Tag: English

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.”

An example of the Fear intervention to darkness in children 

Example protocol designed to be applied on a biweekly or weekly basis, made up of 8 to 12 sessions, lasting 30-45 minutes. A follow-up in 3 to 6 months is recommended. 

SESSION 1

• On introducing the virtual reality, show a neutral environment such as an island or underwater in the sea.

• The objective in the opening session is to create a game where the child feels relaxed and is willing to participate. Explain to the child that he is going to meet Psicobot, the teleportation who he/she can use for help when needed, be shown the rooms in the house which they can visit, and gain tokens for exploring the house, which the child can exchange for prizes at the end of the session (in the case of using token economy)…

• When using the token economy, clarify the operating rules before starting the virtual session. Get the child to interact with the environment and collect tokens easily and exchange the tokens for prizes (in the case of using token economy) at the end of the session.  

ITEM	ENVIRONMENT	CONFIGURATION	EVENT
Virtual Reality Presentation	Underwater in the sea	Fish: maximum
Training Zone	Fear of darkness and storms	Cotherapist: Activated Points: easy. Climate: Clear spells	Introduction Teleportation (on child’s request)  Help (on child’s request)
In the living room	Fear of darkness and storms	Cotherapist: Activated Points: easy. Climate: Clear spells	Introduction Teleportation (on child’s request) Help (on child’s request)
In the hall-attic zone	Fear of darkness and storms	Cotherapist: Activated Points: easy. Climate: Clear spells	Teleportation (on child’s request) Help (on child’s request)
In the bedroom	Fear of darkness and storms	Cotherapist: Activated Points: easy. Climate: Clear spells	Introduction Teleportation (on child’s request)  Help (on child’s request)
Lying down on bed	Fear of darkness and storms	Cotherapist: Activated Points: easy. Climate: Clear spells	Introduction Teleportation (on child’s request)  Help (on child’s request) Lying down on bed (on child’s request)
In the Living room area and dimming the light	Fear of darkness and storms	Cotherapist: Activated Points: easy. Climate: Clear spells	Introduction Teleportation (on child’s request) Help (on child’s request)  Ambient light)

SESSION 2

• Review achievements from the last session and the objectives set in the session: Continue exploring the house to gain tokens and carry out missions with levels of less lighting. 

• To favor confrontation and, in particular in the case of implementing emotive performances techniques, games (counterconditioning) could be introduced in the individual spaces. For example, count the number of vases there there are in the living room (5), the number of pictures on the wall in the training zone and in the living room (7)…count the windows in the house, find the contingency/tokens table (bedroom wall) where you can take note of the tokens obtained. 

• If you use gradual exposure, playing games or distracting is not recommended, use the tokens as a confrontational reinforcement and repetition as a strategy in promoting the bedroom and end to the conditioned galvanic response sensor. As and from the second session in treatment, introducing the systematic and gradual exposure to the distinct spaces in the house is recommendable. In function with the minor’s progress, reduce the light intensity progressively. 

• Use cognitive reconstruction, if necessary. 

• Remember you have been given TOKENS, set up a token economy, if need be, so that confrontational behavior can be positively reinforced. In the beginning, exchanging tokens for prizes is recommendable at the end of the session.

HOMEWORK

Programme activities to be carried out with the parents and the minor between sessions. These activities should be similar to the ones carried out by the healthcare professional via VR. For example, when it’s night-time, using enough lighting, go through the individual rooms in the house, and play teleportation, looking for a specific toy that has been previously hidden by the parents.

If you are using the token economy, using tokens at home is also recommendable: for finding toys and exploring the rooms. Teach the parents never to force the child to do something he/she does not want to do. Whether scenes such as those which are used in gradual exposure are applied, it would also be a good idea for the parents to be present for the sessions so they can see how the coping develops during the VR sessions.  

