Intervention proposal
“All the information contained in this section is for guidance only. Psious environments are therapy supporting tools that must be used by the healthcare professional within an evaluation and intervention process designed according to the characteristics and needs of the user.
Also remember that you have the General Clinical Guide in which you have more information on how to adapt psychological intervention techniques (exposure, systematic desensitization, cognitive restructuring, chip economy…) to Psious environments.”
It is important to emphasise that in this section we will only show and suggest some points to guide the intervention with our patient using the two virtual environments available to Psious for tackling EDCs.
However, we must not forget that the intervention proposal presented below only shows a part of it, as the full treatment of EDs also requires other procedures (diagnostic interview, psychometric assessment, structuring eating patterns, relapse prevention, etc.) and will be more extensive.
SESSIONS TO WORK ON THE DISTORTION OF THE BODY IMAGE: “DRESSING ROOM” SCENE
The intervention sessions described below do not necessarily have to be consecutive, but may be spaced throughout the treatment according to the phase of the treatment (at the beginning, in the middle and at the end). This is so because the perception of one’s body image is hardly going to be modified week by week, so it would make more sense to evaluate their changes according to the phase of treatment in which the patient is located.
SESSION 1: At the beginning of the therapy process
- Provide the necessary basic information on concepts related to body image (ideal of beauty, how it has evolved throughout history…).
- Ask the patient to what degree (from 0 to 10) he is satisfied with his body in general, with which parts of it he is most dissatisfied and which ones he likes the most.
- Assess the fear / discomfort felt by the patient before having to see his own body and to what extent he would avoid it (or feel the need to do so) if this were possible.
- Present and justify the use of VR in this context. Give instructions on how the environment works and let the patient become familiar with the tool.
- Start experience through VR:
- Measure the patient’s BMI and select the corresponding category for each part of the body (“slim”, “very slim”, etc.) according to the table of equivalences provided in this handbook.
- Ask the patient to adjust the dimensions of each part of the body of the avatar that appears in the VR glasses, as perceived by himself. You may ask: “What parts of your body do you perceive as different from those of the avatar and, therefore, are you going to modify?”
- When the patient has established the dimensions of the avatar, we can formulate and record the answers to the following questions:
- “Is this how you see yourself?”
- “What is your level of discomfort with this image (from 0 to 10)?”
- “What is your level of satisfaction with this image (from 0 to 10)?”
- “To what degree do you think your body is really like that (from 0 to 10)?”
- “To what degree do you think others see you this way too (from 0 to 10)?”
- Activate the event “Avatars comparison”.
- Discuss with the patient the distortion of his own image, which he can now observe objectively through the real silhouette. This will lead to a process of cognitive restructuring. We can ask questions like:
- “This is your real body, what do you think?”
- “What is your level of discomfort with this image (from 0 to 10)?”
- “What is your level of satisfaction with this image (from 0 to 10)?”
- “Are both figures (avatar and silhouette) the same?”
- “What differences do you see between the two?”, “What body parts do you have distorted?”
- “What makes you believe that you / they (to mention the distorted part of the body) are / are bigger / bigger than they really are / are?”
- “How does this affect you emotionally?”
- “How does this affect your behavior (avoidance, diets …)?”
- “To what degree do you accept that you overestimate the dimensions of your body and that your perception of your own body image is different from that of your real body (from 0 to 10)?”
- “Could we assume that the parts of your body that least match reality are those that dislike you the most?”
- “What have you learned or what conclusions have you drawn today?”
- Explain how to perform a self-registration of situations, thoughts and emotions related to body image (see appendix) (ex .: Situation: “I went to buy clothes and there were no pants of my size.” Thought: “Surely they do not make pants for fats like me.” Emotion: “Frustration, anger, shame”).
- Explain, if deemed necessary, how to practice a guided SD with an audio tape to work the exposure in imagination to bodily areas (to reduce discomfort to one’s body).
HOMEWORK
- Do daily self-registration of situations, thoughts and emotions related to body image.
- Practice the guided SD with an audio tape to work the exposure in imagination to corporal areas, if applicable.
SESSION 2: Around the halfway of the therapy process
- Review the daily self-registrations made to date and perform the relevant cognitive restructuring.
- Ask the patient to what degree (from 0 to 10) he is satisfied with his body in general, with which parts of it he is most dissatisfied, and which ones he likes the most, at this moment of treatment.
