In this scene the patient will find him/herself on top of a hill surrounded by mountains and trees, where he/she will experience a feeling of spaciousness and relaxation. At the same time, the healthcare professional will be able to add an element, such as a sphere or a ring to guide the ocular movements.
SETTINGS VARIABLES
Visual Stimuli Choose between a ring, a sphere or no visual stimulus at all.
Audio Stimuli Choose between Type 1, Type 2 or no auditory stimulus at all (only ambient sound will be heard).
Movement Choose between horizontal, vertical, left-right diagonal or right-left diagonal.
EVENTS
Initiate and stop the stimulus
Duration (minutes) It can last to 10 minutes. It is necessary to stop the stimulus in order to modify the duration values.
Speed in repetitions per minute. The healthcare professional can choose from 15 to 120 repetitions/minute. It is necessary to stop the stimulus in order to modify the speed values.
Ambient darkness He/she can choose from full brightness to complete darkness.
This environment simulates a restaurant where the patient can eat various menu options (hypocaloric/diuretic/standard/hypercaloric), alone or accompanied, as required by the situation. The healthcare professional will select the menu option the patient should be eating. In this environment, we mainly intend to work the anxiety towards certain foods, awareness on how good eating habits can prevent a subsequent purge/compensation, and not isolation during meals.
Exposure Therapy To reduce the anxiety caused by certain “forbidden” foods (usually, hypercaloric foods).
Exposure with Response Prevention (EPR) To be exposed to certain stimuli (food), which usually precede binge eating and/or compensatory behaviors (e.g., purge) with the aim of preventing the occurrence of such behaviors. The procedure consists of exposing the patient to foods that usually act as a trigger for binge eating. When the patient feels that he/she has broken the diet and wishes to vomit, we will try for him/her to focus on what his/her feelings and what he/she thinks, with the aim of being able to analyze and restructure it together with the therapist during the session. The aim is for the subject to verify he/she can control himself/herself and notice how anxiety, guilt, etc., can be reduced without the need to compensate (e.g., vomiting). These exposures can also work as behavioral tests through which the patient can test whether or not his/her irrational fears regarding the consequences of not compensating are met (e.g., put on a lot of weight, fat accumulation on a certain part of his/her body at once, etc.) (Saldaña, Tomás & Bachs, 1997).
CONFIGURATION VARIABLES
Companion This variable will allow choosing whether the patient eats alone or accompanied and, in that case, whether the companion is male or female. This variable should be taken into account during the exposure based on whether the patient is more or less stressed when eating alone or with a companion, and whether he/she is worried when eating with a person of the same sex (e.g., because he/she tends to compare himself/herself with them) or of the opposite sex (e.g., for fear of feeling judged):
None: The patient appears eating alone, without any companion at his/her table and with no people on the tables surrounding him/her
Female: The patient eats while accompanied by another avatar (a woman). Also, there are people eating on the tables near them.
Male: The patient eats while accompanied by another avatar (a man). Also, there are people eating on the tables near them.
Conversation In the case of the “Accompanied” configuration, the healthcare professional may choose the kind of conversation the patient’s companion will provide during the experience. It is important to keep in mind that this conversation will not be activated if there is no food on the table. In fact, it will not consist of a conversation per se (there will be no exchange), but only the companion will issue sentences/comments. However, the idea is to simulate a real situation in which a conversation takes place during a meal. The subject of said conversation may be:
None: In this option, the companion will not make any comments and will remain silent.
Neutral: In this modality, the companion will issue phrases regarding a neutral subject, such as the movies (going to the movies, favorite movies, upcoming releases…).
Bad: In this case, the companion will issue phrases related to physical appearance, food, social events where eating while with a group of people is included, etc. That is, subjects that often cause anxiety (or discomfort) to this type of patients.
EVENTS
Choose menu In this events, will appear the following menu options for the patient to take:
Hypocaloric: Menu consisting of foods with a low fat content: Water + grilled chicken breast together with a salad + natural yogurt.
