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.”
Intervention example in Claustrophobia
SESSION 1
- Inform the patient about claustrophobia (Causes, symptoms, prevalence…)
- Present and show sufficient grounds for the techniques that are used overtime in the treatment: virtual reality exposure and exposure in vivo…
- Exposure hierarchy development and hierarchy item exposure from 20-30 USA’s (Example)
- Start exposure hierarchy with an item close to USA’s 30. The main objective is to familiarize the patient with the virtual reality and the working dynamics
| ITEM | ENVIRONMENT | CONFIGURATION | EVENT |
|---|---|---|---|
| Standing on landing waiting for (large) elevator in an office building | Claustrophobia | Big elevator | No event |
| Entering a large empty elevator | Claustrophobia | Large elevator, nobody | Enter elevator |
| Standing on landing waiting for (small) elevator in an office building | Claustrophobia | Large elevator, nobody | No event |
| Entering a large empty elevator | Claustrophobia | Large elevator, nobody | Enter elevator |
| Watching the doors close | Claustrophobia | Large elevator, nobody | Enter elevator |
SESSION 2
- Review achievements from previous sessions and set objectives for the current session: see a lot of people in a small elevator when the doors open.
- From the second session onwards, commencing the systematic and gradual exposure in virtual reality environments is recommended. Cognitive restructuring, if necessary
- Demonstrate clinical progress to the patient, using the platform reports
HOMEWORK
Short journeys with exposure in vivo in empty elevators (1 or 2 floors)
| ITEM | ENVIRONMENT | CONFIGURATION | EVENT |
|---|---|---|---|
| Hear the MRI precautions whilst changing | Claustrophobia | Nuclear | Go to the changing room and precautions |
| Ascending in the elevator after leaving a small basement | Claustrophobia | Room | Exit basement |
| Ascending in an elevator with a few people and the elevator starts to move | Claustrophobia | Small Elevator – minimum people | Enter elevator + go to another floor |
| The doors in a small elevator open and there are a lot of people | Claustrophobia | Small Elevator – maximum people | Enter elevator |
SESSION 3
- Review achievements from previous sessions and set objectives for the current session: Alone in a small elevator when a short breakdown occurs
- Systematic and gradual exposure in virtual reality environments. Cognitive restructuring, if necessary.
- Demonstrate clinical progress to the patient, using the platform report
HOMEWORK
Short journey with in vivo exposure in empty elevators with a few people + covert exposure of the session using their imagination at home.
| ITEM | ENVIRONMENT | CONFIGURATION | EVENT |
|---|---|---|---|
| Ascend two floors with a few people in a large elevator | Claustrophobia | Large elevator, a few | Go to another floor and immediately exit the elevator |
| Ascend 2 floors in a large elevator with quite a few people | Claustrophobia | Large elevator, maximum | Go to another floor and immediately exit the elevator |
| A short breakdown occurs in the small empty elevator | Claustrophobia | Small elevator, nobody | breakdown |
SESSION 4
- Review achievements from previous sessions and set objectives for the current session: Be present in a pretty small changing room and the door shuts suddenly.
- Systematic and gradual exposure in virtual reality environments. Cognitive restructuring, if necessary.
- Demonstrate clinical progress to the patient, using the platform reports.
HOMEWORK
Covert exposure at home revising the session using their imagination.
| ITEM | ENVIRONMENT | CONFIGURATION | EVENT |
|---|---|---|---|
| In a pretty large storage room when the door shuts | Claustrophobia | Room | Close door (size of room as large as possible) |
| Ascending a lot of floors in a small elevator with a lot of people | Claustrophobia | Small Elevator | Go long to another floor ( duration long) |
| Ascending a lot of floors in a large empty elevator | Claustrophobia | Large Elevator | Go long to another floor (duration long) |
| Being in a pretty large storage room when the door shuts suddenly | Claustrophobia | Room | Close the door (size or bedroom , in middle) |
SESSION 5
- Review achievements and objectives set in previous session: Ascending a lot of floors in a small elevator with a lot of people
- Systematic and gradual exposure in virtual reality environments. Cognitive restructuring, if necessary.
- Repeat each exercise twice.
- Reveal clinical progress to the patient, using the reports provided in the platform.
HOMEWORK
Covert exposure at home revising the session using imagination + in vivo exposure entering a storage room or other type of room.
| ITEM | ENVIRONMENT | CONFIGURATION | EVENT |
|---|---|---|---|
| Ascending a lot of floors in a full small elevator | Claustrophobia | Small elevator maximum | Go long to another floor ( duration long) |
| In a very small storage room with the doors open quite a lot of people | Claustrophobia | Room | Go to basement (size or room minimum= |
| Two-minute breakdown in a small elevator with | Claustrophobia | Large elevator, | Breakdown |
| Ascending a lot of floors in a small elevator with a lot of people | Claustrophobia | Small elevator maximum | Go long to another floor ( duration long) |
SESSION 6
- Review achievements from previous sessions and set objectives for the current session: Large elevator with a lot of people, long breakdown.