- Assess the fear / discomfort felt by the patient in this phase of treatment before having to see his own body and to what extent he would avoid it (or feel the need to do so) if this were possible
- Start the experience by VR following the same steps described above in points 5 and 6 of Session 1. Note: In this phase of treatment it is possible that the actual body size of the patient has changed (whether the patient has gone up or down in weight, etc.). If so, the patient’s current BMI should be taken into account to introduce the new dimensions of each part of the body to the platform, in order to generate its new real silhouette.
HOMEWORK
- Continue with self-registration of situations, thoughts and emotions related to body image.
- Continue practicing the SD guided with an audio tape to work the exposure in imagination to corporal areas, if necessary.
SESSION 3: At the end of the therapy process
- Review the daily self-registrations made to date and perform the relevant cognitive restructuring
- Ask the patient to what degree (from 0 to 10) he is satisfied with his body in general, with which parts of it he is most dissatisfied, and which ones he likes the most, at this moment of treatment.
- Assess the fear / discomfort felt by the patient in this phase of treatment before having to see his own body and to what extent he would avoid it (or feel the need to do so) if this were possible.
- Start the experience by VR following the same steps described above in points 5 and 6 of Session 1. Note: In this phase of treatment it is possible that the actual body size of the patient has changed (whether the patient has gone up or down in weight, etc.). If so, the patient’s current BMI should be taken into account to introduce the new dimensions of each part of the body to the platform, in order to generate its new real silhouette. The final objective will be for the patient to adjust as much as possible the estimated figure (avatar with subjective measures) to his real measures (silhouette with real measurements).
- Emphasize and reinforce the improvements achieved: Reduction of distortion (show how the avatar with the subjective measures of the patient and the real silhouette have increasingly seemed more) and decrease in levels of anxiety / discomfort (SUDs), if proceeds.
HOMEWORK
- Follow with self-registration of situations, thoughts and emotions related to body image, with the aim that the patient himself who from now on is able to restructure their own thoughts / emotions about it, they learned.
- Continue practicing the SD guided with an audio tape to work the exposure in imagination to corporal areas, if it continues to agree.
SESSIONS TO WORK ON THE EXPOSURE TO THE FOOD: “RESTAURANT” SCENE
SESSION 1
The objective of this first session will be to present and justify the use of VR in the treatment, and for the patient to get used to the tool.
- Present and justify the techniques that will be used throughout the treatment: exposure with VR and live exposure, etc.
- Show the VR “Restaurant” environment, explain how it works, and what the work’s dynamics will be like.
- Elaborate an exposure hierarchy (see appendix) ordered by Subjective Units of Distress (SUDs) from 0 to 100. Note:
- If we wish to work on the fear of consuming certain foods: Elaborate a hierarchy considering feared or “forbidden” foods and the situations that accompany 18 Eating Disorders Handbook them (eating with people, eating alone, etc.), arranging the items from those producing lesser anxiety to those generating more anxiety.
- . If we wish to work on the intake control (desire/”craving” or impulse towards food): Build a hierarchy considering foods and situations that produce a greater desire/impulse to eat, arranging the items from those which cause less urgency/impulse to those causing more urgency/impulse.
- Begin the gradual and systematic exposure to the “Restaurant” environment: Propose to begin by exposing the patient to one of the hierarchy’s items that is close to 20-30 SUDs (see example of items below).
- Explain that the same will be done in the following sessions, progressively increasing the difficulty (advancing in the hierarchy’s items):
- For fear of consuming certain foods: Trying foods and situations that produce greater fear
- To control the intake and compensatory behaviors: Trying foods and situations that produce a greater desire or impulse to eat, without the possibility of binge eating or compensatory behavior.
