Author: Alex Asensi

Surrounded by pigeons

In this environment the patient represents standing, surrounded by children who play and scamper around a large number of pigeons, which are eating and flying. At one point, he bends down and throws food at the pigeons, extends his hand and eats from his palm, so at this moment the level of difficulty to the exhibition will be increased. 

Duration: 4’45”
Difficulty: Medium

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Rottweiler dog

In this environment one of the most commonly feared breeds by people with a dog phobia appears, since they are traditionally considered dangerous. First, the owner of the dog makes him sit, then he gets up, lets himself be petted and goes from one side to the other. At some point he runs to the patient and jumps up friendly. The dog is caressed all the time by the avatar and approaches him. It is barking throughout the video.

Duration: 3’31”
Difficulty: High

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Calm dog

In this environment a dog appears walking. He is very calm and allows himself to be stroked by a foreground hand, as if it were the patient’s.

Duration: 48”
Difficulty: Low

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Close-up of pigeons

In this case the patient represents being crouched. You can see the pigeons eating around him very close to him.

Duration: 29 ”
Difficulty: High

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Cat

The environment shows a hand stroking a cat. At first it bites sometimes, but without force. Then it is allowed to caress calmly under the chin and on the head.

Duration: 1’50” 
Difficulty: High

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ESTE DOCUMENTO HA SIDO TRADUCIDO DEL ESPAÑOL MEDIANTE GOOGLE TRANSLATE Y NECESITA SER TRADUCIDO POR UN TRADUCTOR PROFESIONAL

Index Manual Fear of Animals

1.  Phobia to Animals: Virtual Reality and Augmented Reality
2. Evaluation protocol / psychological intervention proposed by Psious
   1. Evaluation Fear of animals
      1.  Evaluation objectives
      2. Some useful instruments for the evaluation of Fear of animals
      3. Elaboration of the hierarchy of exposure with Psious environments
   2. Treatment in a single session of Öst
   3. Example of intervention in Fear of spiders
3. Recommendations for Use Recommended 
4. bibliography
5. Annex

1. Animal phobia: virtual reality and augmented reality

The treatment of choice for animal phobia is based on the use of exposure techniques, whose success rate is around 90%. However, sometimes it can be difficult to carry out these sessions due to the difficulty of controlling insect reactions, creating specific situations, getting certain species, etc. Furthermore, most patients refuse to perform live exposure tasks and may even drop out of treatment. It is precisely for this reason that Virtual Reality (VR) and Augmented Reality (RA) are good alternatives for the treatment of this phobia. These technologies help facilitate patient adherence to treatment and allow the therapist to have control over different variables during exposure.

In addition to this advantage, AR is a technology that combines the real world with digital objects, making it easy to show three-dimensional objects superimposed on real situations. This facilitates the construction of systematic, gradual and adapted exposition sessions to the needs of each one. 

This is why the abundant research in this regard has confirmed the therapeutic efficacy of both RV and RA in the treatment of this type of phobias (García-Palacios et al, 2001), as well as the wide range of advantages that make them preferable. to traditional techniques (Miloff et al, 2016).

2. Psychological evaluation / intervention protocol

All the information contained in this section is for guidance only. Psious environments are therapeutic 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, token economy …) to Psious settings.

2.1 Evaluation Fear of animals

2.1.1 Evaluation objectives 

• To assess the presence and comorbidity of other emotional disorders, especially anxiety disorders and other phobias.

• Evaluate anxiety associated with components: animals and their movements (especially if they are sudden), their physical appearance, the sounds they make and their tactile properties.

• Define stimulus configurations feared by the patient and to what degree. Elaboration of exposure hierarchy.

• Assess presence of distorted thoughts: believe that they will be terrified of an animal, that they will lose control, that they will harm themselves when trying to escape.

2.1.2 Some useful instruments for the evaluation of Fear of animals

Taking into account the evaluation objectives, we will list some tools and instruments that may be useful to obtain relevant information about the characteristics of your user. Remember that a good definition of objectives, characterization of the patient and planning of the intervention are important for the efficiency and therapeutic efficacy, as well as for the satisfaction of your patients. In the bibliography you will find the articles in which to review the characteristics of the instruments proposed below.

For a complete evaluation of the problem, a combination of the following instruments will be used:

• Open or semi-structured interview.

• Structured interview: Interview for Anxiety Disorders according to the DSM-IV (ADIS-IV) (Brown, Di Nardo & Barlow, D, 1994) 

• Observation and self-observation (with self-registration): 

• In vivo behavioral approach test and / or using virtual reality

• Self-reports

• Fear Recognition Inventory III (Fear Survey Schedule III, FSS-III) (Wolpe & Lang, 1977)

• Inventory of fears (children) (Sosa et al., 1993)

• Psious self-reports for the elaboration of the hierarchy

2.1 .3 Elaboration of the exposure hierarchy with Psious environments: 

Once we have the evaluation information we can proceed to elaborate the exposure hierarchy. For this, in addition to using the data obtained during the initial assessment, we can ask a series of questions (eg, what level of discomfort, on a scale of 0 to 100, does it generate to see a small spider? What level of discomfort , on a scale of 0 to 100, would it generate you to have a cockroach walking by your hand? Do you think there is something that can generate even greater discomfort? …) aimed at planning the intervention using virtual reality.

Below are a number of items that could be used to create an appropriate hierarchy for dealing with animal fear with Psious. It should be borne in mind that we could ask the patient about the anxiety that these items generate, and from this, graduate the different elements of the hierarchy.

• Being in a room and seeing a small spider inside a terrarium (environment afraid of animals, room with spiders) 

• Seeing many pigeons while walking through a plaza (environment afraid of animals, video pigeons in a plaza)

• What a small cockroach walk by your hand (environment afraid of animals, room with cockroaches)

• See many quite large spiders move around the table (environment afraid of animals, room with spiders)

• Petting a cat (environment afraid of animals, video cat)

• Being around a dog of the Rottweiler breed (animal fear environment, Rottweiler video)

• Seeing a few cockroaches on the work table (animal fear environment, augmented reality of cockroaches)

2.2 Treatment in a single session by Öst 

More A treatment protocol using Psious is provided below. The suggested protocol is based on the guidelines for single session treatment proposed by Öst (1989), which is currently one of the recommended treatments for specific phobias. It is an intensive exhibition, the duration of which is usually between one and three hours. The main objective is to confront the patient to the phobic situation in a controlled way, allowing him to see that the feared consequences do not happen. 

An alternative is to carry out several sessions in which the total treatment time does not exceed three hours, so it is proposed to distribute it in six sessions. In addition, for its long-term effectiveness, it is recommended that the patient continue with techniques of self-exposure to the feared situations once the treatment ends.  

Exposure using RV and / or RA is normally combined with traditional techniques, such as cognitive restructuring and modeling techniques.

To apply the Öst single-session technique, patients must meet the following characteristics: present a phobia not associated with other pathologies, be motivated enough to tolerate a high level of anxiety for long periods of time, and not obtain positive consequences derived of phobia. Furthermore, the technique will not be used in patients with physical illnesses such as heart disease. 

It is a prolonged exposure, with no possibility of escape and which is generally graduated through the use of aids and closer approximations to the feared element. Each step in the hierarchy continues until anxiety levels are reduced by at least 50% from their highest value, or when the patient’s negative thoughts are modified. 

Next, an adaptation of this treatment of a single session is proposed to the resources available on the Psious platform. This intensive session is designed to last approximately two hours. To begin with, the patient must be informed of the objective: to approach by a small step towards the insect, with the subsequent maintenance of said approach, which will ultimately lead to a decrease in anxiety (Gunnar Götestam and Hokstad, 2002). 

Each session will begin with the exhibition using virtual reality, with the presence of spiders or cockroaches depending on the patient’s phobia. First, you will start with the insect in question inside the terrarium. Little by little, the distance between them will be reduced (always indicating the patient before). Afterwards, the patient should be asked if he feels prepared to be exposed to the animal outside the terrarium. When the patient feels ready, then this will be done. Little by little, the insect will get closer and closer to the patient, always indicating previously. Finally, through the corresponding menu, the virtual insect will be placed on top of the avatar’s hands. As a last step, it is recommended to use the augmented reality environment so that the hands are those of the patient. In this case, you can first touch the insect with an object and then proceed to contact with your hands. The final objective for the patient will be to be able to catch the insect without suffering anxiety.

2.3 Example of intervention in Fear of spiders

SESSION 1

Psychoeducation: Inform the patient about fear of animals (Causes, symptoms, prevalence …).

• Present and justify the techniques to be used throughout the treatment: virtual reality exposure and live exposure …

• Elaboration of the exposure hierarchy and exposure to items in the 20-30 USA hierarchy (example)

• Start exposure hierarchy with an item close to 30 USA’s.

