follow-up of therapeutic effect was on one month and three months. The first group was treated with virtual reality technique with cat scare software. The second group underwent metacognitive therapy. Before the treatment, the fourth session and at the end of the treatment, one and three-month follow-up was evaluated using the Kettle questionnaire and the construction component of ailerophobia.

Brief description of treatment sessions

Virtual reality sessions

In first session patients get to know the goals and rules of treatment sessions, teaching relaxation techniques, showing photos taken of the cat next in 2nd to 7th session we showed cat in different intervals and numbers, calming the patient finally in Eighth session we combined all the steps were done in the last 7 sessions with calming patients.

Cognitive-behavioral sessions

First session had introduction and evaluation of symptoms of panic disorder, comorbidity, addiction, etc., teaching concepts, providing homework to evaluate situations, thinking, feeling and behavior, summarizing the session and feedback and in second to seventh sessions we set the 2eeting agenda, checked mood, review tasks and efforts made by the patient, evaluated beliefs, recognized cognitive errors and corrected beliefs, help the patient choose a problem or one of the treatment goals and focusing on it, taught how to use from cognitive-behavioral techniques and strung the therapeutic communication.

Criteria for entering the study

• Referees who, according to the diagnostic interview based on the checklist of related symptoms in DSM5, the diagnostic and statistical manual of specific phobias (fear of cats) have been approved for them.

• Have the criteria of being afraid of cats for at least six months.

• Patients who are in the age range of 18 to 45 years.

• Patients are satisfied to participate in this research.

• Do not addict to alcohol or drugs.

• Do not have other mental and physical problems at the same time; For example accompanying mood or psychotic disease, eye diseases that are associated with severe vision loss, major cardiovascular disease.

• Patients who are not treated with other methods of drug therapy and psychotherapy during the trial period.

Exclusion criteria

• Patients who are absent for more than three sessions in treatment sessions.

• Patients who do not want to continue treatment for any reason.

In the descriptive section, the external examination of the data is done, and in the inferential section, the hypotheses of the research are examined: In the descriptive part of this study, the mean, standard deviation, frequency and percentage are presented but in the inferential part, chi-square test or Fisher’s exact test is used to check the relationship between two qualitative factors and Independent t-test was used to compare the mean of a quantitative factor between two groups. Examining and comparing the changes of a quantitative factor over time has been done with repeated measures analysis of variance. To check the normality test, the Kolmogrof-Smirnov test was used and to check the equality of variances, the Lune test was used (The basic significance level in all tests is 0.05).

Results

28 people participated in this study, 14 people (50%) were in the virtual reality group and 14 people (50%) were in the metacognitive therapy group. The age range of participants in both groups was between 18 and 45 years, and their average age was 33 years. The average duration of diagnosis in virtual reality and metacognitive group is estimated as 4.42 and 3.71, respectively. To investigate the relationship between demographic factors such as marital status (married, single), education (under diploma, Diploma, University education), gender (male or female), history of sedative drug use in two groups (has, has not), Fisher’s exact test was performed and according to the results, between the two virtual reality treatment groups and the metacognition group in terms of population factors Cognitively, there is no significant difference (P > 0.05).⁵

In Table 1, the average score of the fear of cats scale in two groups is shown before the start of the intervention. According to the findings of this table, before the intervention there was no significant difference in the average score of fear of cats in the research units in the two groups based on the independent t-test, and the two groups were similar before the intervention (P > 0.05).

Table 1 Comparison of the fear of cats scale before the intervention between the two groups

In Table 2, The average anxiety score in two groups is shown before the start of the intervention. According to the findings of the table before the intervention, the average anxiety score of the research units in two groups was not significantly different based on the independent t-test and two groups were similar before the start of the intervention (P > 0.05).