Note: From now on, using the present intervention example, we will work on a hypothetical case of exposure due to fear of consuming certain foods (option “a”).
| ITEM | SUD’s | CONFIGURATION | EVENT |
|---|---|---|---|
| At the restaurant, alone, eating the diuretic/hypocaloric menu: | 20 | Company: Alone | Menu + Menu 2 (diuretic)/ Menu 4 (hypocaloric) |
| At the restaurant, accompanied, eating the diuretic/hypocaloric menu, while talking about a neutral topic: | 25 | Company: Accompanied. Conversation: Neutral (examples of phrases: “I have a lot of free time lately, and I like to use it to watch movies, one of my favorite hobbies”; “Yesterday, I saw a movie I really liked, I think it was called The Magic of Belle Island”). | Menu + Menu 2 (diuretic)/ Menu 4 (hypocaloric) |
| At the restaurant, accompanied, eating the diuretic/hypocaloric menu, while they are silent: | 30 | Company: Accompanied Conversation: Silence | Events: Menu + Menu 2 (diuretic)/ Menu 4 (hypocaloric) |
SESSION 2
- Review the achievements of the previous session and establish objectives for this session: To be in the restaurant, accompanied, eating the diuretic/hypocaloric menu, while talking about topics related to food/physical appearance.
- Continue with the gradual and systematic exposure to the “Restaurant” environment: Expose the patient to any of the hierarchy’s items close to 35-50 SUDs (see example item below). Cognitive restructuring, if applicable: while the patient is being exposed, ask him/her about his/her thoughts, emotions and the difficulties he/she is experiencing (e.g., “I will not be able to eat,” “to talk about these subjects while eating generates a lot of anxiety for me”…).
- Using the platform reports, show the patient the clinical advances achieved
HOMEWORK
Try to eat together with other people (friends, coworkers, family…), even if the patient still does not dare to eat a normalized diet with them.
| ITEM | SUD’s | CONFIGURATION | EVENT |
|---|---|---|---|
| At the restaurant, accompanied, eating the diuretic/hypocaloric menu, while talking about topics related to food/physical appearance: | 50 | Company: Accompanied Conversation: Uncomfortable (examples of phrases: “Mmmm… how good is this!”; “You know that I brought you here because I’ve been told you can eat very well in this restaurant.”) | Event: Menu + Menu 2 (diuretic)/ Menu 4 (hypocaloric) |
SESSION 3
- Review the achievements of the previous session and establish objectives for this session: To be in the restaurant, accompanied, eating the standard menu, while talking about a neutral topic.
- Continue with the gradual and systematic exposure to the “Restaurant” environment: Expose the patient to any of the hierarchy’s items close to 55-70 SUDs (see example items below). Cognitive restructuring, if applicable: while the patient is being exposed, ask him/her about his/her thoughts, emotions and the difficulties he/she is experiencing (e.g., “I will not be able to eat this”…).
- Using the platform reports, show the patient the clinical advances achieved
HOMEWORK
Try to eat together with other people (friends, coworkers, family…) dishes and quantities belonging to a normalized diet (without restrictions or consuming low-calorie foods only).
| ITEM | SUD’s | CONFIGURATION | EVENT |
|---|---|---|---|
| At the restaurant, alone, eating the standard menu: | 65 | Company: Alone | Menu + Menu 3 (standard) |
| At the restaurant, accompanied, eating the standard menu, while talking about a neutral topic: | 70 | Company: Accompanied Conversation: Neutral (examples of phrases: “I like films a lot, almost all genres, and even though I watch many movies at home, I believe there is nothing quite like going to the movies”; “I think a movie they have been promoting for some time will be released this weekend, I don’t remember what it’s called, but I think it’s a scary one”). | Menu + Menu 3 (standard) |
SESSION 4
- Review the achievements of the previous session and establish objectives for this session: To be at the restaurant, accompanied, eating the standard menu, while talking about topics related to food/physical appearance.
- Continue with the gradual and systematic exposure to the “Restaurant” environment: Expose the patient to any of the hierarchy’s items close to 75-80 SUDs (see example items below). Cognitive restructuring, if applicable: while the patient is being exposed, ask him/her about his/her thoughts, emotions and the difficulties he/she is experiencing (e.g., “I will not be able to eat this,” “to talk about these subjects while eating generates a lot of anxiety for me”…).
- Using the platform reports, show the patient the clinical advances achieved.
