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Intervention proposal

“All the information contained in this section is for guidance only. Psious environments are therapy supporting tools that must be used by the healthcare professional within an evaluation and intervention process designed according to the characteristics and needs of the user.

Also remember that you have the General Clinical Guide in which you have more information on how to adapt psychological intervention techniques (exposure, systematic desensitization, cognitive restructuring, chip economy…) to Psious environments.”

Example of intervention Fear of driving

A proposal for a treatment protocol that includes the Psious tool is described below. It is recommended to combine virtual reality with traditional techniques, such as relaxation or cognitive restructuring. It is recommended that each healthcare professional adapts the virtual exposure within the treatment protocol that he or she uses regularly. 

Description of treatment sessions

SESSION 1: PSYCHOEDUCATION

• Information about driving phobia: origin and manifestations (cognitive, physiological, and behavioral).

• Treatment protocol explanation. The patient should understand the applicability of virtual reality and relaxation techniques.

SESSION 2 + 3: RELAXATION

• Training of two relaxation techniques: Deep breathing and Progressive Muscular Relaxation.

• Patient’s familiarization with VR: Use of neutral environments (e.g., environments for other phobias).

HOMEWORK
Practice of the relaxation techniques. Relaxation diary (see annex 6.2)

SESSION 4: VIRTUAL EXPOSURE + RELAXATION

• Virtual exposure + Relaxation:
  • 1- City without cars, during the day when it’s sunny. Track 1. 

• 2- City with cars, during the day when it’s sunny. Combine track 1 and 2 with traffic jams, slowdown and horn situations.

• 3- City with cars, during a rainy day + interoceptive exposure (blurry vision)

HOMEWORK
Practice relaxation and self exposure. Relaxation and driving phobia diary (see annex 6.2).

SESSION 5: VIRTUAL EXPOSURE + RELAXATION

• Virtual exposure + Relaxation:
  • 1- City with cars during a rainy night. Combine track 1 and 2 with the above mentioned situations.

• 2- City with cars during a rainy night + interoceptive exposure (blurry vision → tunnel vision + hyperventilation)

• 3- Road without cars during the day. Low, mid and high speed.

HOMEWORK  
Practice relaxation and self-exposure. Relaxation register and driving phobia diary (see annex 6.2).

SESSION 6: VIRTUAL EXPOSURE + RELAXATION

• Virtual exposure + Relaxation:

• 1- Highway with cars during a sunny day. Mid speed combined with some type of distractor

• 2- Highway with cars during a rainy day. Sections of tunnels and bridges. Highway with cars during a rainy day. 

• 3- Sections with tunnels and bridges. Add curves and combine with accidented car. High speed.

HOMEWORK
Practice relaxation and self-exposure. Self Recording of relaxation and driving phobia diary (see annex 6.2).

SESSION 7: VIRTUAL EXPOSURE + RELAXATION

• Virtual exposure + relaxation

• 1- Road with cars during a rainy day. Tunnels and bridges. High speed. Combine last session settings and the use of some type of distractor

• 2- Road with cars during a rainy night. Combine the different elements and add interoception effects. 

HOMEWORK
Practicing relaxation and self-exposure. Self Recording of relaxation and driving phobia diary (see annex 6.2).

SESSION 8: CONCLUSIONS AND RELAPSE PREVENTION

• Evaluation of the treatment. 

• Future self-exposure planning.

• Tools for future relapse prevention. 

Evaluation

“All the information contained in this section is for guidance only. Psious environments are therapy supporting tools  that must be used by the healthcare professional within an evaluation and intervention process designed according to the characteristics and needs of the user. 

Also remember that you have the General Clinical Guide in which you have more information on how to adapt psychological intervention techniques (exposure, systematic desensitization, cognitive restructuring, chip economy…) to Psious environments.”

Fear of Driving

Evaluation Objectives

• Evaluate the presence and comorbidity of other emotional disorders, in particular specific phobias, other anxiety and mood disorders.

• Evaluate anxiety associated with components: intensity, frequency, characteristics…

• Set the feared stimulative settings for the patient and define to what extent. Exposure hierarchy development. 

• Measure the presence of distorted thoughts.