Table 2 Comparison of the anxiety scale before the intervention between the two groups

In Table 3, Variance results with repeated measurements for between-group and intra-group comparisons of the mean score of fear of cats for the intervention groups are presented before, during the intervention, immediately after, one and three months after the intervention. As can be seen, there is a significant difference between two groups of VR and MCT (F = 27.7 and P < 0.001). Also, the average score of fear of cats decreased significantly from before to after the intervention in two treatment groups. (F = 32.6 and P < 0.001(.

Table 3 Intergroup and intragroup comparison of the mean score of the fear of cat’s scale for the intervention groups before, during the intervention, immediately after, one and three months after

In Table 4. Bonferroni’s pairwise comparison test is presented for pairwise comparison of cat fear scores of people between times. As seen. There is a significant difference (P < 0.05).

Table 4 Investigating pairwise comparisons of cat fear scale scores between stage 1 and stage 5 in the virtual reality group

In Table 5. Analysis of variance with repeated measures shows a significant difference between the mean of virtual and metacognitive reality in the anxiety score during the process (P < 0.001).

Table 5 Between-group and intra-group comparison of the average anxiety score for the intervention groups before, during, immediately after, one and three months after the intervention

In Table 6. Bonferroni’s pairwise comparison test is presented to compare two-by-two anxiety scores of people between times. As seen. There is a significant difference (P < 0.05).

Table 6 Investigating pairwise comparisons of anxiety scale scores between stage 1 and stage 5 in the virtual reality group

Discussion

In this research, 28 patients suffering from Ailurophobia participated, 14 of them were in the virtual reality group and 14 were in the metacognitive therapy group. According to the findings of the research, before the intervention, there was no significant difference between the virtual reality and metacognitive groups in terms of demographic information, anxiety score and cat fear score, and the two groups were the same. Based on this, it can be said that one of the presuppositions of the experimental research, which is the similarity of people in the two comparison groups before the intervention, has been established. The findings of this study have been analyzed in line with the goals and assumptions of the project. Also, considering the non-significance of demographic factors between the two groups, it can be stated that these changes were not effective as a confounding factor in the results of this study.

According to the information in Table 5, which examines and compares between and within groups the average anxiety score of people for the intervention groups before, during the intervention, immediately after, one and three months after the intervention and is designed in line with the analysis of the study objectives. The results of the study showed that there is a significant difference between the two groups of virtual reality and metacognition. Also, the average anxiety score has decreased significantly from before to three months after the intervention in two treatment groups. However, in the third stage, we have faced an increase in the metacognition group. In this regard, the results of the study by Amelkamp et al. (2020), the results indicated that the use of virtual reality method has a significant effect in reducing the level of social anxiety [40], which is in line with the present study. According to other results of the study, although both treatment approaches had a significant effect in reducing the level of anxiety in the participants, virtual reality treatment showed more effectiveness during the 6-month period. Therefore, it can be said that the use of virtual reality therapy along with other therapeutic approaches is recommended to prolong and increase the effectiveness of the treatment and reduce the level of anxiety [41].

Kaussner et al. (2020) conducted a study aimed at investigating the behavioral effects of virtual reality therapy on patients with fear of driving in Sweden. The results showed that this treatment was useful for overcoming fear and avoiding driving [42]. The results of Kaussner’s study are in line with the present study, which shows the effect of virtual reality-based intervention on the reduction of fear. Also, Gujjar et al. (2020) conducted an experimental study aimed at investigating the effect of virtual reality treatment on the fear of dentistry in Malaysia. Study results showed a multivariate interaction between time and condition for all primary outcome measures. Also, VRET was reported to be effective in the treatment of dental phobia [36], and the mentioned results are in line with the results of the present study.

Miloff et al. (2019) compared a study aimed at investigating the effectiveness of technician-assisted single-session virtual reality exposure therapy (VRET) for the treatment of spider phobia with software to a single-session in-vivo treatment with the gold standard. The results showed that automatic VRET effectively reduced the symptoms of spider phobia in the short term and the therapeutic effects were reduced in the long term [43]. In the other hand, it can be said that the mentioned results are somewhat inconsistent with the present study. Considering that the results of the present study showed that the use of the approach based on virtual reality had a lasting effect during the period of six months. In justification of this problem, it can be stated that the way of presenting the intervention and the duration of the course should be adjusted based on the condition of the patients.