HOMEWORK
Try to eat together with other people (friends, co-workers, family…) dishes and quantities belonging to a normalized diet (without restrictions or consuming low-calorie foods only), while the patient start (if not done by others) a talk regarding physical appearance/food topics that generates some discomfort (e.g., “What is your favorite food? I have always liked macaroni with tomato”, etc.) with the aim of talking about these topics normally and without feeling so much anxiety
| ITEM | SUD’s | CONFIGURATION | EVENT |
|---|---|---|---|
| At the restaurant, accompanied, eating the standard menu, while silent: | 75 | Company: Accompanied Conversation: Silence | Event: Menu + Menu 3 (standard) |
| At the restaurant, accompanied, eating the standard menu, while talking about topics related to food/physical appearance: | 80 | Company: Accompanied Conversation: Uncomfortable (examples of phrases: “Now that I think about it, maybe tomorrow afternoon I won’t be able to meet you because I want to go to the gym, I have not been there for days…”; “I believe I haven’t told you I’m thinking of going to the Islands in summer… I would have to buy a new swimsuit, but I can’t find one that I like how it makes me look…”). | Events: Menu + Menu 3 (standard) |
SESSION 5
- Review the achievements of the previous session and establish objectives for this session: To be at the restaurant, accompanied, eating the hypercaloric menu, while talking about a neutral topic.
- Continue with the gradual and systematic exposure to the “Restaurant” environment: Expose the patient to any of the hierarchy’s items close to 85-90 SUDs (see example items below). Cognitive restructuring, if applicable: while the patient is being exposed, ask him/her about his/her thoughts, emotions and the difficulties he/she is experiencing (e.g., “I will not be able to eat this,” “this food has a lot of fat,” “I feel I’m going to put on weight if I eat this,” “if there is someone with me, I get more distracted while I eat, but if I’m alone, I’m more focused on the food…”).
- Using the platform reports, show the patient the clinical advances achieved.
HOMEWORK
Try to eat, both alone and with other people (friends, co-workers, family, both at home and at a family/friends meal…), some “forbidden” foods (with higher caloric content) that generate discomfort (e.g., pizza, pasta, chocolate, soft drinks with high sugar content…).
| ITEM | SUD’s | CONFIGURATION | EVENT |
|---|---|---|---|
| At the restaurant, alone, eating the hypercaloric menu | 85 | Menu + Menu 1 (hypercaloric) | |
| At the restaurant, accompanied, eating the hypercaloric menu, while talking about a neutral topic | 90 | Company: Accompanied Conversation: Neutral (examples of phrases: “Next month, there will be a 2×1 promo in all the city’s cinemas, I saw it on the internet”; “I’ve noticed that the more films I watch, the more I notice the amount of good stories you can write about”). | Menu + Menu 1 (hypercaloric) |
SESSION 6
- Review the achievements of the previous session and establish objectives for this session: To be at the restaurant, accompanied, eating the hypercaloric menu, while talking about topics related to food/physical appearance.
- Continue with the gradual and systematic exposure to the “Restaurant” environment: Expose the patient to any of the hierarchy’s items close to 95-100 SUDs (see example items below). Cognitive restructuring, if applicable: while the patient is being exposed, ask him/her about his/her thoughts, emotions and the difficulties he/she is experiencing (e.g., “I will not be able to eat this,” “this food has a lot of fat,” “I feel I’m going to put on weight if I eat this,“” if there is someone with me, I get more distracted while I eat, but if I’m alone, I’m more focused on the food “, ”when somebody tells me I look better, I think it’s because I gained weight right away”…).
- Show the clinical advances achieved using the platform reports, analyze the improvements achieved (reduction of anxiety when compared to the first exposures), and provide the final feedback to the patient regarding the results obtained.
HOMEWORK
Eat together with other people (friends, coworkers, family, both at home and at a family/friends meals…) some “forbidden” foods (with higher caloric content) that generate discomfort (e.g., pizza, pasta, chocolate, soft drinks with high sugar content…), while the patient start (if not done by others) a talk regarding physical appearance/food topics that generates some discomfort (e.g., “What is your favorite food? I have always liked macaroni with tomato”, etc.) with the aim of talking about these topics normally and without feeling so much anxiety, while being capable of incorporating previously “forbidden” foods to his/her diet.
| ITEM | SUD’s | CONFIGURATION | EVENT |
|---|---|---|---|
| At the restaurant, accompanied, eating the hypercaloric menu, while silent: | 95 | Company: Accompanied Conversation: Silence | Menu + Menu 1 (hypercaloric) |
| At the restaurant, accompanied, eating the hypercaloric menu, while talking about topics related to food/physical appearance: | 100 | Company: Accompanied Conversation: Uncomfortable (examples of phrases: “You know, I think you look much better”; “Oh! I forgot to tell you that we have organized a barbecue next week, I’m counting on you to come…”). | Carta + Menu + Menu 1 (hypercaloric) |