ITEM	ENVIRONMENT	CONFIGURATION	EVENT
Training zone	Fear of darkness and storms	Cotherapist: Activated Points: easy. Climate: Mild	Introduction Teleportation (on child’s request) Help (on child’s request)
In the hall-attic area	Fear of darkness and storms	Cotherapist: Activated Points: easy. Climate: Mild	Teleportation (on child’s request) Help (on child’s request)  Ambient light 75%
In the bedroom	Fear of darkness and storms	Cotherapist: Activated Points: easy. Climate: Mild	Teleportation (on child’s request) Help (on child’s request) Ambient light 75%
Lying down on the bed	Fear of darkness and storms	Cotherapist: Activated Points: easy. Climate: Mild	Teleportation (on child’s request) Help (on child’s request) Lying down on bed (on child’s request) Ambient light 75%

SESSION 3 TO SESSION N

• Review achievements from the last session, go over the activities done at home and objectives set in the last session: Continue exploring the house to gain tokens and carry out missions.

• Emotive performance techniques/Gradual and systematic exposure to the distinct spaces in the house. In function with the minor’s progress, gradual light intensity reduction. REMEMBER BY SETTING THE TOKENS CONFIGURATION SETTINGS (Easy, Medium, Difficult) YOU WILL IN TURN INCREASE THE TIME SPENT IN GAINING TOKENS. 

• Cognitive reconstruction, if necessary.

• To favor confrontation and, in particular in the case of implementing emotive performances techniques, games (counterconditioning) could be introduced in the individual spaces. Be creative by offering a variety of games, get the child to make suggestions…

• If you use gradual exposure playing games or distracting the child will not be necessary, use the tokens system as a confrontational reinforcement and repetition as a strategy in promoting the bedroom and end the conditioned response. 

• If you have used a token economy, within the last 2-3 sessions schedule a fading to the token economy: the exchanging of tokens for prizes becomes further apart and reinforcement becomes more social, from the environment itself (child’s autonomy) and self-administered.

HOMEWORK 
When based on the emotive performance technique, continue with the kitchen, which will not be accessible, will also be visible from the zones described above, starting at the training zone. 

FINAL SESSION

Review achievements and objectives set from the previous session. Lie down on bed with the light turned off (to proceed use rain and even storms if needed).

• Systematic and Gradual exposure/Emotive performances techniques to distinct spaces in the house. ”Tokens” configuration settings in difficult mode and lights offs. Cognitive reconstruction, and proceed.

• If you have used environment tokens to carry out a token economy, make sure it has been completely withdrawn: behaviors are maintained from natural and social effort and not from exchanging tokens.

• Arrange a follow-up within 3, 6 months.

ITEM	ENVIRONMENT	CONFIGURATION	EVENT
Training zone	Fear of darkness and storms	Cotherapist: Activated Points: Difficult. Climate: Storms	Introduction Teleportation (on child’s request) Help (on child’s request)
Living room	Fear of darkness and storms	Cotherapist: Activated Points: Difficult. Climate: Storms	Teleportation (on child’s request) Help (on child’s request) Ambient Light 25-0%
In the hall-bathroom zone	Fear of darkness and storms	Cotherapist: Activated Points: Difficult. Climate: Storms	Introduction  Teleportation (on child’s request) Help (on child’s request)
In the hall-attic zone	Fear of darkness and storms	Cotherapist: Activated Points: Difficult. Climate: Storms	Teleportation (on child’s request) Help (on child’s request) Ambient Light 25-0%
In the bedroom	Fear of darkness and storms	Cotherapist: Activated Points: Difficult. Climate: Storms	Teleportation (on child’s request)  Help (on child’s request) Ambient Light 25-0%
Lying down on the bed	Fear of darkness and storms	Cotherapist: Activated Points: Difficult. Climate: Storms	Teleportation (on child’s request) Help (on child’s request) Lying down on bed (on child’s request) Ambient Light 25-0%

PLEASE REFER TO OUR CLINICAL GUIDE ON OBSERVATIONAL EVIDENCE THERAPEUTIC PROCEDURES AND HOW TO ADAPT THE INTERVENTION TO VIRTUAL REALITY ENVIRONMENTS WITH PSIOUS

An example of Fear Intervention to storms in adults  

Example protocol designed to be applied on a biweekly or weekly basis, made up of 6 to 8 sessions, lasting 30- 45 minutes. A follow-up in 3 to 6 months is recommended.