The main objective will be to familiarize the patient with virtual reality and work dynamics.

Item	USA’s	Environment	Configuration	Event
Being at a table having a terrarium over	20	rooms withspiders,	minimal  terrarium, small	Maximum distance
See a very small spider in a terrarium	30	rooms withspiders,	minimal  terrarium, small	Maximum distance
See a few small spiders inside of a terrarium	40	Room with spiders	maximum, terrarium, small	Maximum distance

SESSION 2

• Review achievements previous session and set objectives of the session: See large spiders in a terrarium.

• Thebegins exhibitionwith gradual and systematic response prevention with virtual reality. Cognitive restructuring, if applicable

• Reports are shown to the patient for clinical progress.

Homework

Live exhibition before an empty terrarium or with a small insect.

Item	USA’s	Environment	Setting	Event
See a medium spider inside a terrarium	45	Room with spiders	minimum, terrarium, medium	Maximum distance
See some large spider inside the terrarium and that moves	50	Room with spiders	minimum, terrarium, large	Disorder
See a medium spider in a terrarium quite close	55	Room with spiders	minimum, terrarium, medium Medium	distance
See enough large spiders inside a terrarium	60	Room with spiders	maximum, terrarium, large	Maximum distance

SESSION 3

• The achievements of the previous session are reviewed and objectives of the current: See a large spider on the other side of the table.

• is carried out Exposurewith prevention of gradual and systematic response with virtual reality. Cognitive restructuring, if applicable.

• Clinical advances are shown to the patient, through platform reports.

Homework

Live exhibition looking at an empty terrarium or with a couple of insects + covert exhibition at home reviewing the session through the imagination.

Item	USA’s	Environment	Configuration	Event
View some small spiders to the other side of the table	60	room withchandeliers,	minimal  table, small	maximum distance
that a few large spiders you begin to move much while in a terrarium	65	room withspiders,	maximum  terrarium, large	disorder
See a small group of mediumsized spiders to the other side of the table	65	room withchandeliers,	minimal  table medium	maximum distance
See some large spider to the other side of the table	70	room withchandeliers,	minimal  table, large	maximum distance

SESSION 4

• are reviewed achievements from the previous session and session objectives are set: Have a small group of medium-sized spiders moving in front of you. 

• is carried out Exposurewith prevention of gradual and systematic response with virtual reality. Cognitive restructuring, if applicable.

• Clinical advances are shown, through platform reports, to the patient.

Homeworks

Exhibition covertly through imagination

Item	USA’s	Environment	Configuration	Event
Standfront of a small spider does not move	70	Augmented Reality: Spiders	small, low
See some spider medium halfway between the end of the table and your hands	75	roomspiders	minimum, table, mediumMedium	distance
Have a small number of medium moving	80	spidersRoom withspiders	medium, medium, walk

SESSION 5

• Review previous session achievements and set session objectives: Have a group of spiders in front and move.

• is carried out Exposurewith prevention of gradual and systematic response with virtual reality. Cognitive restructuring, if applicable.

• Repeat 2 times each of the exercises

• Show clinical progress, through platform reports, to the patient.

Homework

Exhibition in imagination reviewing the objectives discussed in consultation.

Item	USA’s	Environment	Setting	Event
Having a few spiders nearby and not moving	80	Augmented Reality:	Large, medium
spiders See how many medium spiders approach you	85	Augmented Reality:spiders	Large, maximum, walking
Having a large group of spiders moving ahead of you	90	Room with spiders	maximum, table, medium	Reduce distance

SESSION 6

• Review achievements of the previous session and establish objectives of the session: That many large spiders walk by your hand

• is carried out Exposurewith prevention of gradual and systematic response with virtual reality. Cognitive restructuring, if appropriate.

• Repeat each exercise twice

• Show clinical progress, using platform reports, to the patient.

Homework

Covert exposition, reviewing the process followed in the session at home.

Item	USA’s	Environment	Setting	Event
Having a medium-sized spider walking by your hand	85	Video: Spider
Having enough spiders in front, a loud noise is heard and they begin to move	90	Room with spiders	maximum, table, large	Minimum distance + Disorder
See in front of you a large group of large spiders that move	95	Augmented Reality:spiders	Large, maximum, walk
Have many large spiders nearby and walk by your hand	100	Room with spiders	maximum, table, large	Minimum distance + Walk by hand

3. Recommendations for use

It is important to accompany the presentation with comments, questions or indications so that the patient is more in position and experiences the exhibition in a more realistic way.

Some examples for fear of animals

• Now we are going to take a walk in a square where there will probably be pigeons.

• How do you feel when the dog approaches you? Does this make you feel uncomfortable? 

• What sensations does the terrarium in front of you generate, now that it is empty?

• You are seeing some roaches approaching, what do you think could happen?

• At this moment you are going to feed a group of pigeons, and you are going to see that they surround you, are you ready?

• Now that you have a little spider in your hand, what makes you more anxious?

• The cockroach that just appeared is bigger than the previous one, how does that make you feel?

• Do you feel comfortable petting this cat? Does the fact that he opens his mouth make you anxious?

• Now you see that the terrarium is empty, but let’s see how it would look if there were small spiders in it; are you ready?

4. Recommended bibliography

Bados, A. (2005). Specific phobias. Barcelona. University of Barcelona.

Bottle, C., Breton-López. J., Quero, S., Baños, RM, García-Palacios, A., Zaragoza, I. and Alcañiz, M. (2011). Treating cockroach phobia using a serious game on a mobile phone and augmented reality exposure: a single case study. Computers in Human Behavior, 27, 217-227.

Botella, CM, Juan, MC, Baños, RM, Alcañiz, M., Guillén, V. and Rey, B. (2005) Mixing Realities? An Application of Augmented Reality for the Treatment of Cockroach Phobia. Cyberpsychology and Behavior, 8 (2), 162-171.

Brown, TA, Di Nardo, PA & Barlow, DH (1994). Anxity Disorders Interview Schedule for DSM-IV (ADIS-IV). San Antonio: The Psychological Corporation.

García-Palacios, A., Hoffman, HG, Kwong See, S., Tsai, A. and Botella, C. (2001) Redefining Therapeutic Success with virtual reality exposure therapy. Cyberpsychology & Behavior, 4, 341-348

Gunnar Götestam, K. and Hokstad, A. (2002). Single-session treatment of Arachnophobia in a group through Active Rotating Exposure. The European Journal of Psychiatry, 16 (3), 133-138. 

Juan, MC, Alcañiz, M., Montserrat, C., Baños, RM and Guerrero, B. (2005). Using augmented reality to treat phobias. IEEE Computer Graphics and Applications, 25 (6), 31-37.

Miloff, A., Lindner, P., Hamilton, W., Reuterskiöld, L., Andersson, G., & Carlbring, P. (2016). Single-session gamified virtual reality exposure therapy for spider phobia vs. traditional exposure therapy: study protocol for a randomized controlled non-inferiority trial. Trials, 17 (1), 60. https://doi.org/10.1186/s13063-016-1171-1

Öst, LG (1989). One-session treatment for specific phobias. Behavior Research and Therapy, 27, 1-7.

Sosa, CD, Capafóns, JI, Conesa-Peraleja, MD, Martorell, MC, Silva, F. and Navarro, AM (1993). Inventory of fears. In F. Silva and C. Martorell (dirs.), Assessment of childhood and youth personality (vol. 3, pp. 101-124). Madrid: MEPSA

Wolpe, J. and Lang, P. (1977). Manual for the Fear Survey Schedule. San Diego, CA: Educational and Industrial Testing Services. 