Some useful instruments for fear of driving

Taking the evaluation objectives into account let’s proceed onto listing some tools and devices that can be useful in gathering relevant information on the user characteristics. Always remember good goal setting, patient characterization and intervention planning are important in effective and efficient therapies, as that of your patients’ satisfaction. The following are the articles you will find in the bibliography where you can refer to the proposed tool characterization:

• Open or semi-structured interview

• Structured interview: ADIS-IV

• Behavioral approach test/behavior avoidance (in vivo or with virtual reality)

SELF-REPORTING

• Cuestionario para la evaluación del Miedo a Conducir (CEMIC, Sánchez y Sánchez, 2017)

• Driving Cognitions Questionnaire (DCQ, Ehlers A et al., 2007 )

• Psious Self-Reports for the elaboration of the hierarchy

Exposure Hierarchy development with Psious environments

Once we have received the evaluation information we can then proceed to develop the hierarchy exposure. To do this, in addition to using the data obtained during the initial evaluation, we can carry out a series of questions, (For example, what level of discomfort, on a scale of 0 to 100, does driving have to generate? What level of discomfort, on a scale of 0 to 100, would lead you to take a long car trip? Is there something that makes you feel even more uncomfortable?) all geared at the planning of the intervention via the virtual reality.

Fear of driving
and virtual reality

Fear of Driving is defined in the current mental disorders classification system as a situational phobia within specific phobias. It is characterized by an intense and persistent fear that increases with the anticipation or exposure to the driving stimuli. Recent studies have shown that the prevalence of this phobia is 4% of the population, although the percentage of people with some type of driving-related fear could raise up to 22%. The symptoms of this phobia can cause significant discomfort and serious interference with the daily lives of the patients.

Certain factors affect the intensity of the patient’s emotional reaction to driving. The typical and most important ones are: speed, weather, amount of traffic, distance to be covered, time of day, characteristics of the road, type of car, if they are driving alone or with company, where the patient is driving through, etc.

Virtual Reality has been proved to be a good alternative to traditional exposure techniques in the treatment of driving phobia. This technology is especially useful in repeating the exposure as many times as necessary in order to recreate the unpredictable circumstances that occur in the real situation. Moreover, VR naturally eliminates the chances of suffering an accident and the healthcare professional has total standardization and control over the exposure session parameters.  

Appendix

Economy Contingency table

PSYCHOBOT TOKENS

Self-report Hierarchy home (children)
Darkness Psious 

ITEM	LEVEL OF DISCOMFORT (0-100)
You are in the living room at home and, with the help of Psychobot , you can explore the different areas. You teleport to the dining room where there is less light and your mission is to find where the tallest vase is and which is closest to the ceiling. What level of difficulty do you think that mission has?
After you have teleported into the hallway, you see that it is quite dark. Your mission is to stay in this area for at least a minute… How difficult do you think this activity is?
With Psychobot you have moved super fast to the hallway bathroom, great! Now your mission is to explore this area that has very little light. Do you find it easier or more difficult than the others?
You are in the hall. You see the entrance to the bathroom, with the bathtub and the shower curtain half open. Although there was little light when you teleported, there is now a little more. How long can you stay here for a mission?
When you are in the room, which is very dark, you ask the Psychobot for help and he tells you that you are doing very well. How do you have your energy level?
After teleporting with your Psychobot friend, you have reached the hallway. Since there is enough light now, you can see the attic door and everything in the hallway. Do you find it a very complicated mission?
You are in the living room of your house with all the lights on, it is night and the moon shines a lot. Suddenly, a Psychobot appears, and explains that you have a super power to teleport, and that you are going to have to explore all the areas of your house to get points. Are you afraid of this new adventure?
When you and the Psychobot have already arrived in the room, you lie down on the bed and you only see the moon through the window because it is very dark. Do you think this mission is very difficult?
You and Psychobot have teleported super fast from the bathroom hallway to the living room, and there is a little light there. Your mission now is to explore the room as long as you want, do you find it easy or difficult?
You have a super important mission: teleport to the loft hallway, which has just a little bit of light, and be there for two minutes. Do you dare with this super mission?
You are with a Psychobot in the dining room of your house where there is a lot of light, and suddenly you teleport super fast to the room, which is very dark. What difficulty would you put on this mission?
Now your mission is to teleport from the room, which is very dark, to the living room, which is very bright, and your mission is to explore the area, does this seem easy to you?
Now you are going to be a super explorer! With the help of Psychobot, go to the dark room, and try to discover everything in it. Then, if you are very adventurous, lie down for a minute in bed. What do you want to accomplish this mission?
You’ve reached the bathroom hallway in no time thanks to your superpower! There you can see the bathroom door and what is inside, because now it seems that there is enough light. What you have to do is explore the area. Do you find it an easy mission or more difficult than others?
With your superpower you have teleported from the living room to the dining room in just a second, great! Now you have to use another super power, be very brave and explore the area as long as you can, even if it is a bit darker. Do you dare or do you think it is very difficult?
You just got to the hallway that leads to the loft, and you see it’s very dark. Can you explore the area to see what you find in it?
Now your mission is to teleport from the hallway that leads to the loft to the one that leads to the bathroom. On your way you can see how, although there is not much light, it seems that there is a little more each time. Do you think this is very difficult?
You are in the dark room, and suddenly you and the Psychobot teleport to thein a second dining room. How does it make you feel to go from a place without light to another that has much more?