SESSION 1

• Inform the patient about fear of storms (Causes, symptoms, prevalence…)

• Present and show sufficient grounds for the techniques that are used overtime in the treatment: virtual reality exposure and exposure in vivo…

• Exposure hierarchy development and hierarchy item exposure development from 20-30 USA’s.

• Start exposure hierarchy with an item close to USA’s 30. The main objective is to familiarize the patient with the virtual reality and the working dynamics. 

ITEM	ENVIRONMENT	CONFIGURATION	EVENT
Training zone. In the dining room	Fear of darkness and storms	Cotherapist: deactivated Points: easy. Climate: Clear spells	Teleportation (on adult’s request)
In the living room without light turned on	Fear of darkness and storms	Cotherapist: deactivated Points: easy. Climate: Clear spells	Teleportation (on adult’s
Hall-attic without light turned on	Fear of darkness and storms	Cotherapist: deactivated Points: easy. Climate: Clear spells	Teleportation (on adult’s
In the bedroom at night without light turned on	Fear of darkness and storms	Cotherapist: deactivated Points: easy. Climate: Clear spells	Teleportation (on adult’s request)
Lying down on the bed at night	Fear of darkness and storms	Cotherapist: deactivated Points: easy. Climate: Clear spells	Lying down on bed (on adult’s request)

SESSION 2

• Review achievements and objectives set from the previous session: reduce light in the environments and increase rain intensity.

• From the second treatment session, it is recommended to start systematic and gradual exposure in light of virtual reality environments. Cognitive reconstruction, if applicable. 

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

HOMEWORK
Covert and/or assisted exposure by computer to the sound of rain (light-moderate) with heavy overcast imaging. Foster in vivo exposure.

ITEM	ENVIRONMENT	CONFIGURATION	EVENT
In the living room with dim light and raining.	Fear of darkness and storms	Cotherapist: deactivated Points: easy. Climate: rain	Teleportation (on adult’s request) Ambient light 50% Rain intensity 30%
Hall-attic zone with dim light and raining	Fear of darkness and storms	Cotherapist: deactivated Points: easy. Climate: rain	Teleportation (on adult’s request) Ambient light 50% Rain intensity 30%
Bedroom with dim light and raining	Fear of darkness and storms	Cotherapist: deactivated Points: easy. Climate: rain	Teleportation (on adult’s request) Ambient light 50% Rain intensity 30%
Lying down on bed with dim light and raining	Fear of darkness and storms	Cotherapist: deactivated Points: easy. Climate: rain	Lying down on bed (on adult’s request) Ambient light 50% Rain intensity 30%
In the living room with dim light and raining	Fear of darkness and storms	Cotherapist: deactivated Points: easy. Climate: rain	Teleportation (on adult’s request) Ambient light 50% Rain intensity 50%
Hall-attic zone with dim light and raining	Fear of darkness and storms	Cotherapist: deactivated Points: easy. Climate: rain	Teleportation (on adult’s request) Ambient light 50% Rain intensity 50%
Bedroom with dim light and raining	Fear of darkness and storms	Cotherapist: deactivated Points: easy. Climate: rain	Teleportation (on adult’s request) Ambient light 50% Rain intensity 50%
Lying down on bed with dim light and raining	Fear of darkness and storms	Cotherapist: deactivated Points: easy. Climate: rain	Lying down on bed (on adult’s request) Ambient light 50% Rain intensity 50%

SESSION 3

• Review achievements and objectives set from the previous session: reduce light in the environments and increase rain/storm intensity.