6. Annexes

6.1 Self-report hierarchy Augmented Reality spiders / cockroaches Psious environments

* The self-report only talks about cockroaches, but it is applicable to the RA of spiders (both environments work exactly the same)

Item	Level discomfort (0-100)
Above the table there are some roaches. I can see that they are moving and that they are quite large.
There are a few roaches, neither too big nor too small, that are static on the table.
I have a small roach in front of me, and it does not move.
There are a few roaches, not too large. not too small, they are walking on the table
I have a small cockroach in front of me that is moving
I have a cockroach in front, which is not too big but not too small, and that does not move
I can see many cockroaches that move and they are quite small
I have some roaches in front, they are rather small and they do not move
I can see many roaches in front of me. I see that they do not move but that they are medium, neither too small nor too big.
In front of me I can see a very large cockroach that moves from one side to the other.
I can see many cockroaches that do not move and that are quite small.
I have some cockroaches moving in front, and they are rather small
I have a cockroach in front, which is not too big but not too small, and it is moving
I have a large group of large cockroaches in front. Still, they don’t move too much.
I can see a lot of roaches in front of me. I see that they move but they are medium, neither too small nor too big.
In front of me I can see a very large cockroach that does not move.
On the table there are some cockroaches. I can see that they do not move and that they are quite large
I have in front of me a large group of large cockroaches that move all over the table

6.2 Self report hierarchy room spiders / cockroaches Psious environments

* In the self report we only talk about spiders, but it is applicable to the environment of cockroaches (both environments work exactly the same)

Item	Level discomfort (0-100)
I have a small group of large spiders on the other side of the table, and suddenly a noise is heard that makes the spiders move a lot
I am faced with a table, and I can see that there is some very small spider moving around there
In the terrarium on top of the table I can see that there are many rather medium-sized spiders, they are not small but not very large
Halfway between the end of the table and my hands there is a small group of spiders that are quite big and they move
I have a couple of small spiders very close to my hands
I am looking at a terrarium and I can see that there are a lot of very small spiders
There are a small number of very large spiders on the table, but they are quite far from my hands.
There are many medium spiders on the table, and they move until they are at a medium distance between my hands and the end of the table.
I am in a room, with a terrarium in front. In it I can see that there are a couple of very large spiders that move.
I have my hands resting on the table, and I can see how a small spider begins to move through them.
When I have many large spiders near me, there is a loud noise and spiders move from side to side
I am at a table and I can see that there are a lot of very small spiders
I am sitting in a chair and at the table in front I can see that there are a couple of very large spiders that move
There are a small number of medium sized spiders on the table, but they are quite far from my hands.myself in
I findfront of a terrarium, and I can see that there is some very small spider inside.
While sitting in a chair I see that there is some medium sized spider above the table.
There are many, many fairly small spiders on the table, but they are quite far from my hands.
I am with my hands resting on the table, and I see how some spider, neither too big nor too small, moves quite close to me.
I have my hands resting on the table, and I can see how many small spiders start to move around them
On the table I can see that there are many, many medium-sized spiders, they are not small but they are not very large either.
I have many large spiders very close, and they start to walk by my hand
While sitting in a chair I see the terrarium in front of me, and in it there is some medium spider.
Halfway between the end of the table and my hands there is a large group of spiders that are quite large and move.
I have a pair of medium spiders very close, and they start to walk by my hand
I am in a room, and on the table there are many spiders that are very large
I am with my hands resting on the table, and I see how many spiders, neither very large nor very small, move quite close to me
I’m in a room, and in the terrarium there on the table there are many spiders that are very large
there are some small spiders near me, and begin to move much when a loud noise heard in the room
have a pa r of large spiders very close, and they start to walk by my hand
There are a small number of quite small spiders on the table, but they are quite far from my hands
As I am looking at the table, I see like a large group of spiders, which are quite large, they move very close to my hands
I have many small spiders very close to my hands
On the table there are some small spiders, and although they are not at the end of the table, they are not touching my hands
On the table there are quite a few spiders small, and although they are not at the end of the table, they are also not touching my hands
There are some medium-sized spider on the table, and they move until they are at a medium distance between my hands and the end of the table
I have many spiders very large quite far from my hands
While I’m looking at the table, I see a small group of spiders, which are quite large, they move very close to my hands
There are many medium-sized spiders near my hands, and they start walking around one of them
There are a large number of ara Medium-sized nails on the table, but they are quite far from my hands

6.3 Self-report hierarchy environment Fear of Dogs

Item	Level discomfort (0-100)
I see a dog in the distance sitting muzzled next to its owner and tied on a leash
In the distance I see to a dog sitting, muzzleless next to its owner and on a leash
I can see in the distance a dog with a muzzle sitting on a leash, somewhat separated from its owner
In the distance I see a dog without a muzzle, sitting and separated from its owner but tied on a leash
I see a dog sitting with a muzzle in the distance, without a leash but next to its owner
I see a dog sitting in the distance, without a muzzle, next to its owner and without a leash
I can see a dog with a muzzle in the distance , sitting, without a leash and a little far from its owner
I observe a dog without a muzzle, sitting, without a leash and a little far from its owner
I observe a dog in the distance standing with a muzzle next to its owner and tied on a leash
A in the distance I see a dog standing, muzzleless next to its owner and on a leash
I can see in the distance a dog with a muzzle standing on a leash, somewhat separated from its owner
In the distance I see a dog without a muzzle, standing and separated from its owner but tied on a leash
I see in the distance a dog with a muzzle standing , without a leash but next to its owner
I see a dog standing in the distance, without a muzzle, next to its owner and without a leash
I can see in the distance a dog with a muzzle, standing, without a leash and a little away from its owner
I see far away a dog without a muzzle, standing, without a leash and a little far from its owner
In the distance I see a dog sitting, without a muzzle next to its owner and tied on a leash and barking
In the distance I see a dog without a muzzle and barking, sitting and separated from its owner but tied on a leash
I observe in the distance a sitting dog, without a muzzle, next to its owner and without a leash and barking
I observe far a dog without a muzzle, sitting, without a leash and a little away from its owner and barking
In the distance I see a dog standing, muzzleless next to its owner, on a leash and barking
A l or far I see a dog without a muzzle and barking, standing and separated from its owner but tied on a leash
I see in the distance a dog standing, without a muzzle, next to its owner, without a leash and barking
I see far a dog without a muzzle, standing, off leash, slightly away from its owner and barking
I observe a medium-distance dog sitting muzzled next to its owner and tied on a leash
At a medium distance I see a dog sitting, muzzled next to its owner and tied on a leash
I can see at a medium distance a dog with a muzzle sitting on a leash, somewhat separated from its owner
At a medium distance I observe a dog without a muzzle, sitting and separated from its owner but tied on a leash
I observe at a medium distance a dog sitting with a muzzle, without a leash but next to its owner
I observe at a medium distance a dog sitting, without a muzzle, next to its owner and without a leash
I can see at a medium distance a dog with a muzzle, sitting, without a leash and a little away from its owner
I observe at a medium distance a dog or without a muzzle, sitting, without a leash and slightly away from its owner
I observe a dog at a medium distance standing with a muzzle next to its owner and tied on a leash
At a medium distance I see a dog standing, without a muzzle next to it from its owner and on a leash
I can see at a medium distance a dog with a muzzle standing on a leash, somewhat separated from its owner
At a medium distance I see a dog without a muzzle, standing and separated from its owner but on a leash
I observe At a medium distance a white dog standing with a muzzle, without a leash but next to its owner
I observe at a medium distance a dog standing, without a muzzle, next to its owner and without a leash
I can see at a medium distance a dog with muzzle, standing, without a leash and a little far from its owner
I observe at a medium distance a dog without a muzzle, standing, without a leash and a little far from its owner
At a medium distance I see a dog of the sitting dog breed, muzzleless next to its owner and leashed and barking
At a medium distance I watch a dog without a muzzle and barking, sitting and separated from its owner but tied on a leash
I observe at a medium distance a dog sitting, without a muzzle, next to its owner and without a leash and barking
I see far away a dog without a muzzle, sitting, without a leash and slightly away from its owner and barking
At a medium distance I see a dog of the breed dog standing, without a muzzle next to its owner, tied on a leash and barking
At a medium distance I see a dog without a muzzle and barking, from standing and separated from its owner but tied on a leash
I observe at a medium distance a dog standing, without a muzzle, next to its owner, without a leash and barking
I observe at a medium distance a dog without a muzzle, standing, without a leash, a little away from its owner and barking
I see a dog nearby sitting muzzled next to its owner and tied on a leash
Nearby I have a dog sitting muzzleless next to its owner and tied on a leashon a leash
I can see near a dog with a muzzle sittingleash, somewhat detached from its owner.
Nearby I observe a dog without b ozal, sitting and separated from its owner but tied on a leash
I see a dog sitting near with a muzzle, without a leash but next to its owner
I have a dog sitting nearby, without a muzzle, next to its owner and without a leash
I can see near me a dog with a muzzle, sitting, without a leash and a little far from its owner
I observe nearby a dog without a muzzle, sitting, without a leash and a little far from its owner
I observe a dog nearby, standing, with a muzzle, next to its owner and on a leash
Near me I see a dog standing, without a muzzle next to its owner and tied on a leash
I have a dog near me with a muzzle standing on a leash, somewhat separated from its owner
Near me I see a dog without a muzzle , standing and separated from its owner but tied on a leash
I see near me a white dog standing with a muzzle, without a leash but next to its owner
I closely observe a dog standing, without a muzzle, next to its owner and without correa
Puedo ver cerca de mí un perro con bozal, de pie, sin correa y un poco alejado de su dueño
Observo de cer ca un perro sin bozal, de pie, sin correa y un poco alejado de su dueño
Cerca de mí veo a un perro de la raza perro sentado, sin bozal al lado de su dueño y atado con correa y ladrando
Cerca puedo observar un perro sin bozal y ladrando, sentado y separado de su dueño pero atado con correa
Observo de cerca un perro sentado, sin bozal, al lado de su dueño y sin correa y ladrando
Tengo cerca un perro sin bozal, sentado, sin correa y un poco alejado de su dueño y ladrando
Cerca de mí veo a un perro de pie, sin bozal al lado de su dueño, atado con correa y ladrando
Cerca observo un perro sin bozal y ladrando, de pie y separado de su dueño pero atado con correa
Observo cerca de mí un perro de pie, sin bozal, al lado de su dueño, sin correa y ladrando
Observo cerca un perro sin bozal, de pie, sin correa, un poco alejado de su dueño y ladrando