Soso et al. (2019) conducted a study with the aim of examining the data of three randomized control trials to evaluate the different effectiveness of three forms of exposure therapy, i.e. in vivo (iVET), virtual reality (VRET) and augmented reality (ARET) in the treatment of small animal phobia. They gave. The main finding of the study was that the three treatment conditions were similarly effective in the treatment of small animal phobia for all study outcomes [33]. Therefore, the results of the study are in line with the results of the present study. In both studies, the effectiveness of virtual reality-based treatment on the level of phobia has been determined. Also, the results of the study are in line with the study of Majidi colleagues (2021) who evaluated the effect of virtual reality treatment on the level of phobia.

Generally, it can be said that virtual reality therapy has had significant therapeutic effects in phobia disorder and has advantages such as spending less time and costs, and it can be done in the therapist’s office and the patient accepts it easily. Traditional mental health interventions can be combined with advanced technology to place clients in safe, controlled, and environmentally valid situations [32]. Consequently, VR provides a suitable and valuable environment for safely recreating anxiety and other complex emotions. The potential of virtual reality for simulating situations and social interactions is unlimited [44].

Today, although conventional therapeutic approaches are used in the management of anxiety disorders, virtual reality-based therapy and metacognitive therapy are among the most important and widely used. According to the reported results of this study, although both approaches had significant and significant clinical effects, virtual reality therapy showed more obvious clinical effects than metacognitive therapy. Especially after the passage of time, more lasting therapeutic effects have been included. Of course, psychotherapy with virtual reality does not mean presenting a new therapeutic theory and rejecting conventional psychotherapy theories, but in these methods, the basic elements of psychotherapy, including establishing a therapeutic relationship and using techniques whose effectiveness has been confirmed (such as exposure), have been preserved, and VR is a useful tool in The expert hand therapist and the therapist determine when, how long, what program or application and for what clients to use it [32, 45]. In the end, according to the results of the present study, it is necessary for therapists to receive the necessary training on how to implement this type of intervention in order to provide an effective and standard intervention.

Conclusions

The results of this research can be used in four clinical, managerial, educational and research fields. On the other hand, the results of the present study showed that the use of virtual reality-based treatments is effective in reducing the level of anxiety and phobia of patients suffering from Ailurophobia. As a result, it is recommended to use this treatment approach appropriately in the treatment of anxiety disorders in clinical centers. Also, the results of the study can be provided to the officials of the treatment-care centers to provide the necessary facilities by equipping the necessary platforms for the use of virtual reality interventions. According to the results of the research, it can be said that teaching the techniques of using and how to use the necessary equipment to provide interventions based on virtual reality seems essential.

However, considering that the study was only followed for three months, and considering the limited population of our study (28 participants), we cannot exaggerate the superiority of virtual reality therapy over cognitive behavioral therapy. And there is a need for more time and number of samples in the next studies.

Research limitations

Non-cooperation of some patients to fully follow the instructions of cognitive behavioral therapy.

This study will be the beginning of a way to conduct more extensive studies in the field of using the approach based on virtual reality. Researchers interested in this topic are advised to conduct similar studies with a larger number of participants or as a large country study. The small sample size (28 participants) is acknowledged as a limitation affecting the generalizability of the results.

It is also recommended to examine the effects of the intervention in a longer period of time if possible. In the following, some research suggestions for future studies will be mentioned:

Investigating the effect of virtual reality therapy on psycho-social adaptation of patients with anxiety disorders and the effect of virtual reality therapy on the anxiety level of patients with fear of heights. It is also suggested that Comparing the effects of cognitive therapy and virtual reality on stress control of children with separation anxiety disorder and Investigating the effect of metacognitive therapy on the psycho-social adjustment of students with anxiety disorders.