• Systematic and gradual exposure in light of virtual reality environments. Cognitive reconstruction, if applicable.

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

HOMEWORK
Covert and/or computer-assisted exposure to the sound of rain (light-moderate) with heavy overcast imaging. 

ITEM	ENVIRONMENT	CONFIGURATION	EVENT
Training zone with dim light and moderate rain	Fear of darkness and storms	Cotherapist: deactivated Points: easy. Climate: Storms	Teleportation (on adult’s request) Ambient light 50% Rain intensity 30%
Hall-bathroom zone with dim light and moderate rain	Fear of darkness and storms	Cotherapist: deactivated Points: easy. Climate: Storms	Teleportation (on adult’s request) Ambient light 50% Rain intensity 30%
Bedroom with dim light and moderate rain	Fear of darkness and storms	Cotherapist: deactivated Points: easy. Climate: Storms	Teleportation (on adult’s request) Ambient light 50% Rain intensity 30%
Lying down on bed with dim light and heavy rain	Fear of darkness and storms	Cotherapist: deactivated Points: easy. Climate: Storms	Lying down on bed (on adult’s request) Ambient light 50% Rain intensity 30%
In the living room with dim light and heavy rain	Fear of darkness and storms	Cotherapist: deactivated Points: easy. Climate: Storms	Teleportation (on adult’s request) Ambient light 50% Rain intensity 70%
Hall-attic with dim light and heavy rain	Fear of darkness and storms	Cotherapist: deactivated Points: easy. Climate: Storms	Teleportation (on adult’s request) Ambient light 50% Rain intensity 30%
Bedroom with dim light and heavy rain	Fear of darkness and storms	Cotherapist: deactivated Points: easy. Climate: Storms	Teleportation (on adult’s request) Ambient light 50% Rain intensity 70%
Lying down in bed with dim light and heavy rain	Fear of darkness and storms	Cotherapist: deactivated Points: easy. Climate: Storms	Lying down on bed (on adult’s request) Ambient light 50% Rain intensity 70%

SESSION 4

• Review achievements and objectives set from the previous session: reduce light in the environments and increase rain/storm intensity (intense). 

• Systematic and gradual exposure in light of virtual reality environments. Cognitive reconstruction, and proceed.

• Repeat each exercise twice.

• Reveal clinical progress to the patient, using the reports provided in the platform.

HOMEWORK
Covert and/or assisted exposure by computer to the sound of rain (light-moderate) with heavy overcast imaging. Foster in vivo exposure.

ITEM	ENVIRONMENT	CONFIGURATION	EVENT
Training zone with light rain and storms	Fear of darkness and storms	Cotherapist: deactivated Points: easy. Climate: Storms	Teleportation (on adult’s request) Ambient light 50% Rain intensity 80%
Living room with dim light and scant storms	Fear of darkness and storms	Cotherapist: deactivated Points: easy. Climate: Storms	Teleportation (on adult’s request) Ambient light 25% Rain intensity 80%
Hall-attic zone with dim light and scant storms	Fear of darkness and storms	Cotherapist: deactivated Points: easy. Climate: Storms	Teleportation (on adult’s request) Ambient light 25% Rain intensity 80%
Bedroom with dim light and scant storms	Fear of darkness and storms	Cotherapist: deactivated Points: easy. Climate: Storms	Teleportation (on adult’s request)  Ambient light 25% Rain intensity 80%
Lying down on the bed with dim light and scant storms	Fear of darkness and storms	Cotherapist: deactivated Points: easy. Climate: Storms	Lying down on bed Ambient light 50% Rain intensity 80%

SESSION 5

• Review achievements and objectives set from the previous session: reduce light in the environments and increase rain/storm intensity (very intense).  

• Systematic and gradual exposure in light of virtual reality environments. Cognitive reconstruction, and proceed.

• Repeat each exercise twice.