ESTE DOCUMENTO HA SIDO TRADUCIDO DEL ESPAÑOL MEDIANTE GOOGLE TRANSLATE Y NECESITA SER TRADUCIDO POR UN TRADUCTOR PROFESIONAL

Index Manual Bullying

1.  Bullying and Virtual Reality
2. Evaluation protocol / psychological intervention proposed by Psious
   1. Evaluation and psychological intervention for the Bulliyng
   2. Evaluation of victims of bullying 
      1. Evaluation objectives
      2. Some useful instruments for evaluation 
   3. Intervention for victims of bullying
      1. Therapy steps to overcome the bullying
      2. Proposal for intervention for victims of bullying
3. Recommendations for use
4. Recommended Bibliography
5. Annexes 
   1. Self-registration of negative thoughts
   2. Protocol for action in situations of bullying – UNICEF

1. Bullying and Virtual Reality 

As Morán Sánchez (2006) points out, it is very difficult to detect how a harassment process. A small lie, a slight lack of respect, or an attempt at manipulation are sometimes such daily acts that they are even considered normal (Hirigoyen, 1999; Morán Sánchez, 2006). However, these types of behaviors can get worse, especially in the school context. This phenomenon considered on many occasions as a circumstantial issue typical of the immaturity of children and adolescents is, today, an alarming issue both due to its high incidence and the alteration it causes in the person who suffers from it (Morán Sánchez, 2006). 

Bullying is a concept that is used to refer to those aggressive and intentional behaviors that are constantly practiced among schoolchildren. Although it may occur in other areas, the most common place where we find cases of bullying is at school (remember the concept of mobbing associated with the workplace). This harassing behavior can vary between more direct manifestations such as physical or verbal aggression (insults, threats, coercion, humiliation, nicknames …), to other more indirect forms in the form of social exclusion (defamatory rumors, contempt …) (Cerezo, 1997 ; Morán Sánchez, 2006; Ma Jesús Irrutia, Victor Arias, 2009). 

Although the application of support therapies using Virtual Reality for the treatment of bullying cases is still a very novel fact, its effectiveness has already been proven in certain pioneering investigations in this field (Carmona et al, 2011; Langer et al, 2016 ; Quero et al., 2017; Seinfeld et al., 2018). In these studies we can see how immersive therapy through Virtual Reality is a very helpful tool both to carry out the evaluation process and the victim’s intervention. This new therapeutic format allows us to bring the victim closer to the threatening environment with the possibility of controlling the variables that occur in the situation of harassment and influence its maintenance.

In this way, Psious offers the therapist, through this new school environment, a useful tool to conduct evaluation and intervention sessions in relation to cases of bullying.

2. Psychological evaluation / intervention protocol proposed by Psious

All the information contained in this section is for guidance only. Psious environments are therapeutic 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, cognitive restructuring, etc.) to Psious settings. 

2.1. Psychological evaluation and intervention for bullying

The psychological evaluation / intervention protocol for dealing with bullying cases is usually divided into three phases. A first evaluation phase, where information is collected on the psychological profile of the affected person (levels of self-esteem, anxiety, communication skills, problem solving skills, educational deficits of the parents, etc.) and information on the case of bullying. (type of assaults, frequency, place of occurrence, subjective assessment of the severity of the assaults, feeling of security and information about the assailants). A second intervention phase whose objective is usually focused on improving social skills and the degree of assertiveness (equipping the victim with effective strategies to improve their communication skills, increase their self-esteem, learn to protect and defend their rights, as well as express effectively and socially acceptable their emotions and desires to promote integration into the group). And finally a followup phase post-intervention-. 

2.2. Assessment of victims of bullying 

2.2.1. Evaluation objectives 

• Evaluate risk:

factorsIndividual factors associated with the victim, such as: Low self-esteem; insufficient social skills to relate to other classmates; visible physical or cultural traits, different from those of the majority (ethnic, racial and cultural minorities); disability; anxiety disorders or other psychopathological disorders: mood disorders (depressive disorder), behavior disorders (attention deficit hyperactivity disorder, challenging disorder), adaptive disorders (with mixed alteration of emotions and behavior). 

Family-related factors, such as: Inappropriate, authoritative, or negligent parenting practices; education on the margins of society; restricted family life forms (social, religious or cultural group communities); dysfunctional families; high pressure, demand and / or little objective expectations; little family communication. 

Factors associated with the school, such as: Low participation in group activities; little communication between students and teachers; absence of reference authority figure in the school, profile of “good boy / girl” who never gives or gets into trouble; threats such as imposing silence on the victim on the part of the aggressor, on the part of other students, or in exceptional cases on the part of a teacher or the school itself, can lead to general behavior of self-deprivation of expression in the school environment, Poor relationships with peers … 

Factors associated with the case of bullying, such as: Type of assaults (insults, physical assaults, comments, teasing …); place / is where these attacks occur (patio, classroom, bathrooms …); frequency of assaults; subjective assessment of the severity of the attacks; feeling of security (possible help) and information about the aggressors (number of people against them). 

• Assessing the profile of the child / adolescent: 

Research on bullying and victimization [Schwartz, 2000] has identified four different types of children:

• Normal children / adolescents (neither victims nor aggressors).

• Non-aggressive victims: those who are generally victims. They show a hostile attribution style and have negative expectations of outcomes for aggression.

• Aggressive victims: Those who habitually exhibit reactive aggression. They tend to have a hostile attribution style, but no expectation of positive or negative results for aggression. 

• Non-victimized offenders: Those who show proactive aggression. They have positive hopes for aggression, but do not have a hostile attribution style. 

2.2.2. Some useful instruments for the evaluation 

For bullying: Bullying

• and Violence (AVE) (Piñuel and Oñate, 2007a)

• Brief Assessment Test of Bullying (TEBAE) (Piñuel and Oñate, 2007b)

• Questionnaire on School Violence (CVE ) (Serrano and Iborra, 2005) 

For PTSD symptoms

Childhood post-traumatic stress syndrome explains that bullied children / adolescents develop a sense of imminent danger, pervasive restlessness or nervousness, and a type of recurrent and nonspecific anxiety with permanent sensation that something terrible is going to happen imminently to them or their loved ones. 

The harassed child / adolescent develops a hyperreaction to frustration, or to environmental stimuli such as a strong light, a door that closes suddenly, loud noises, etc …

Childhood post-traumatic stress syndrome generates an extraordinary and intense irritability that the victim of bullying she projects immediately on her family and colleagues. 

It also causes a type of hypervigilance that consists of enormous mistrust and suspicion of the intentions of others. 

Among the tests that can be used to assess post-traumatic harm among victims of bullying in childhood and adolescence are the following:

• Child Post-Traumatic Stress Disorder Reaction Index (CPTSD-RI; Pynoos et al. 1987)

• Post Stress Scale Traumatic of Bullying and School Violence (AVE) (Arce, Velasco, Novo, & Fariña, 2014)

• Diagnostic Interview for Children and Adolescents (Ezpeleta, De La Osa, Domenech, Navarro, & Losilla, 1997) 

For anxiety symptoms

• Questionnaire of thoughts automatic negatives (ATQ-30, Automatic Thoughts Questionnaire) (Hollon and Kendall, 1980. Adapted by Cano and Rodríguez, 2002). 

• Bullying Anxiety Scale School Violence (Arce, Velasco, Novo, & Fariña, 2014)

• Revised Anxiety Scale in Children (CMASR-2) (Reynolds & Richmond’s, 2012)

• State-Trait Anxiety Inventory for Children (STAIC) (Kirisci, Clark, & Moss, 1997)

For symptoms of depression

• Childhood Depression Questionnaire (CDI) (Kovacs, 1992; del Barrio et al, 1999)

• School Violence Bullying Depression Scale (AVE) (Arce, Velasco, Novo, & Fariña, 2014)

• Depression Self-Rating Scale in Childhood (Birleson et al, 1987)

Others:

• Profile of Educational Styles for Parents (PEE) (García Pérez and Magaz Lago, 2011 a)

• Magellan Adaptation Scales (EMA) (García Pérez and Magaz Lago, 2011 b)

2.3. Intervention for victims of bullying 

It is important to note that in this section we will only show and suggest some points to guide the intervention through the virtual environment of Psious to address bullying or bullying. The treatment must be adapted to the characteristics of each patient and the therapist may adapt it according to their criteria. A good first orientation can be obtained in Protocol of action in situations of bullying – UNICEF 

2.3.1. Therapy steps to overcome bullying

As we have seen in the evaluation section, the treatment of bullying cases is usually carried out in 3 phases: evaluation, intervention and follow-up. 