Diuretic: Menu consisting of foods that help the elimination of liquid (urine), often eaten by people who wish to lose weight: Green tea + salad (lettuce, beet, and carrot) + Fruit (kiwi).
Standard: A normal diet’s menu: Water + Steamed vegetables + Omelette with tomato slices + Natural yogurt.
Hypercaloric: Menu including foods with higher fat content: 1 soft drink (Coca-Cola) + Hamburger with French fries + Pie.
View menu The patient (and the companion, if also present) will have a menu in their hands with different menu options. However, the healthcare professional will be the one to choose the patient’s menu, by selecting the event described below.
The healthcare professional can make the avatar (patient) hold the menu in his/her hands for as long as he/she wants. When the healthcare professional wants the avatar to start eating, he/she must select the kind of menu to which he/she wishes to expose the patient from the “Menu” event.
Once the menu option is selected, the menu will automatically disappear and the first course of the chosen menu option will be displayed. Once the patient finishes the dish, the second course will appear (if there is one), and finally the dessert
Once the configuration/event variables have been selected and the patient has the corresponding course in front of him/her, he/she should pretend to eat the food by staring at the dish until the little circle that appears on the goggles is completed. Each time the patient stares at the dish, the avatar will ingest a portion of the food, until the food is finished (approximately, 7-10 bites). However, if the patient takes too long to perform this action, the system will automatically simulate a mouthful intake after approximately 30 seconds. The drinking action can also be activated by looking at the glass with the goggles. When finishing each course, the avatar will leave the cutlery on the plate. When the full menu is finished, the scene will return to its initial state, and the option to choose another menu will be available
In order for the healthcare professional to receive a more accurate feedback of the patient’s behavior during the experience, some signs will appear on the platform viewer notifying him/her of each time the patient ingests a portion of food, whether the patient has decided to eat it voluntarily, or if the system has automatically simulated the intake after 30 seconds, etc. The different signs (feedbacks) that will appear will be the following ones:
Initial state: Informs that the avatar is at the table, without the menu or the food, still in “standby mode”
Showing menu: Informs that the avatar (patient) is looking at the menu
Changing menu: A brief fade to black will be shown on the goggles at that moment, and immediately after it, the menu selected by the therapist will appear.
Menu [kind of menu] – [course]: Signals the kind of menu and the specific course the avatar (patient) is eating. Example, “Hypercaloric menu-Hamburger”
Eating portion [number] of [number], voluntarily: Informs that the patient is currently taking a bite and what bite number it is (for example, 3 of 8 would inform the patient is eating the third bite of a total of 8 bites in which the course can be eaten), and also that he/she has voluntarily decided to eat it (it has been the patient who, using the goggles, has deliberately selected the action of eating that bite).
Eating portion [number] of [number], automatically: Informs that the patient is currently taking a bite and what bite number it is (for example, 3 of 8 would inform the patient is eating the third bite of a total of 8 bites in which the course can be eaten), but that the bite has not been voluntary (i.e., that 30 seconds have passed without the patient deciding to take a bite, and the system has performed the action automatically).
Menu [kind of menu] – Drinking: Informs that the patient has directed the goggles towards the drink to take a sip at that moment.
Finished course: Informs that the patient has finished the dish he/she was eating at that time.
Changing course: When the patient has finished a dish, a brief fade to black is shown on the goggles, and the next course of the menu will appear immediately afterwards.
Menu [kind of menu] – Completed: Informs the patient has just finished eating the full menu (after eating the dessert). Example, “Hypercaloric menu – Completed”.
If the healthcare professional wants to expose the patient to the plate but not to eat it (that is, to watch the plate), it is sufficient for the patient to place the pointer of the viewer outside the plate (e.g. on the table) and, keeping your head in that position, lower your gaze to the plate (only with your eyes, otherwise you would place the pointer again on top of the food and the intake would begin).