• Reveal clinical progress to the patient, using the reports provided in the platform.

HOMEWORK
Covert and / or computer-assisted exposure to the sound of light-moderate rain) and images of very cloudy skies. Promote live exhibition.

ITEM	ENVIRONMENT	CONFIGURATION	EVENT
Training zone with dim light and very intense storms	Fear of darkness and storms	Cotherapist: deactivated Points: easy. Climate: Storms	Teleportation (on adult’s request) Ambient light 25-0% Rain intensity 90%-100
Living room with dim light and very intense storms	Fear of darkness and storms	Cotherapist: deactivated Points: easy. Climate: Storms	Teleportation (on adult’s request) Ambient light 25-0% Rain intensity 90%
Hall-attic with dim light and very intense storms	Fear of darkness and storms	Cotherapist: deactivated Points: easy. Climate: Storms	TTeleportation (on adult’s request)  Ambient light 25-0% Rain intensity 90%-100
Hall-bathroom with dim light and very intense storms	Fear of darkness and storms	Cotherapist: deactivated Points: easy. Climate: Storms	Teleportation (on adult’s request) Ambient light 25-0% Rain intensity 90%-100
Bedroom with dim light and very intense storms	Fear of darkness and storms	Cotherapist: deactivated Points: easy. Climate: Storms	Teleportation (on adult’s request) Ambient light 25-0% Rain intensity 90%-100
Lying down on bed with dim light and very intense rain	Fear of darkness and storms	Cotherapist: deactivated Points: easy. Climate: Storms	Lying down on bed Ambient light 25-0% Rain intensity 90%-100

SESSIONS 6 & 7

• Review achievements from previous session and set objectives for current session: generalization and overlearning.

• Systematic and gradual exposure in light of virtual reality environments. Cognitive reconstruction, and proceed. 

• Repeat each exercise twice, in function with levels of discomfort.

• Reveal clinical progress to the patient, using the reports provided in the platform.

• Foster in vivo exposure and set follow-up at 3-6 months. 

ITEM	ENVIRONMENT	CONFIGURATION	EVENT
At home watching television and it’s raining. One family member is not at home	Generalized Anxiety	Concerns about family	Reproduce
At home, just on way to do some errands. TV weather forecast warns of storms	Fear of flying	At home: daytime, rain	Forecast
Driving in the city at night in a storm.	Fear of driving	City: night, rain, maximum, driving, minimum	Circuit 1
Driving on the road at night in a storm	Fear of driving	Road, night, rain, driver, show, hide.	Highway, Medium speed,Bends
Taking a taxi by day in a storm	Fear of flying	On the way to the airport: day, rain.	Weather forecast on radio
At the airport, going to travel in bad weather	Fear of flying	Boarding area:day, rain, maximum	Window, Boarding call
Traveling on a plane in bad weather	Fear of flying	Plane:maximum day, rain, window,middle,off
Traveling on a plane in bad weather	Fear of flying	Plane:maximum, storm,- day window, behind,off	Taxi, Landing
Traveling on a plane in bad weather	Fear of flying	Plane: maximum, storm,day window, behind,off	Flight, Take-off, Light,Turbulences

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 darkness and storms evaluation

Evaluation Objectives

• Evaluate the presence and comorbidity of other emotional disorders, in particular anxiety from separation, night terrors, sleep alterations, other phobias…

Evaluate anxiety associated with dimensions

• DARKNESS
  • Personal safety (eg. rapture, robbers)
  • Loss or separation (eg. in children, for example with their parents)
  • Nightmares
  • Imaginary creatures 
  • Darkness 

• STORMS
  • Personal safety/damage
  • Intense sounds

• Set the feared stimulative settings for the patient and define to what extent. Exposure hierarchy development, assess if there is only fear of darkness or storms or both collectively.
  
• Measure the presence of distorted thoughts: monsters, robbers, lightning coming through the windows… In the case of MRI, especially those associated with suffocation, possible damage caused by the machine and fear of losing control.