- Systematic and gradual exposure in virtual reality environments. Cognitive reconstruction, if necessary.
- Repeat each exercise twice.
- Reveal clinical progress to the patient, using the reports provided in the platform.
HOMEWORK
In vivo exposure with elevators with quite a lot of people + covert exposure at home revising specific ítems from the session using imagination.
| ITEM | ENVIRONMENT | CONFIGURATION | EVENT |
|---|---|---|---|
| In a very small storage room and the door closes | Claustrophobia | Room | Close doors (in a small-sized room) |
| In a very small storage room that starts to shrink in size | Claustrophobia | Room | Close doors and reduce size of bedroom |
| In a large elevator with a lot of people and a long breakdown occurs (more than 5 minutes) | Claustrophobia | Large elevator, maximum, off | Breakdown |
Intervention example in Claustrophobia/ Magnetic Resonance Imaging (MRI)
Short case introduction
Case: a person who attends a consultancy due to having a fear of a nuclear magnetic resonance for a study of headaches with aura
The evaluation indicates the presence of anxiety-depressive symptomatology associated with an adaptive process, due to the possible diagnosis: mild claustrophobia and slight discomfort associated with having undergone nuclear magnetic resonance
The principal fear is associated with the immobility incurred and loss/lack of control during the session. Symptomatology does not appear to be associated with asphyxia. Similarly, the user is unaware of the procedure that is used and fears that the radiation may worsen their pain and cause a secondary symptom. When intense claustrophobia is not apparent, focus the intervention on the magnetic resonance procedure. Here you will find an example of intervention planning, including exposure hierarchy.
Example of intervention planning
SESSION 1
- Inform the patient about claustrophobia (Causes, symptoms, prevalence…)
- Present and show sufficient grounds for the techniques that are used overtime in the treatment: virtual reality exposure and exposure in vivo…
- Exposure hierarchy development and item exposure development from 20-v30 USA’ example
- Start exposure hierarchy with an item close to USA’s 30. The main objective is to familiarize the patient with the working dynamics and the virtual reality
- Before commencing the exposure, and to facilitate the immersion, you could provide the patient with an informed consent form requesting permission to carry out the NMR (se appendix)
| ITEM | ENVIRONMENT | CONFIGURATION | EVENT |
|---|---|---|---|
| Just about to leave home in a taxi to have a nuclear magnetic resonance | Fear of flying | At home | Go to airport |
| On way to hospital in car/metro to have a magnetic resonance (select most common form of transport of patient) *A | Fear of driving | City (medium, sun, day, driver, minimum) | Circuit 1 |
| On way to hospital in car/metro to have a magnetic resonance (select most common form of transport of patient) *B | Agoraphobia | Metro (maximum light, easy) | Go to platform, enter, next stop, exit |
| In waiting room waiting to have a magnetic resonance | Claustrophobia | Magnetic | Resonance: leg, by defect, off |
| In waiting room before being briefed about the test | Fear of needles | Waiting Room | Read and sign the informed consent form in the appendix |
| Driving through a tunnel on way to hospital in a car | Fear of drying | Highway ( day, sun, driver, show, hide) | Type of highway tunnel |
| Watching a video in the waiting room explaining what nuclear magnetic resonance is. | Claustrophobia | Magnetic resonance: leg, by defect, on) | Close doors (in a small-sized room) |
SESSION 2
- Review achievements from previous sessions and set objectives for the current session: Magnetic resonance room
- As and from the second session in treatment, introducing the systematic and gradual exposure to virtual reality environments is recommendable. Cognitive reconstruction, if necessary.
- Reveal clinical progress to the patient, using the reports provided in the platform.
HOMEWORK
Exposure in vivo to a hospital close by and expose them to being present in the MRI waiting room, asking them to observe a person entering the changing room and to imagine they are doing so themselves.
| ITEM | ENVIRONMENT | CONFIGURATION | EVENT |
|---|---|---|---|
| Whilst being informed on how to collect the results, the MRI technician tells me that the test has terminated whilst I notice the bed moving out of the tube | Claustrophobia | Magnetic resonance – leg, by defect, on. | Terminate resonance |
| On my way to get changed, before doing the magnetic resonance | Claustrophobia | Magnetic resonance – leg, by defect, on. | Go to changing room |
| Whilst in the changing room I am informed of the precautions that need to be taken into account, before entering the nuclear magnetic resonance: do not enter with metallic objects, notify if wearing a pacemaker… | Claustrophobia | Magnetic resonance – leg, by defect, off | Precautions |
| On entering the magnetic resonance room, I see the machine where the test will be taken, with the leg coil setup, and I am informed on the test procedure and not to move during the magnetic resonance | Claustrophobia | Magnetic resonance – leg, by defect, off | – |
| On entering the magnetic resonance room, I see the machine where the test will be taken, with the abdomen and chest coil set up, and I am informed on the test procedure | Claustrophobia | Magnetic resonance – , torso by defect, off | – |
SESSION 3
- Review achievements from previous sessions and set objectives for the current session: Changing room and lying down on the treatment bed.