REFERENCES
Saldaña, C., Bach, L., & Tomás, I. (1997). Técnicas de intervención en los trastornos del comportamiento alimentario – Dialnet. Aniedad y Estrés, 3(2–3), 319–337.
This is a scenario specially designed to work through the cognitive restructuring the distortion of the body image of some patients with eating disorders. This tool allows, on the one hand, for the patient to modulate the body dimensions of a human avatar according to how he perceives himself, and on the other hand, for the healthcare professional to generate a silhouette with the real body dimensions of the patient. This allows the patient to reflect how he perceives his body image, being able to contrast it later with his real body image (by superimposing the silhouette with the objective dimensions of the patient on top of the first avatar). The objective is that the patient can observe and check on his own the difference (and therefore, the distortion) that there is between the perception of his own body and how it really is. The patient must become aware of how body dissatisfaction is maintaining his eating disorder.
Given the high anxiety that some patients often feel in situations that require the measurement or vision of their body (weigh them, measure certain parts of the body, expose them in front of the mirror, etc.), this task can also function as exposure therapy to their own body. In that case, we remind you that the healthcare professional has the option of asking the subjective units of distress (SUDs) experienced by the patient throughout the exercise. Also, to reduce maladaptive emotions, this VR task may also be combined with the systematic desensitization (SD) technique.
SETTINGS VARIABLES
Chest It can be chosen, according to the BMI of the patient, for the size of this part of the body to be: Very slim; Slim; Normal; Wide; Quite wide; Very wide.
Gender It can be chosen, according to the gender of the patient, for the avatar to be a Male or a Female.
Height It can be chosen, according to the height of the patient, the most approximated height for the avatar: 5’ 3”; 5’ 7”; 5’ 11”; 6’ 3”
Hip It can be chosen, according to the BMI of the patient, for the size of this part of the body to be: Very slim; Slim; Normal; Wide; Very wide.
Legs It can be chosen, according to the BMI of the patient, for the size of this part of the body to be: Very slim; Slim; Normal; Wide; Quite wide; Very wide.
Neck It can be chosen, according to the Body Mass Index (BMI) of the patient, for the size of this part of the body to be: Very slim; Slim; Normal; Wide; Quite wide; Very wide.
Skin color It can be chosen, according to the skin color of the patient, for the avatar to be White skin or Black skin.
Waist It can be chosen, according to the BMI of the patient, for the size of this part of the body to be: Very slim; Slim; Normal; Wide; Quite wide; Very wide.
Below is a table of equivalences between the BMI of the patient and the category to be selected for all parts of the body of the real silhouette :
Category
BMI (Kg/m2)
Very slim
<17 (Severely underweight)
Slim
17-18.49 (low weight)
Normal
18.5 – 24.9 (Normal weight)
Wide
25-29.9 (Overweight)
Quite wide(*)
30 – 39.9 (Obesisty)
Very wide
≥40 (Morbid obesity)
(*) For the “Hip” value, the category “Very wide” will be assigned when the BMI is ≥ 30.
Later, when the patient is in the environment, will be able to modify the body dimensions of the avatar through the plus (+) and minus (-) symbols that appear on both sides of each body part, by clicking on the corresponding symbol with the Touch panel to select the VR glasses (or, depending on the model of glasses, staring at the symbol until the circle that appears is completed). You can increase (+) or reduce (-) the size of a certain part of the body as the symbol is selected. In this part, the tool allows the patient to adjust the size of the aforementioned body parts (Neck, chest, waist, hips and legs) through the glasses, to make them correspond to the size that they think they have in their body.
Finally, from the Events tab, the healthcare professional can activate the option Compare Avatars; this will make the contour of a silhouette appear with the actual dimensions of the patient (previously introduced by the therapist through the configuration variables) and superimpose it on the avatar generated by the patient. The difference in body size between the avatar handled by the patient and the actual silhouette will reflect the degree of distortion of the body image presented by the patient.