Some useful instruments for fear of darkness and/or storms evaluation (children and adults) 

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:

Child evaluation

• OPEN INTERVIEWS
  • Structured interview: ADIS-IV:C (Children)
  • Interview with one or both parents: education background, coping with fear…
  • Natural observation procedures for parents (similar to Orgilés proposal, Méndez y Espada, 2005): Register of Behavior to Darkness and Register at Bedtime. 
  • Artificial observation procedures for parents (based on Orgilés, Méndez y Espada, 2005): behavioral approach test to darkness and darkness tolerance test.
  • Fear level thermometer for children applicable to the observation procedures.
  • Bedtime register (BD)
• SELF-REPORTING
  • General diagnosis examination questionnaire for parents: e.g CBCL.
  • General questionnaire of fears for children: e.g FSSC-R
  • Fear of Darkness assessment scale (EMO)
• ELECTROMYOGRAPHY BIOFEEDBACK
  Set the baseline in a neutral environment. 

Evaluation in Adults

• STRUCTURED INTERVIEW: ADIS-IV
• BEHAVIORAL APPROACH TEST/BEHAVIOR AVOIDANCE
  (in vivo or with Virtual Reality)
• SELF-REPORTING
  • Fear Survey Schedule FSS-III (Fear Survey Schedule) 
• ELECTROMYOGRAPHY BIOFEEDBACK
  Set the baseline in a neutral environment. 

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, (e.g What level of discomfort is generated, on a scale of 0 to 100, when left alone without any light in the living room? What level of discomfort is generated, on a scale of 0 to 100, when left alone without any light in this bedroom? Can you think of anything else that would generate even more discomfort?…) all geared at the planning of the intervention via Virtual Reality.

Fear of the dark
and virtual reality

This Psious Virtual Reality environment (VR) will assist you in the intervention and evaluation of children and adults who are showing signs of fear of darkness and/or storms. With the help of the events and the environment settings provided in the platform each environment can be adapted to the therapeutic procedure requirements.

For example, it will allow you to carry out a behavioral avoidance test (Orgilés, Méndez & Espada, 2005) or psychological intervention with the procedures that have shown the most empirical evidence, in this case multi-component programs (systematic desensitization, exposure, modeling, token economy, parenting training…). Amongst them, one worthy of mention is that of Mikulas andCoffman (1989) and the “emotive performances technique” ( EPT) by Méndez (1986) that suggested using EPT as an alternative to emotive imagery by Lazarus and Abramovitz (1979). Furthermore, an environment can be used to carry out gradual exposure, psychoeducation, cognitive reconstruction, relaxation… 

Lastly, let’s focus on the advantages that VR brings to this type of intervention and denote, as bibliography shows, that VR has already demonstrated to be very effective as a treatment in phobias (Capafons, J.I, 2001). With respect to darkness phobia in children, as already indicated, multicomponent programs have shown greater effectiveness than other intervention techniques. For example, in the emotive performances technique counterconditioning components are clearly combined (a child being introduced to a game should be sufficiently attractive to offset the effects of the feared stimulus) with other operant conditioning techniques, not only the strengthening of approach behaviors to the phobic stimulus, but also the elimination of possible conduct behaviors that parents or adults involved in the treatment could apply.The control that the Healthcare professional acquires in addition to the gradual process that patients undergoes, on the one hand, facilitates the transition from the simulated environment to the real environment, delivering greater levels of accuracy, and on the other hand, due to the fact that this type of coaching encourages acceptance of the intervention. Thereby, favoring the coaching of parents through observation during the visit and lastly, allowing us to easily “gamify” the therapeutic process.

When it comes to storm phobias, VR provides the solution to solving one of the major drawbacks to in vivo exposure: unpredictability and the lack of frequency. Exposures in Psious can be exposed to patients systemically and the levels of anxiety can be adjusted accordingly to the degree of: night or day, amount of light, intensity of rain or storms. 