Self-report Hierarchy home (Kids)
Darkness and Storms Psious 

ITEM	LEVEL OF DISCOMFORT (0-100)
After reaching the dark room, you lie down on the bed. Nothing is heard, everything is calm because the weather is good. How long could you stay here?
You are in the living room at home and your mission, with the help of Psychobot, is to explore the different areas. You teleport to the dining room where there is less light and you can see lots of lightning and hear thunder. Your mission is to find where the tallest vase is and which is closest to the ceiling. What level of difficulty do you think that mission has?
After teleporting into the loft hallway, which is quite dark, you have a very important mission. You have to be very brave and look for where the window is, look through it and see the great storm that is tonight. Don’t be scared by lightning and thunder, think you have the help of Psychobot!
You are in the living room with your friend Psychobot, and the lights are all on. Through the window you only see that it is night, and you don’t hear any noise from outside either. Does it seem like an easier or more difficult mission than the previous ones?
When you are in the dark room, where you can hear it raining a lot, you ask Psychobot for help and he tells you that you are doing very well. How do you feel to hear this?
You are in the hallway of the bathroom, which is not very very dark. Now you are going to have to look out the window to see what the weather is like; after doing it, you see that the night is dark but it doesn’t rain, you only see the very big and bright moon in front of you, are you very afraid?
You have teleported very quickly to the dining room, and you see that the light there is not very strong. After exploring the area, your mission this time is to look out the window and see how it rains. What degree of difficulty do you think this mission has?
You are in the living room of your house with all the lights on, it is night and the moon shines a lot. Suddenly, a Psychobot appears, and explains that you have a super power to teleport, and that you are going to have to explore all the areas of your house to get points. What would you say your energy level is?
When you and the Psychobot have already arrived in the dark room, you lie on the bed and see many rays through the window. Do you think this mission is very difficult?
Now your mission is to teleport from the room, which is very dark, to the living room, which has a lot of light, and your mission is to look at the weather through the window. What do you want to do on this mission?
You and Psychobot have teleported super fast from the bathroom hallway to the living room, and there is a little light there but you hear a lot of thunder. Your mission now is to explore the room as long as you want. How difficult do you think this activity is?
After you have teleported into the hallway, you see that it is dark and that it is raining heavily. Your mission is to stay in this area for a minute, do you dare to do this activity?
You are in the dining room and it is dark, but you have to be brave and look out the window. Your mission is to approach this window and look and listen to the lightning and thunder that there is tonight. What degree of difficulty would you put on it?
You have reached the room in just a moment, great! Still, as soon as you get there you can see out the window that there is a big storm tonight, is this scary?
After you’ve teleported into the attic hallway, your mission is to find where the window is. After you have explored the entire hallway and found it, you have to look through it and see that it is raining. Are you afraid of this new adventure?
With Psychobot cobot you have moved super fast to the bathroom hallway, great! Now, your mission is to explore this area that has very little light, and you will have to dare to look out the window and see how it rains. Do you think this mission is easier or more difficult than the others?
You are lying on the bed in the room, which is very dark. Psychobot is with you, and when you look out the window you can see that it is raining. How calm would you say you feel?
With your superpower you have teleported from the living room to the dining room in just a second, great! Now you have to use another super power, be very brave and explore the area as long as you can, even if it is a bit darker and you are hearing how it rains. Do you dare to explore the area?
You have reached the loft hallway super fast, and you see that it is quite dark. Still, you are very brave and you explore the area, and through the window you can see that it is not bad weather and that the moon shines a lot. How difficult do you think this mission is?
You just got to the room, and you can only see the moon shine through the window because it’s so dark. Are you afraid or are you calm?

[ DISCLAIMER: This document has been automatically translated using Google Translate. ]

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Bibliography

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