By using our environment it will be possible to bring the victim of bullying closer to a similar situation that helps us carry out the approach of the different phases of bullying treatment.

• Evaluation:

In this first phase we will confront our patient with the environment in order to evaluate his behavior in relation to the problem. During the course of the scene and once its execution is finished, we will try to collect relevant information about the case, through a semi-structured interview 2. We will therefore focus on knowing the patient’s profile. It is important to collect information both from the intrapersonal part (as I am), and from the interpersonal part (as they see me and I relate to others). In this way, once the initial exploration has been carried out, we will have more information to determine a personalized action plan. 

• Intervention: 

In this second phase our objective of locating the patient in the environment will be to try to execute theaction plan appropriateor training in relation to the evaluation phase. Therefore, we will provide the patient with those tools that help them solve psychopathological aspects that contribute to aggravating or maintaining the problem of bullying.

The following table summarizes groups different useful aspects to work in cases of bullying and the different techniques often applied:

Aspects psychopathological	therapeutic techniques
Deficitselfesteem	Restructuringcognitive
anxiety	diaphragmatic breathing / relaxation (can leverage environments relaxation Psious)
Deficit problem solving	Training in problem solving / Training in self-instruction
Social skills / assertiveness	Training in communication skills / debate / discussion / argumentation

Summary table: Adapted from Morán Sánchez, 2006

² The relevant information to collect is detailed in section 2.2 .one.

• Follow-up:

It is important, once the intervention has been carried out, to schedule follow-up sessions after a period of time. In this way we can ensure the effectiveness of the intervention and detect possible aspects that may need to be reinforced again.

2.3.2. Proposal for intervention for victims of bullying 

Below we show you a proposal for intervention with PSIOUS for victims and participants in situations of bullying. 

The following proposal is made to evaluate coping styles in a school conflict situation. 

Session 1

• Inform the patient about discomfort in relation to problems at school, as well as about the emotional responses involved: anxiety, sadness, anger …

• Present and justify the techniques that will be used throughout the treatment: evaluation of thoughts and strategies for dealing with situations of conflict and aggression at school, empathy

• Observation and evaluation of thoughts in a neutral school situation (in the hallway of the institute and during the exam.

Item	Environment	Setting	Event
Psychoeducation anxiety	What are emotions How do we feel emotions
Being alone in the hall, waiting for the teacher to arrive and start the exam	Institute, easy, just
Being with a few classmates in the hall before an exam and they seem very calm	Institute, easy, few people
Being doing an exam that is short in a classroom full of people	Anxiety before exams	Institute, easy, many people	many people Start exam

Session 2

• Review achievements previous session and establishing objectives of the session: Assessment behavior, thoughts and emotions in a situation of aggression at school. 

• Evaluation of thoughts and strategies for dealing with situations of conflict and aggression at school. 

• Identification emotional states 

Item	Environment	Configuration	Event
Being with a few classmates in the hallway before an exam and they seem very calm	Anxiety exams	Institute, easy, many people
Being in class and being approached by a classmate alone to rebuke	Bullying	Just	Begin
Identification emotional states (up to 12 years old)	Mindfulness kids: Summer	Exercises in Summer environment, especially Energy recharge and end of summer	Begin
Control of physiological activation: Breathing exercises	Relaxation Breathing Under the sea / Prairie	At the patient’s choice, adjust the frequency of comfortable breathing for the patient	Begin

Session 3

• Review achievements of the previous session and establish objectives of the session: Evaluation of behavior, thoughts and emotions in a situation of aggression at school.

• Cognitive restructuring 

• Orientation of the attention focus 

Item	Environment	Configuration	Event
To be in class and to be approached by a single partner to reprimand	bullying	Accompanied	Begin
Focus Attention	Mindfulness kids: Winter	Introduction, home and lighthouse	Begin
Control of physiological activation: Breathing exercises	Relaxation Breathing Sea / Meadow	At the patient’s choice, adjust the comfortable breathing rate for the patient.	Begin

Session 4

• Review achievements of the previous session and establish session objectives: Assessment of behavior, thoughts and emotions in a school environment. 

• Cognitive restructuring

• Social skills training

• Generation of pleasant emotions

Item	Environment	Configuration	Event
Being with a few classmates before an exam and they seem very calm	Anxiety exams	Institute, easy, many people	start
Social skills training	Audience	Few people	Start, easy questions
Generation pleasant emotions	Mindfulness kids: Autumn	Introduction, Pinwheel	start

Session 5

• Review previous session achievements and set session objectives: Assessment behavior, thoughts and emotions in school environment. 

• Restructuring Cognitive

• Trainingsocial skills

• emotionsGeneration nice

Item	Environment	Setting	Event
Being with few peers in class before an exam and they seem very calm	anxiety exams	Institute, difícill, many people	begin
Generation pleasant emotions	Mindfulness kids: Autumn	Introduction, Pinwheel and Projection joy and end of autumn	begin

Session 6

• Review achievements of the previous session and establish objectives of the session: Evaluation of behavior, thoughts and emotions in a school environment. 

• Cognitive restructuring

• Social skills training

• Energy generation = Activation

Item	Environment	Configuration	Event
Being in class and being approached by a companion to be shocked	bullying	Accompanied	Begin
Training in social skills	Audience	Many people	Start, difficult questions
Generation Activation	Mindfulness kids: summer	Introduction, magic items , recharges energy, End of summer	beginning

Session 7

• Review achievements of the previous session and establishment of session objectives: Assessment of behavior, thoughts and emotions in a school environment.

• Cognitive restructuring

• Activation generation

• Relaxation

Item	Environment	Configuration	Event
Being with a few classmates before an exam and they seem very calm	Anxiety exams	Institute, easy, many people	start
Generation Activation	Mindfulness kids: summer	Introduction, magic items, recharge energy, End of summer	start
control physiological arousal: breathing exercises	Relaxation breathing Under the sea / Meadow	a choice of the patient, adjust frequency comfortable breathing for the patient	start

RECALLS thathave the Clinical Guide toabout PROCEDURES THERAPEUTIC wITH EVIDENCETHUMB AND HOW TO ADAPT THEM TO THE INTERVENTION WITH THE VIRTUAL ENVIRONMENTS OF PSIOUS

3. Recommendations for use

It is always interesting and positive to try to complement the Virtual Reality experience with comments, questions or indications to facilitate that the patient can more easily put himself in situation and feel a greater immersion in the environment. 

Some examples could be: “Imagine that these are your classmates with whom you are having problems” … “How does it feel to see them?” “What do you think they think of you?” “Which one do you feel the most uncomfortable with and why?” “Which generates the most fear or anxiety?” “Which one do you trust or give you greater security?” “Do they make you nervous?” “What do they usually do when the teacher is away?”, Etc.

In turn, it is highly recommended to try to keep the patient in the same body position in which the protagonist of the scene is (in this case, sitting at the classroom desk).

Similarly, it can be useful to add any element of the scene or context where the events happen. In this case, offering the patient a pen or pencil and a notebook can help to make the immersion more effective and provide the child / adolescent with the sensations of the conflictive environment. 

4. Recommended Bibliography

Arce, R., Velasco, J., Novo, M., & Fariña, F. (2014). Preparation and validation of a scale for the evaluation of bullying. Iberoamerican Journal of Psychology and Health, 5 (1), 71–104. 

Birleson P. Hudson I, Gray-Buchanan D, Wolff S. (1987). Clinical Evaluation of a Self-Rating Scale for Depressive Disorder in Childhood (Depression Self-Rating Scale). J. Child Psychol. Psychiat 28, 43-60 https://doi.org/10.1111/j.1469-7610.1987.tb00651.x

Cerezo, F. (1997). Aggressive behavior at school age. Madrid: Pyramid. 

Da Silva, JL, de Oliveira, WA, de Mello, FC, de Andrade, LS, Bazon, MR, & Iossi Silva, MA (2017). Anti-bullying interventions in schools: a systematic literature review. Ciência & Saúde Coletiva, 22 (7), 2329–2340. https://doi.org/10.1590/1413-81232017227.16242015

Del Barrio, V., Moreno-Rosset, C., López-Martínez, R., (1999). The Children’s Depression Inventory [CDI; Kovacs, 1992]. Its application in the Spanish population. Clinica y Salud 10, 393-416.