Ultimately, it combines your knowledge with the tools that you are provided with by Psious, thus enhancing user experiences and achieving better results.

Appendix

Self-report hierarchy Augmented Reality
spiders / cockroaches

ITEM	LEVEL OF 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 in front of a large group of large cockroaches. 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 roaches that move all over the table

Self report hierarchy Virtual Reality
spiders / cockroaches

ITEM	LEVEL OF 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 at a table , and I can see that there is some very small spider moving around there
In the terrarium on 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 large 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 is a small number of very large spiders on the table, but they are quite far from my hands
There are many medium-sized spiders on the table, and they move until they are in a middle 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 find myself in front 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 pair 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 also 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 nails on the table, but they are quite far from my hands

Self-report hierarchy environment Fear of Dogs

ITEM	LEVEL OF 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 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 in the distance a dog sitting with a muzzle, without a leash but next to its owner
I see in the distance a dog sitting, without a muzzle, next to its owner and without a leash
I can see in the distance a dog with a muzzle, sitting, leash and a little away from its owner
Observe away a dog without muzzle, sitting, leash and a little away from its owner
Observe a dog in the distance standing with muzzle on the side of his owner and strapped
To him distance I see a dog standing without muzzle to the side of his owner and strapped
Pue I 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 standing dog with a muzzle , 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
the distance I see a dog standing without muzzle on the side of his owner, strapped and barking
At him I observe 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 away a dog without a muzzle, from standing, off leash, slightly away from its owner and barking
I observe a dog at medium distance sitting with a muzzle next to its owner and tied on a leash
At a medium distance I see a dog sitting, without a muzzle next to its owner and tied on a leash
I can see a dog with a muzzle sitting on a leash at a medium distance, somewhat separated from its owner
At a medium distance I see a dog without a muzzle, sitting and separated from its owner but tied on a leash
I see a dog sitting at a medium distance with a muzzle, without a leash but next to its owner
I observe at a medium distance a sitting dog, 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 bit far away from its owner
I observe at a medium distance a dog if 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 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 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 a muzzle , standing, without a leash and a little away 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 dog breed sitting, without muzzle next to its owner and leashed and barking
At a medium distance I observe ap erred without 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 observe far 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 breed dog standing, muzzleless next to its owner, leashed and barking
At a medium distance I see a dog muzzle and barking, 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 with a muzzle next to its owner and tied on a leash
Nearby I have a dog sitting, without a muzzle next to its owner and tied on a leash
I can see near a dog with a muzzle sitting on a leash , somewhat separated from its owner
Nearby I observe a dog without a muzzle , 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 away from its owner
I see nearby a dog without a muzzle, sitting, without a leash and a little away from its owner
I observe a dog nearby, standing, with a muzzle, next to its owner and tied on a leash
Near me I see a dog standing, without a muzzle next to its owner and tied on a leash
I have nearby a dog 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 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 a leash
I can see around me a dog muzzled, standing a little leash and away from his owner
looked closely or n dog without a muzzle, standing, without a leash and a little away from its owner
Near me I see a dog of the breed dog sitting, without a muzzle next to its owner and tied on a leash and barking
Nearby I can see a dog without a muzzle and barking, sitting and separated from its owner but tied on a leash
I closely observe a dog sitting, without a muzzle, next to its owner and without a leash and barking
I have a dog close without a muzzle, sitting, without a leash and a little away from its owner and barking
Near me I see a dog standing, muzzleless next to its owner, leashed and barking
Nearby I see a dog muzzle and barking, standing and separated from its owner but leashed
I observe near me a dog standing, without a muzzle, next to its owner, without a leash and barking
I see nearby a dog without a muzzle, standing, without a leash, slightly away from its owner and barking

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

Download appendix

Bibliography

• Bados, A. (2005). Fobias específicas. Barcelona. Universidad de Barcelona.