The Distraction environment is similar to a game. It is set in the sea and the patient will have to capture different marine creatures according to the indications of the game itself. To capture them, the patient will have to place a white dot on top of the creature and wait for a circle to be generated around the point.
By capturing the indicated creatures, the patient will earn rewards. Specifically, he/she can add points, level up and change the scene. When the patient makes mistakes (to catch other species than those mentioned, marine mines or drums) there will be penalties, for example, to end with the dot-dash multiplier or reducing the level status bar. Repeatedly making mistakes will prevent the status bar from filling up, which will prevent leveling up.
This environment will not require supervision of a healthcare professional to activate events or configuration variables. The patient will discover how to play on his/her own.
The goal of this environment is immersion, interactivity and focused attention. The user must be alert at all times to the indicators to know which type of fish or animal has to be focused on at that time.
This environment, unlike “Big Elevator”, allows the option of getting in the elevator and going to another floor but in a smaller space. In addition, this time there is not the control variable option, so the healthcare professional will have to completely guide the exposure. The reason for this change is increasing the level of difficulty , since the patient will have less control over the situation, hence being forced to cope with anxiety.
EVENTS
Emergency stop When the button is pressed, a temporary fault occurs inside the elevator.
Finish The elevator stops, the doors open, and the patient exits the elevator.
Go to another floor The elevator moves to another floor.
In this scenario, the patient has to get in the elevator and ride to the basement, which consists in a room whose size can be modified by the therapist. This environment is even harder, so it is recommended to use it when optimal results have been obtained in the previous ones.
The scene starts on the floor in which the patient gets in the lift. Once inside, it will get down to the basement. The patient will then leave and start walking a corridor until reaching the room in which the exercise will take place. The therapist will be able to modify the size of the room in order to design a gradual exposition.
EVENTS
Go to the first floor By pressing this button the patient goes from the basement to the first floor.
Walk The patient starts walking / stops.
Open Door The basement door opens or closes.
Go to room: By pressing this button the patient goes from the first floor to the basement.
Size room Allows room size to be modified based on the slider.
This environment is devised to deal with discomfort and claustrophobia associated with magnetic resonance imaging. The level of difficulty is high in this environment and it is divided up into three stages (hierarchal from lower to higher difficulty). In the first stage, the patient is located in a waiting room where they will listen to information given on a television screen. Anticipatory anxiety and psychoeducation can be worked on in this environment.
In the second stage, the patient will enter a room to get changed, the room is small and has no windows, and serves as exposure in a small closed space.
Lastly, in the third stage they will go to the magnetic resonance room, here they will be able to work on a diversity of hierarchy items: be present in the room while the technician speaks to them, lie down on the treatment bed, both partially and wholly enter the machine, and adjust the volume from low to high.
VARIABLES SETTINGS
Body parts Corresponding to the part of the body that will be scanned: leg, trunk, limb.
Television This variable implies that the TV in the waiting room is on or off.
Sanitary mask You can choose whether or not the people around you will have a mask.
EVENTS
Zone 1 The patient will be in the waiting room, he will see how several avatars approach the reception desk. Then you must go to the changer.
Zone 2 The patient will be in the changing room and after an informative session that he will hear from a loudspeaker, he will go to the resonance room.
Zone 3 The doctor’s avatar will tell us some directions before we lie down in the resonance cabin. The patient should lie down to maintain the immersion and look towards the indication that will appear on the ceiling, to become lying in the environment.
Zone 4 The patient will enter the cabin and undergo the resonance process, the noise will depend on the configuration slider. At the end of the process the patient will leave the cabin and the avatar the doctor will inform us that the session has ended.
Noise volume The noise generated from the magnetic resonance machine can be adjusted in this slider. Do remember to use the platform volume (up down) as a further hierarchy exposure setting.