Ezpeleta, L., De La Osa, N., Domenech, JM, Navarro, JB, & Losilla, JM (1997). Test-retest reliability of the Spanish adaptation of the diagnostic interview for children and adolescents (DICA-R). Psicothema, 9 (3), 529–539.

García Pérez, EM and Magaz Lago, A. (2011 a). PEE Profile of educational styles (ed. Rev.). Bilbao: COHS Human Sciences Consultants.

García Pérez, EM and Magaz Lago, A. (2011 b). EMA Magellan Adaptation Scales (ed. Rev.). Bilbao: COHS Human Sciences Consultants. 

Guillén, KG, Rojas Molina, L., Astorga, R., Joya, R., & et al. (2015). Protocol of action in situations of Bullying, 57. Retrieved from https://www.unicef.org/costarica/Documento-Protocolo-Bullying.pdf

Hollon, SD, & Kendall, PC (1980). Cognitive self-statements in depression: Development of an automatic thoughts questionnaire. Cognitive Therapy and Research, 4 (4), 383–395. https://doi.org/10.1007/BF01178214

Hirigoyen, MF (1999). Moral harassment. Barcelona: Paidós. 

Irurtia Muñiz, MJ, Avilés Martínez, JM, Arias González, V., & Arias Martínez, B. (2009). The treatment of victims in the resolution of bullying cases. AMAzônica (Revista de Psicopedagogia, Psicologia Escolar E Educaçao), 2 (1), 76–99. 

Kirisci, L., Clark, DB, & Moss, HB (1997). Reliability and Validity of the State-Trait Anxiety Inventory for Children in Adolescent Substance Abusers: Journal of Child & Adolescent Substance Abuse, 5 (3), 57–70. 

Kovacs, M. (1992). Children’s Depression Inventory (CDI). Toronto, ON: Multi-Health Systems Inc. 

Langer, LI, Aguilar-Parra, JM, Ulloa, VG, Carmona-Torres, JA, & Cangas, AJ (2016). Substance Use, Bullying, and Body Image Disturbances in Adolescents and Young Adults Under the Prism of a 3D Simulation Program: Validation of MySchool4web. Telemedicine and E-Helath, 22 (1), 18–30. https://doi.org/10.1089/tmj.2014.0213

Melero, S. (2017). Cognitive-behavioral intervention in an adolescent victim of bullying. With Children and Adolescents, 4, 149–155.

Morán Sánchez, C. (2006). Cognitive-behavioral intervention in bullying: a clinical case of bullying, 2, 51–56.

Piñuel, I and Oñate, A. (2007a). AVE, Harassment and School Violence Test. Madrid: TEA Editions.

Piñuel, I. and Oñate, A. (2007b) Bullying and School Violence in Spain: Report Cisneros X. Madrid: IIEDDI 

Pynoos, RS, Frederick, C., Nader, K., Arroyo, W., Steinberg, A., Eth, S., et al. (1987). Life threat and posttraumatic stress in school-age children. Archives of General Psychiatry, 44, 1057–1063.

Quero, S., Andreu-Mateu, S., Moragrega, I., Baños, RM, Molés, M., Nebot, S., & Botella, C. (2017). A Cognitive-Behavioral Program Using Virtual Reality for the Treatment of Adaptive Disorders: A Case Series. Argentine Journal of Psychological Clinic, 26 (1), 5–18.

Reynolds, CR and Richmond, BO (2012). CMASR-2. Revised Anxiety Scale in Children Revised (2nd ed). Mexico: Modern Manual.

Seinfeld, S., Arroyo-Palacios, J., Iruretagoyena, G., Hortensius, R., Zapata, LE, Borland, D., … Sanchez-Vives, MV (2018). Offenders become the victim in virtual reality: impact of changing perspective in domestic violence. Scientific Reports, 8 (1), 1–11. https://doi.org/10.1038/s41598-018-19987-7

Serrano, A. and Iborra, I. (2005). Report Violence between classmates at school. Valencia, Spain: Reina Sofía Center for the Study of Violence. Recovered from http://www.centroreinasofia.es

Schwartz, D. (2000). Subtypes of Victims and Aggressors in Children’s Peer Groups. Journal of Abnormal Child Psychology, 28 (2), 181–192.

5. Annexes

5.1. Self-registration of negative thoughts

Name: _________________________________________ Date: ___________

Date	Day and Time	Situation what happened?	With whom?	Thought	Emotion	Behavior

5.2. Action protocol in bullying situations – UNICEF

Index OCD Manual

1. OCD and Virtual Reality
2. Psychological Evaluation/Intervention protocol proposed by Psious
   1.  OCD Evaluation
      1. Evaluation Objectives
      2. Useful tools for the OCD evaluation
      3. Exposure hierarchy elaboration with Psious’ environments
   2. OCD intervention example
3. Use recommendations 
4. Recommended Bibliography
5. Annexe

1. OCD and Virtual Reality

According to the American Psychiatric Association, the obsessivecompulsive disorder is an anxiety disorder in which people have undesirable thoughts, ideas or sensations (obsessions), which carry out ritualized behaviors (compulsions) or repetitive thoughts (neutralizations). These behaviors, such as washing hands, checking or cleaning, interfere in a significant way with the daily activities and social relationships of a person. (Gorrindo, T., Parekh, R., 2015)

For OCD’s differential diagnosis there must be presence of obsessions and/or compulsions that consume a lot of time (more than one daily hour), which cause stress, harm work and social relationships, as well as other important areas. (APA, 2007). The cognitive-behavioral therapy, the treatment with medication, apart from other somatic therapies of cerebral stimulation, have been till now the most effective alternatives to treat this disorder (APA, 2007).

Virtual reality appears as a good alternative tool to the traditional techniques used in mental disorder treatments and in obsessive compulsive disorders among others. Virtual Reality allows the standardization and the control on the parameters of the exposure sessions. Likewise, it turns out to be very useful to repeat the exposure to the fear or anxiogenic situations as many times as necessary, making the customization and flexibilization of the therapeutic process much easier.

Psious’s environments allow you the use of diverse psychological intervention techniques: exposure, cognitive restructuring, systematic desensitization, training in social skills… Use the most adapted characteristics of the patient and use those with major empirical support to obtain better results.

2. Psychological evaluation/ intervention protocol 

All the information in this section is indicative. Psious’ environments are therapeutic tools that must be used by the sanitary professional inside an evaluation and intervention process designed according to the characteristics and needs of the user.

Remember that you have a General Clinical Guide where you will find more information on how to adapt the psychological intervention techniques (exposure with response prevention, cognitive restructuring…) to Psious’ environments.

2.1 OCD Evaluation

2.1.1  Evaluation objectives 

• Evaluate presence and comorbidity with other emotional disorders.

• Evaluate the presence of obsessions, compulsions and neutralizations.

• Define anxiogenic stimular settings on the side of the patient and in what degree. Elaboration hierarchy of exposure.

• evaluate the presence of distorted thoughts. In case of OCD, those associated to obsessions and compulsions.

2.1.2 Useful tools for the OCD evaluation

Considering the evaluation objectives, we will enumerate some of the tools that can be useful to obtain relevant information about the characteristics of your user. Remember that good objectives definitions, patient characterization and planification of the intervention are important for the therapeutical efficiency and effectiveness just like the user satisfaction. In the bibliography you will find articles where you can revise the characteristics of the proposed tools:

• Open or semi-structured interview.

• Structured interview ADIS-IV

Self-report:

• Obsessive Beliefs Questionnaire (OBQ-44) 

• The Brief Obsessive–Compulsive Scale (BOCS)

• Yale-Brown Obsessive-Compulsive Scale (Y-BOCS)

• Children’s Yale-Brown Obsessive Compulsive Scale (CY-BOCS)

• The Maudsley Obsessive-Compulsive Inventory (MOCI).

• Leyton Obsessional Inventory (LOI).

• Psious self-reports for the elaboraton of the hierarchy.

Tests for behavioral approach:

• Behavioral avoidance test for obsessive compulsive disorder (BATs).

2.1.3 Exposure hierarchy elaboration with Psious’ environments: 

Once we have all the evaluation information we can proceed to elaborate an exposure hierarchy. For that, we need to make some questions made to plan the intervention with virtual reality: e.g. what level of discomfort, on a scale from 0 to 100, does it cause you to be sitting on a toilet? What level of discomfort from 0 to 100 does it cause you to wash your hands? Do you think there’s something that can cause you even more discomfort than that?

2.2 OCD intervention example

SESSION 1

Psychoeducation: inform the patient about OCD. What are the causes, symptoms, prevalence, and definition.

