VR Acrophobia Protocol: A 6-Level Height Exposure Hierarchy

Why acrophobia is the first scenario you try with VR

If you have never run a VR exposure session before, starting with acrophobia is a clinically defensible choice. Three reasons converge:

1. The stimulus is objectively difficult to reproduce in vivo: you cannot have a patient go up and down a balcony 18 times in one session without losing them to logistics.
2. The height hierarchy is linear and reproducible: 1 m, 5 m, 15 m, 30 m, 80 m, urban panorama. Few variables for the psychologist to improvise.
3. The empirical evidence is solid, dating back to the first RCT by Rothbaum and colleagues in 1995, which established feasibility and efficacy in a clinical sample.

If your target phobia is claustrophobia, fear of flying, or social anxiety, we have dedicated protocols on fear of flying and social anxiety, part of our full VR scenario catalog. This article focuses on heights.

Before the first session: screening and contraindications

Four filters the psychologist applies to the patient before planning the first VR session:

1. Vestibular history. Benign positional vertigo, Ménière's disease, or a history of vestibular migraine are a relative contraindication. Not absolute, but they require shorter sessions and specific monitoring of motion sickness.
2. Photosensitive epilepsy or a history of seizures. An absolute contraindication for immersive headset use in a general private practice setting; refer to a neurology team.
3. Pregnancy in the first and third trimester. A relative contraindication due to increased cybersickness associated with physiological changes. Postpone if possible.
4. Recent medication with vestibular effects (sedating antihistamines, anxiolytics). Adjust the timing of the medication relative to the session, or document it to modulate intensity.

For a longer review of contraindications, we have a dedicated article. And to avoid iatrogenic cybersickness, check the motion-sickness prevention protocol before the first session.

The 6-level height hierarchy: the operational matrix

Build the hierarchy with the patient in a prior session (not during the VR appointment). Assign anticipated SUDS per level and check that progression is linear. The matrix that has worked in practice over the past 24 months is as follows:

Level 1 — Second-floor balcony (≈5 m)

Typical anticipated SUDS: 30-45. Low-immersion headset setting, view from an interior balcony with a solid railing. No movement. Duration: 8-12 minutes. Goal: initial habituation, validation of VR tolerance.

Level 2 — Urban lookout point (≈15 m)

Anticipated SUDS: 50-65. View from an elevated platform with a translucent railing. Minimal background movement (people passing below). Duration: 12-15 minutes. Goal: confront depth perception without self-movement.

Level 3 — Suspended walkway (≈30 m)

Anticipated SUDS: 65-75. Outdoor walkway with a direct view into open space, low railing. The patient can choose to move forward or stay still (control on the psychologist's panel). Duration: 12-15 minutes. Goal: integrate the avoidance response within the hierarchy.

Level 4 — Tall building rooftop terrace (≈80 m)

Anticipated SUDS: 75-85. Upper terrace with a panoramic urban view, with the option of approaching the edge. Movement controlled from the psychologist's panel. Duration: 15 minutes. Goal: tolerance to extreme height with an element of choice.

Level 5 — Panoramic glass elevator (≈100 m)

Anticipated SUDS: 80-90. The VRET Glass Elevator scenario covers this level: an elevator with glass walls, a procedural city, and live transparency and wind-sway controls. Duration: 12 minutes. Goal: consolidate habituation with a movement element.

Level 6 — Combined stimulus (movement + extreme height)

Anticipated SUDS: 85-95. Combination of panoramic height with sustained movement (slow rotation, swaying elevator). Duration: 10-12 minutes. Goal: the maximum habituation achievable in VR before the transition to in-vivo exposure.

If the patient reaches a sustained SUDS ≤4 at level 6, the VR hierarchy has served its purpose. The transition to in-vivo exposure (a real lookout point in the city, an accessible terrace) is the next scheduled step in the treatment plan.

SUDS criteria: when to advance a level and when to repeat

An operational rule that reduces guesswork for a psychologist new to VR:

• Advance a level: final SUDS ≤4 sustained for 5 consecutive minutes. Confirm with two consecutive sessions if the patient has significant underlying anxiety.
• Hold the level and repeat: final SUDS between 5 and 6. Repeat the same level in the next session; wait for a habituation plateau.
• Step down a level: final SUDS ≥7 in two consecutive sessions, or an intra-session crisis that forces you to stop. Drop one level and consolidate.

Document the session-by-session SUDS curve in the clinical record. For the GDPR-compliant documentation piece, we have a dedicated protocol.

The three adjustments unique to the virtual medium

The difference between running this protocol in VR and running it through imaginal exposure or an improvised in-vivo hierarchy comes down to three adjustments the psychologist controls live from the panel:

1. Intensity adjustable second by second. If SUDS rises too fast, you can reduce transparency, remove background movement, or lower perceived height without stopping the session. None of that exists in vivo.
2. Exact repetition of the stimulus. Once you validate level 3 with a patient, the next session is exactly the same. Habituation is built on repetition; the controlled stimulus makes that possible.
3. Control over exit. The patient can request immediate closure without the social friction of climbing down from a physical lookout point. The psychologist decides whether to accommodate it or modulate first. This sense of control is part of the therapy.

Bridge sessions: transitioning to in-vivo exposure without wasting the gains

The VR protocol does not end in the office. The transition to the real-world stimulus is what prevents headset dependence and consolidates generalization. Three recommendations:

1. Session 7 or 8 — schedule light in-vivo exposure. An accessible lookout point in the city, a café terrace with a view, a real panoramic elevator (shopping malls usually have one). Accompany the patient the first time; do not send them alone.
2. Address the habituation rationale explicitly. A patient who has reached SUDS ≤4 in VR needs to hear you say, "what you achieved in the office transfers to reality." The cognitive element is not delegated to the headset.
3. Schedule a follow-up session at 3 months. This is not optional. Acrophobia has relapse rates that a short booster session helps mitigate.

Take-home material for the patient

Give the patient, before the first session, a one-page handout covering:

• What cybersickness is and how you manage it in the office.
• The agreed signal to stop (hands up or an agreed verbal cue).
• How many sessions are estimated based on the screening.
• What the panoramic elevator they will see at advanced levels looks like (without spoiling the anticipated SUDS).
• What is needed between sessions (there is no homework except during the in-vivo transition).

To have all the operational material ready in the office on day one (specific informed consent, briefing, debriefing, pre-session checklist), the VR practice checklist is the downloadable resource covering the 27 points of any VR session, not just acrophobia.

This article is for informational purposes for psychology professionals. It is not clinical advice for any individual case and does not replace the judgment of the licensed psychologist in charge. VRET is professional clinical-support software, not a CE-marked medical device.