- Systematic and gradual exposure in virtual reality environments. Cognitive reconstruction,if it’s necessary.
- Reveal clinical progress to the patient, using the reports provided in the platform.
HOMEWORK
Covert exposure at home repeating the procedure worked on in the consultancy using imagination.
| ITEM | ENVIRONMENT | CONFIGURATION | EVENT |
|---|---|---|---|
| Entering the room to leave metallic objects, you hear the door close and are left in the room, with no windows, and all the doors are closed from the inside. | Claustrophobia | Magnetic resonance – leg, by defect, of | Go to changing room |
| At home after making magnetic resonance appointment on the telephone | Generalized anxiety | Worried about infectious diseases | – |
| On entering the magnetic resonance room, I see the machine where the test will be taken, with the head coil set up, and I am informed of the test procedure | Claustrophobia | Magnetic resonance – head, by defect, off | – |
| Lying down, facing upwards, foot immobilized, before entering the magnetic resonance tube. | Claustrophobia | Magnetic resonance – leg, by defect, off | Lie down |
SESSION 4
- Review achievements from previous sessions and set objectives for the current session. Lying immobile on the treatment bed.
- Systematic and gradual exposure in virtual reality environments. Cognitive reconstruction, if it’s necessary.
- Reveal clinical progress to the patient, using the reports provided in the platform.
HOMEWORK
Covert exposure and make an MRI appointment on the telephone (even if they already have made an appointment)
| ITEM | ENVIRONMENT | CONFIGURATION | EVENT |
|---|---|---|---|
| Before leaving the room, Before leaving the room, tells me to lie down on the treatment bed and that the test with begin shortly: the leg coil is already in place | Claustrophobia | Magnetic resonance – leg , by defect, off | Lie down |
| Lying down on the treatment bed the medical technician places the coil on my chest, whilst explaining what is going to happen, and then exits | Claustrophobia | Magnetic resonance – torso, by defect, off | Lie down |
| On the treatment bed looking at the ceiling and the coil on my chest, before being placed all the way into the magnetic resonance machine | Claustrophobia | Magnetic resonance – torso, by defect, off | Lie down |
| Whilst on the treatment bed the medical technician stops moving my head to start the test when finished he/she goes to the control room. | Claustrophobia | Magnetic resonance – head, by defect, off | Lie down |
SESSION 5
- Review achievements from previous session and set objectives for the current session, Immobility lying down on treatment bed inside the NMR tube (asphyxia)
- Systematic and gradual exposure in virtual reality environments. Cognitive reconstruction, if necessary.
- Reveal clinical progress to the patient, using the reports provided in the platform.
HOMEWORK
Covert Exposure
| ITEM | ENVIRONMENT | CONFIGURATION | EVENT |
|---|---|---|---|
| Lying down, facing upwards, head immobilized, before entering the magnetic resonance tube and I see the medical technician in the control room in the coil mirror | Claustrophobia | Magnetic resonance – head, by defect, off | Lie down |
| The test starts: entering cramped magnetic resonance tube to the waist point, leg immobile due to the coil and hear the sounds of the machine for the first time | Claustrophobia | Magnetic resonance – leg , by defect, off | Start resonance |
| The test starts and I notice my immobile body, due to the coil, sliding to the inside of the magnetic resonance tube. Small space. | Claustrophobia | Magnetic resonance – torso , by defect, off | Start resonance |
SESSION 6
- Review achievements from previous sessions and set objectives for the current session. Immobility lying down on a treatment bed inside the NMR tube (asphyxia).
- Systematic and gradual exposure in virtual reality environments. Cognitive reconstruction, if necessary.
- Reveal clinical progress to the patient, using the reports provided in the platform.
HOMEWORK
General guidelines for coping with the NMR test in vivo.
| ITEM | ENVIRONMENT | CONFIGURATION | EVENT |
|---|---|---|---|
| Hear the technician’s voice a short while after entering saying we are about to start Entire body enters the magnetic RMN tube, head immobilized from the coil, watching how the technician controls the machine through the little mirror. | Claustrophobia | Magnetic resonance – head , by defect, off | Start resonance |
| Whilst placed inside the machine, I hear how the sound of the magnetic resonance changes. | Claustrophobia | Magnetic resonance – head , by defect, off | Noise |
| Noticing how the sound of the magnetic resonance machine becomes deeper | Claustrophobia | Magnetic resonance – head , by defect, off | General volumeregular |
PLEASE REFER TO OUR GENERAL CLINICAL GUIDE FOR INFORMATION ON THERAPEUTIC PROCEDURES WITH EMPIRICAL EVIDENCE AND HOW TO ADAPT THEM TO THE INTERVENTION WITH PSIOUSʼ VIRTUAL REALITY ENVIRONMENTS.