• Explain which techniques will be used during the treatment: in anxiogenic situations and in others where relaxation techniques and mindfulness can be used.

• An exposure hierarchy with be elaborated.

• The exposure will be carried out with items that are around the 30 USAs, to familiarize the patient with VR.

The main objective will be familiarizing the patient with virtual reality and the work dynamics.

Recommended protocol for the first session:

Item	USA’s	Environment	Settings	Event
Be at a public toilet’s door	20	OCD	Clean	Outside the toilet
I place myself in front of a public clean toilet cubicle’s door.	30	OCD	Clean	Inside the toilet
After entering a clean public toilet, I enter the toilet cubicle and look at the toilet.	35	OCD	Clean	Standing inside the cubicle

SESSION 2

• Revision of the past session’s achievements and establishing of objectives of the actual session: Lower a public toilet’s lid to sit down.

• We begin with gradual exposure and systematic response prevention with virtual reality. Cognitive restructuring, if necessary.

• The reports should be shown to the patient so they can see their clinical progresses.

Homework

• Live exposure entering clean public toilets, enter the cubicle and sit on the toilet. Use relaxation if necessary

Recommended protocol for the second session:

Item	USA’s	Environment	Settings	Event
In front of a clean public toilet, I touch the wall with my left hand.	40	OCD	Clean	Touch the wall (standing inside the cubicle)
Walk through Ramblas with many people.	40	OCD	Dirty	Outside the toilet
Inside the cubicle of a clean public toilet. I grab paper and I throw it in the trash	40	OCD	Clean	Grab paper
I touch the toilet brush in a clean public toilet	45	OCD	Clean	Touch toilet brush
I lower the toilet lid in a clean public toilet to sit on it	45	OCD	Clean	Lower lid

SESSION 3

• Revision of the past session’s achievements and establishing of objectives of the actual session: Place myself in front of a sink in a clean public toilet.

• We begin with gradual exposure and systematic response prevention with virtual reality. Cognitive restructuring, if necessary.

• The reports should be shown to the patient so they can see their clinical progresses.

Homework

• Live exposure by entering a cubicle in a clean public toilet, sit on the toilet, touch the wall and stand in front of the sink. Carry out relaxation exercises if necessary

Recommended protocol for the third session:

Item	USA’s	Environment	Settings	Event
I sit on a clean public toilet	50	OCD	Clean	Sitting on the toilet
Sitting on a clean public toilet, I then touch the wall with my left hand	50	OCD	Clean	Touching the wall (sitting onthe toilet)
I enter a public toilet that doesn’t smell well with paper all over the floor and I place myself in front of the toilet cubicle	50	OCD	Dirty	Inside the toilet
I flush the toilet after using it (clean public toilet)	55	OCD	Clean	Flush the toilet
I place myself in front of the sink in a clean public toilet	60	OCD	Clean	In front of the sink

SESSION 4

• Revision of the past session’s achievements and establishing of objectives of the actual session: Touching the walls inside a cubicle of a dirty public toilet.

• We begin with gradual exposure and systematic response prevention with virtual reality. Cognitive restructuring, if necessary.

• The reports should be shown to the patient so they can see their clinical progresses. 

Homework

• Live exposure entering a clean public toilet. Use the toilet, flush it, and wash hands in a non-compulsive way. Relaxation exercises if necessary

Recommended protocol for the fourth session:

Item	USA’s	Environment	Settings	Event
Standing outside a clean public toilet, I open the door, I stand in front of the cubicle, I open the door, I stand in front of the toilet, lower the lid and I sit down	60	OCD	Clean	From outside until sitting on the toilet
I enter the cubicle and it smells bad, it’s dirty and it has urine drops	60	OCD	Clean/Easy	Standing inside the cubicle
In the cubicle of a clean public toilet, I grab paper and I throw it in the trash	65	OCD	Clean/Easy	Washing hands
Sitting on a clean public toilet, I grab paper, I stand up, I flush the toilet, I stand in front of the sink, I wash my hands without touching the faucet, the soap or the dryer.	70	OCD	Clean/Easy	Complete
I touch the walls of the cubicle of a dirty and smelly toilet	70	OCD	Dirty	Touching the wall (standing in the toilet cubicle)

SESSION 5

• Revision of the past session’s achievements and establishing of objectives of the actual session: Touching the brush inside the cubicle of a dirty public toilet.

• We begin with gradual exposure and systematic response prevention with virtual reality. Cognitive restructuring, if necessary.

• The reports should be shown to the patient so they can see their clinical progresses.

Homework

• Live exposure, entering a public toilet, touching several elements inside the cubicle, using the toilet, leaving and washing hands in a non-compulsive way. Relaxation exercises if necessary.

Recommended protocol for the fifth session:

Item	USA’s	Environment	Settings	Event
I use the sink in a public toilet after using the toilet. I touch the faucet, the soap and the hand dryer	75	OCD	Clean/Difficult	Washing hands
Sitting on a clean public toilet, I grab paper, I stand up, I flush the toilet, I stand in front of the sink and I use it touching faucet, soap and hand dryer	75	OCD	Clean/Difficult	From sitting on the toilet to washing hands
I´m outside a clean public toilet, I open the door and I stand in front of the cubicle. I open the door and I stand in front of the toilet. I lower the lid, I sit on the toilet, I grab paper, I stand up, I flush the toilet and I stand in front of the hand dryer. I wash my hands without touching the faucet, soap or hand dryer.	75	OCD	Clean/Easy	Complete
I grab paper from the cubicle in a dirty public toilet and I then throw it in the trash	75	OCD	Dirty	Grabbing paper
I touch the toilet brush inside a cubicle of a dirty public toilet	80	OCD	Dirty	Touching toilet brush

SESSION 6

• Revision of the past session’s achievements and establishing of objectives of the actual session: Standing outside a dirty public toilet, I open the door, I stand in front of the cubicle, I open the door, I stand in front of the toilet, I lower the lid and sit on the toilet.

• We begin with gradual exposure and systematic response prevention with virtual reality. Cognitive restructuring, if necessary.

• The reports should be shown to the patient so they can see their clinical progresses.

Homework 

• Live exposure, entering a public toilet, touching several elements inside the cubicle, using the toilet, leaving and washing hands in a non-compulsive way. Relaxation exercises if necessary.

Recommended protocol for the sixth session:

Item	USA’s	Environment	Settings	Event
Standing outside a dirty public toilet, I open the door, I stand in front of the cubicle I open the door, I stand in front of the toilet, I lower the lid and sit on the toilet, I grab paper, I stand up, I flush the toilet and I stand in front of the sink. I wash my hands, I touch the faucet, soap and hand dryer	80	OCD	Clean/Difficult	Complete
Lower the lid of a dirty public toilet	85	OCD	Dirty	Lower the lid of a dirty public toilet
Sitting on a dirty public toilet	90	OCD	Dirty	Sitting on the toilet
While I’m sitting on a dirty public toilet, I touch the wall with my left hand	90	OCD	Dirty	Touching the wall (sitting on the toilet)
I’m standing outside a dirty public toilet, I open the door, I stand in front of the cubicle, I open its door, I stand in front the toilet, I lower the lid and I sit on it.	90	OCD	Dirty	From standing outside until sitting on the toilet

SESSION 7

• Revision of the past session’s achievements and establishing of objectives of the actual session: Make a complete sequence, in a dirty public toilet with easy settings.

• We begin with gradual exposure and systematic response prevention with virtual reality. Cognitive restructuring, if necessary.

• The reports should be shown to the patient so they can see their clinical progresses.

Homework

• Live exposure, entering a public toilet, touching several elements inside the cubicle, using the toilet, leaving and washing hands in a non- compulsive way. Relaxation exercises if necessary. 

Recommended protocol for the seventh session:

Item	USA’s	Environment	Settings	Event
I flush a dirty public toilet and it smells bad after having used it	95	OCD	Dirty	Flushing toilet
I stand in front of the sink of a public toilet that stinks	95	OCD	Dirty	In front of the sink
I wash my hands in a dirty public toilet without touching the faucet, soap or hand dryer.	95	OCD	Dirty/Easy	Washing hands
I’m standing outside a dirty public toilet, I open the door, I stand in front of the cubicle, I open the door, I standing front of the toilet, I lower the lid, I sit down, I grab paper, I stand up, I flush the toilet, I stand in front of the sink and I wash my hands without touching the faucet, soap and hand dryer.	95	OCD	Dirty/Easy	Complete

SESSION 8

• Revision of the past session’s achievements and establishing of objectives of the actual session: Complete sequence, dirty environment and difficult level. 

• We begin with gradual exposure and systematic response prevention with virtual reality. Cognitive restructuring, if necessary.

• The reports should be shown to the patient so they can see their clinical progresses.