The patient is located in a room and must get into the lift. Initially, these two spaces have people, although the presence or absence of people can be regulated using the configuration button “Number of people”. Specifically, you can choose that there is no one in the elevator, that there are few people (3 people), or that there are many people (7 people).
SETTINGS VARIABLES
Number of people You can choose between Nobody, Medium and Maximum.
Sanitary mask You can choose whether or not the people around you will have a mask.
EVENTS
The sequence of events will always follow the order presented in the diagram below:
Start breakdown: when the button is pressed, the elevator will stop.
Finish breakdown: when the button is pressed, the elevator will work again.
Exit elevator : the elevator stops, the doors open and leaves the elevator.
Move elevator: the doors close and the elevator changes floors.
The patient will be in the position of the student, in a classroom, a few minutes before the class starts, there are 7 students (between 13 and 18 years old) around him. The aggressor and the rest of the students will also be in the class, away from the patient, but in a position where the patient sees them.
When the start event is activated, the aggressor will appear (after a fade to black) in front of the patient along with the rest of the students present. Afterwards, the type of aggression/bullying can be selected in events: verbal, physical or relational. Once the “type of bullying” event is over, the reaction of the audience can be modulated by activating booing, laughing and whispering (by means of the behaviour-observers event). Playing the event option “Evaluation”, will trigger 4 possible responses (2 aggressive and 2 passive) to appear in the patients view in the goggles, so that the patient can choose, guiding the selector by looking at their desired response, what they would do in this situation.
SETTINGS VARIABLES
Gender Choose between a male or female body. A neutral body is selected by default.
Skin tone Choose the skin tone that best represents your patient to enhance the feeling of immersion.
Group of the aggressor Alone / Accompanied This variable determines whether the aggressor will be alone or accompanied in front of our patient. Once the event “Start” is activated, the aggressor will appear near the patient alone or accompanied by two other students, depending on the selection of the drop-down menu
EVENTS
Start Once the configuration variables are defined, this event will make the avatars (the aggressor accompanied or alone), appear near the patient and remain in that situation until a new event is activated. The distance and non-verbal behaviour of the aggressor in relation to the patient will be very close, being already in itself an invasion of the personal space and therefore uncomfortable and aggressive.
Type of aggression After the “Start” event we can activate the type of action we want the offender to take:
Verbal assault of the abuser: By selecting ‘verbal assault’ the avatar will utter a verbalization “Hey, look who’s here… what’s up you idiot!”
Physical assault of the abuser: By selecting ‘physical assault’, the avatar will approach from an intimate distance and say, “I’m going to beat you up.”
Abuser’s relational aggression: By selecting indirect aggression there will be no clear verbalization or invasion of intimate personal space, but there will be a defiant look and threatening paraverbal language.
Evaluation Makes the victim’s reaction options appear, so that the victim can select them and thus enable the evaluation of our user’s coping profile, based on the type of aggression we have previously activated. Passive/aggressive profile.
Observers When this event is activated, the group of 4 students who are neither the aggressor nor his buddies will perform one of these three actions.
Booing: the group makes reproachful sounds towards our user
Laughs: the group laughs looking at our user
Whispers: they will talk to each other looking at the mobile phone and the patient alternately
This option can be activated simultaneously after the type of aggression we have established, or while the user is selecting his response in the “evaluation” event.
End environment:When this event is activated, the students will appear seated in their chairs with the teacher (clinically irrelevant) in the background behind the table ready to start the class.
Therapeutic objectives
To evaluate the type of response of alleged victims of bullying to a situation of school bullying in order to know the profile of the victim (aggressive, submissive…).
To train victims of bullying to a classic situation of school bullying, in order to teach and rehearse social skills and how to manage the situation properly.
There is also the possibility of using this environment to work with aggressors and companions. Putting the aggressor in the victim’s position can facilitate empathic work by encouraging them to feel as the victim would.