• Botella, C., Breton-López. J., Quero, S., Baños, R.M., García-Palacios, A., Zaragoza, I. y 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, C.M., Juan, M.C., Baños, R.M., Alcañiz, M., Guillén, V. y Rey, B. (2005) Mixing Realities? An Application of Augmented Reality for the Treatment of Cockroach Phobia. Cyberpsychology and Behavior, 8(2), 162-171.

• Brown, T.A., Di Nardo, P.A. & Barlow, D.H. (1994). Anxiety Disorders Interview Schedule for DSM-IV (ADIS-IV). San Antonio: The Psychological Corporation.

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

• Gunnar Götestam, K. y Hokstad, A. (2002). Tratamiento en sesión única de la Aracnofobia en grupo mediante Exposición Rotativa Activa. The European Journal of Psychiatry, 16(3), 133-138. 

• Juan, M.C., Alcañiz, M., Montserrat, C., Baños, R.M. y 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, L.G. (1989). One-session treatment for specific phobias. Behaviour Research and Therapy, 27, 1-7.

• Sosa, C.D., Capafóns, J.I., Conesa-Peraleja, M.D., Martorell, M.C., Silva, F. y Navarro, A.M. (1993). Inventario de miedos. En F. Silva y C. Martorell (dirs.), Evaluación de la personalidad infantil y juvenil (vol. 3, pp. 101-124). Madrid: MEPSA

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

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

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.”

Treatment in a single session of Öst 

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 from 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.

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	SUD’s	ENVIRONMENT	CONFIGURATION	EVENT
Being at a table having a terrarium over	20	rooms with spiders,	minimal  terrarium, small	Maximum distance
See a very small spider in a terrarium	30	rooms with spiders,	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 of the previous session and set objectives of the session: See large spiders in a terrarium.

• The exhibition begins with 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	SUD’s	ENVIRONMENT	CONFIGURATION	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 Exposure with 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	SUD’s	ENVIRONMENT	CONFIGURATION	EVENT
View some small spiders to the other side of the table	60	room with chandeliers,	minimal  table, small	maximum distance
that a few large spiders you begin to move much while in a terrarium	65	room with spiders,	maximum  terrarium, large	disorder
See a small group of medium sized spiders to the other side of the table	65	room with chandeliers,	minimal  table medium	maximum distance
See some large spider to the other side of the table	70	room with chandeliers,	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 Exposure With 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	SUD’s	ENVIRONMENT	CONFIGURATION	EVENT
Stand in front 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 with spiders	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 Exposure With 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	SUD’s	ENVIRONMENT	CONFIGURATION	EVENT
Have a spiders few close and not move:	80	Augmented Reality  Chandeliers	large, medium
View as many medium sized spiders are close to you	85	Augmented Reality: Chandeliers	large, maximum, ride
Having a large group of spiders moving forward you	90	Room with spiders,	maximum  table, middle	distance Reduce

SESSION 6

• achievementsReview previous session and session establishment objectives: that many large spiders walk by your hand

• is made gradual exposure prevention 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	SUD’s	ENVIRONMENT	CONFIGURATION	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

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

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.”

Assessment Fear of animals

Assessment 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.

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 for obtaining 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

Elaboration of the exposure hierarchy with Psious environments

Once we have the evaluation information we can proceed to develop 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 square (environment afraid of animals, video pigeons in a square)

• What a small cockroach walk by your hand (animal fear environment, room with cockroaches)

• See many quite large spiders move around the table (animal fear environment, room with spiders)

• Pet a cat (animal fear environment, cat video)

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

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

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

Fear of animals
and virtual reality

The treatment of choice for animal phobia is based on the use of exposure techniques, the success rate of which 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) is a good alternative for the treatment of this phobia. This technology helps facilitate patient adherence to treatment and allow the healthcare professional to have control over different variables during exposure.

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

Appendix

https://www.apa.org/ptsd-guideline/treatments/eye-movement-reprocessing