Homework

• Live exposure by entering both dirty and clean public toilets, enter the toilet cubicle and sit on the toilet, use the sink in a non-compulsive way. relaxation exercises if necessary.

Recommended protocol for the eighth session:

Item	USA’s	Environment	Settings	Event
I use the sink in a dirty public toilet, touching the faucet, soap and hand dryer	95	OCD	Dirty/Difficult	Washing hands
Sitting on a dirty public toilet, I grab paper, I stand up, flush the toilet, I stand in front of the sink, and I wash my hands without touching the faucet, soap or hand dryer	95	OCD	Dirty/Easy	From sitting down until washing hands
Sitting on a dirty public toilet, I grab paper, I stand up, flush the toilet, I stand in front of the sink, and I wash my hands touching the faucet, soap and hand dryer	100	OCD	Dirty/Difficult	From sitting down until washing hands
I find myself outside a dirty public toilet, I open the door, I stand in front of the cubicle, I open the door, I stand in front of the toilet, I sit on the toilet, I grab paper, I flush the toilet, I stand in front of the sink and i wash my hands touching faucet, soap and hand dryer.	100	OCD	Dirty/Difficult	Complete

4. Use recommendations

To favor a better immersion, the therapist can contribute adding comments.

For example: 

• “The patient is going to enter the cubicle of a public toilet. Many other people have already entered it and touched the walls.”

• “The patient will touch the toilet brush, water could’ve splashed on the brush stick” 

• “The patient will sit on the toilet; many people have been sitting there previously.”

• “The patient will flush the toilet. Many people have been touching that without washing their hands.”  

• “He/she finds himself in front of the sink with dirty hands after touching the objects inside the cubicle.”

• “Feels the need of doing compulsions while washing hands.”

• “He/she will use the sink for 10 seconds and that will be enough to clean them.”

5. Recommended bibliography

American Psychiatric Association. Practice guideline for the treatment of patients with obsessive-compulsive disorder. Arlington, VA: American Psychiatric Association, 2007.

Kim, K., Kim, Ch. H., Kim, S. Y., Roh, D., Kim., S. I. (2009). Virtual Reality for Obsessive-Compulsive Disorder: Past and the Future. Official Journal of Korean Neuropsychiatric Association, 6, 115-121

Ortiz, J. F. (2002). Trastorno obsesivo-compulsivo (TOC). Acta Neurol Colomb, 18 (1), 51-65.

Reid, J.M., Storch, E.A. & Murphy, T.K. (2011). Clinical Correlates and Treatment Response of the Yale-Brown Obsessive Compulsive Scale Auxiliary Items. Cognitive Therapy and Research, 35, 404-413 

Bejerot, S., Edman, G., Anckarsäter, H., Berglund, G., Gillberg, C. et al. (2014). The Brief Obsessive-Compulsive Scale (BOCS): a self-report scale for OCD and obsessive-compulsive related disorders. Nordic Journal of Psychiatry, 68(8), 549-559. http://dx.doi.org/10.3109/08039488.2014.884631 

Freeman, J., Flessner, Ch. A,. y Garcia, A. (2011). The Children’s YaleBrown Obsessive Compulsive Scale: Reliability and Validity for Use Among 5 to 8 Year Olds with Obsessive- Compulsive Disorder. J Abnorm Child Psychol, 39, 877-883.

Steketee, G., Chambless, D. L., Tran, G. Q., Worden, H., y Gillis. M. M. (1996). Behavioral Avoidance Test for Obsessive Compulsive Disorder. Behaviour Research and Therapy, 34 (1), 73-83. http://dx.doi.org.sire.ub.edu/10.1016/0005-7967(95)00040-5

Sánchez, J., López, J. A., López, J. A., Marín, F., Rosa, A. I., y Gómez. A. (2011). The Maudsley Obsessive-Compulsive Inventory: A reliability generalization meta-analysis. International Journal of Clinical and Health Psychology ,11(3), 473-493.

Bamber, D., Tamplin, A., Park, R. J., Kyte, Z. A., Goodyer, I. M. (2002). Development of a Short Leyton Obsessional Inventory for Children and Adolescents. Journal of the American Academy of Child & Adolescent Psychiatry 41 (10), 1246-1252. http://dx.doi.org.sire.ub.edu/10.1097/00004583-200210000-00015

Obsessive-compulsive disorders; research conducted at mental health institute has provided new information about obsessivecompulsive disorders. (2014). Mental Health Weekly Digest, , 31. Retrieved from https://search-proquest-com.sire.ub.edu/ docview/1516545423?accountid=15293

Gorrindo, T., y Parekh, R. (2015). What Is Obsessive-Compulsive Disorder?. American Psychiatric Association. https://www.psychiatry.org/patients-families/ocd/what-is-obsessivecompulsive-disorder

6. Annexe

6.1 Hierarchy for OCD

Item	Discomfort level (0-100)
Being in front of a clean public toilet’s door.
I stand in front of a toilet cubicle door of a clean public toilet.
Enter the cubicle and stare at the toilet.
Standing in front of a clean public toilet, I touch the wall with my left hand.
I’m inside a clean public toilet cubicle, I grab paper and I throw it in the trash.
I touch the brush of a clean public toilet.
I lower the lid of a clean public toilet.
I sit on a clean public toilet.
Sitting on a clean public toilet, I touch the wall with my left hand.
I flush the toilet after having used a clean public toilet.
I stand in front of a sink in a clean public toilet.
I wash my hands in a clean public toilet after using the toilet, without touching the faucet, soap and hand dryer.
I wash my hands in a clean public toilet after using the toilet, without touching the faucet, soap and hand dryer.
I’m outside a clean public toilet, I open the door, I stand in front of the toilet cubicle, I open the door, I stand in front of the cubicle, I lower the lid and I sit on it.
I’m sitting on a clean public toilet, I grab paper, I stand up, I flush the toilet, I stand in front of the sink, I wash my hands without touching the faucet, the soap or the hand dryer.
I’m sitting on a clean public toilet, I grab paper, I stand up, I flush the toilet, I stand in front of the sink, I wash my hands touching the faucet, the soap or the hand dryer
I’m outside a clean public toilet, I open the door, I stand in front of the cubicle, I open the door, I stand in front of the toilet, I lower the lid, I sit on the toilet, I grab paper, I flush the toilet, I stand in front of the sink, I wash my hands without touching the faucet, soap or hand dryer.
I’m outside a clean public toilet, I open the door, I stand in front of the cubicle, I open the door, I stand in front of the toilet, I lower the lid, I sit on the toilet, I grab paper, I flush the toilet, I stand in front of the sink, I wash my hands touching the faucet, soap or hand dryer.
Being in front of a dirty public toilet’s door.
I enter a public toilet that stinks and has paper all over the floor and I stand in front of the toilet cubicle.
I enter a cubicle in a smelly and dirty public toilet and the toilet has urine drops.
I touch the walls of a cubicle in a smelly and dirty public toilet.
I touch the brush inside the cubicle of a dirty public toilet.
I grab paper inside the cubicle of a dirty public toilet and I throw it in the trash.
I lower the lid of a dirty public toilet.
Sitting on a dirty public toilet
Touching the wall of the cubicle with my left hand sitting on a dirty public toilet
I flush a dirty public toilet after using it and at the same time it smells bad.
I stand in front of the sink of a dirty and smelly public toilet.
I wash my hands in a dirty public toilet, without touching the faucet, soap or hand dryer, but they’re next to me.
I use the sink of a dirty public toilet after using the toilet, touching the faucet, soap and hand dryer.
I’m outside a dirty public toilet, I open the door, I stand in front of the toilet cubicle, I open the door, I stand in front of the cubicle, I lower the lid and I sit on it.
I’m sitting on a dirty public toilet, I grab paper, I stand up, I flush the toilet, I stand in front of the sink, I wash my hands without touching the faucet, the soap or the hand dryer.
I’m sitting on a dirty public toilet, I grab paper, I stand up, I flush the toilet, I stand in front of the sink, I wash my hands touching the faucet, the soap or the hand dryer.
I’m outside a clean public toilet, I open the door, I stand in front of the cubicle, I open the door, I stand in front of the toilet, I lower the lid, I sit on the toilet, I grab paper, I flush the toilet, I stand in front of the sink, I wash my hands without touching the faucet, soap or hand dryer.
I’m outside a dirty public toilet, I open the door, I stand in front of the cubicle, I open the door, I stand in front of the toilet, I lower the lid, I sit on the toilet, I grab paper, I flush the toilet, I stand in front of the sink, I wash my hands touching the faucet, soap or hand dryer.
What discomfort level does it produce you, at the present moment, to be in a public toilet? (doesn’t belong to the hierarchy)
Other situations: