To increase the sense of immersion in Virtual Reality, you can include comments, questions or ideas in the session so the experience will seem more realistic to your patient.
Some examples for High Places environments
Today we are going to climb up a building of 15 floors. You will be located at the balcony on the highest floor, from where you will observe the fall from above, paying attention to the movement of cars and to the ground distance.
Is it true that falling from this height could be deadly?
Do you feel that it is a risk situation?
We are now in a very high place. Do you feel anxious?
Move the head to both sides and look how we are in a very high place.
Is it hard not to look down?
Do you feel anxious or fearful looking down?
Do you feel fear? Is it more intense or less than before?
Do you feel like you are in danger right now? How real do you think it is?
(Inside the glass elevator) Notice that as the elevator goes up, the distance from the ground is increased and everything looks smaller. How does that make you feel?
“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.”
As detailed below, a treatment protocol is offered as an example. It includes the Treatment protocol based on Psious Manual Acrophobia use of Psious combined with traditional techniques. Nevertheless we recommend the healthcare professional to adjust the VRʼs strategies to the techniques he already uses in his clinic practice. Moreover, the techniques will have to be adjusted to the needs and evolution of the patient, but especially to the exposure hierarchy, which healthcare professional and patient should elaborate in the first session
SESSION 1: PSYCHOEDUCATION
Information about acrophobia is provided (origin, upkeep and appearance of the triple system cognitive, physiological and motor).
Treatment techniques that will be used throughout the protocol are explained (emphasizing the exposure to the VirtualReality environments).
An exposure hierarchy is elaborated.
SESSION 2 and 3 : RELAXATION
The patient learns and practices two types of relaxation techniques: controlled breathing and Jacobson’s progressive muscular relaxation.
Familiarization with the Psious platform. The patient learns to use the VR helmets and navigate inside the virtual scenes.
HOMEWORK Daily practice of relaxation techniques. The self registers of relaxation and negative thoughts are completed (See appendix section)
SESSION 4: COGNITIVE RESTRUCTURING
Revision and adjustment of the patient’s negative thoughts.
Cognitive restructuring for each of the negative thoughts. Two kinds of cognitive therapy may be used: the one proposed by Beck or the one belonging to Ellis.
HOMEWORK Daily practice of relaxation techniques. Self-registers of relaxation and negative thoughts are completed (See appendix section)
SESSION 5: VIRTUAL EXHIBITION + RELAXATION
As of the fifth session of treatment the gradual and systematic exposure to the virtual environments begins. Throughout all exposure sessions, VR is combined with techniques of relaxation and cognitive restructuring.
The patient is exposed to:
Bridge and/or Cliff
Getting to the second level of the crystal elevator
HOMEWORK Daily practice of the relaxation techniques, selfregister of relaxation and negative thoughts and tasks of self exposure to stimulus related to heights..
SESSION 6: EXHIBITION RV + TRADITIONAL TECHNIQUES
Homework review.
The patient is exposed to:
Getting to the terrace by the crystal elevator introducing interoceptive exposure and leaning to the rail.
Getting to the terrace by the crystal elevator introducing a breakdown
HOMEWORK Daily practice of relaxation techniques, self-registers and tasks of self-exposure to height related stimuli.
SESSION 7: EXHIBITION RV + TRADITIONAL TECHNIQUES
Homework review.
The patient is exposed to:
Getting to the terrace by the metal elevator.
HOMEWORK Daily practice of relaxation techniques, self-registers and self-exposure tasks to height related stimuli.
SESSION 8: EXHIBITION RV + TRADITIONAL TECHNIQUES
Homework review
The patient is exposed to:
Getting to the terrace by the metal elevator introducing interoceptive exposure.
HOMEWORK Daily practice of relaxation techniques, self-registers and self-exposure tasks to height related stimuli.
SESSION 9: EXHIBITION RV + TRADITIONAL TECHNIQUES
As of the ninth session of treatment the exposure is re-started to the virtual environments but with a higher level of difficulty. With this scenario, we propose to examine the thoughts of the patient and the achieved results. Like in the rest of the exposure it is used in combination with relaxation and cognitive restructuring.
The patient is exposed to:
New York or Barcelona.
HOMEWORK Daily practice of relaxation techniques, self-registers and self exposure tasks to height related stimuli.
SESSION 10: RELAPSE PREVENTION
Homework review.
The therapeutic process is evaluated and future self-exposure tasks are programmed, as well as booster sessions.
“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.”
Goals of evaluation
To evaluate the presence and comorbidity of other emotional disorders, especially panic disorder, anxiety disorders and other phobias.
Evaluate component-related anxiety: intensity, fear characteristics…
Define stimulating configurations feared by the patient and the degree of it. Elaboration Hierarchy of Exposure.
Evaluate the presence of distorted thoughts.
Some useful tools for evaluating acrophobia
In consideration to the evaluation objectives, we will provide a list of some tools that can be useful to obtain relevant information and characteristics about your patient. Remember that a good definition of objectives, characterization of the patient and planning of the intervention are important for the efficiency and efficacy of the therapy, as well as for satisfaction of your patients. In the bibliography, you will find articles to review the characteristics of the instruments proposed below. A combination of the following tools will be used for a complete evaluation of the problem.
Open or semi-structured interview.
Structured interview: Interview for the Anxiety disorders According to DSM-IV (ADIS-IV)
Behavioral approach Test in vivo and/or through virtual reality
Auto – reports
Acrophobia Questionnaire (Cohen, Behaviour Therapy, IS, 17-23, 1977).
Fear Questionnaire (FSS-III) (Wolpe J. y Lang P.J., 1964 published by Landy & Gaupp, 1971).
Psious Auto-Reports for the elaboration of the hierarchy
Fear of heights —also known as acrophobia— is a condition that affects 3–5% of the general population. It is not necessarily pathologic, and it only implies a problem if the anxiogenic response is uncontrollable, if it can drive the patient into a panic attack or into suffocation sensations, etc. This phobia belongs to the category of “specific phobias”, which may provoke an intense and anxious response to a specific stimulus —in this case, when people are exposed to heights. Fear of heights is considered natural, even adaptative, since the avoidance response could be positive when people feel they are in a risk environment.
There are several agents implied in the development and maintenance of this phobia and Coelho, Waters, Hine and Wallis (2009) consider both non associative —hereditary— and associative —conditioned— factors in their model. So, it is considered as a multi-causal phenomena because not all the patients that seem to suffer this phobia have developed it in a conditioned or learned way. Moreover, it was found in a longitudinal study realized by Poulton , Davies, Menzies, Langley and Silva (1998) that those who took part in the study and suffered significant lesions and falls before the age of 9 do not show a phobic response when they are 18.
However, some people manifest a phobic behavior pattern when they are exposed to heights, such as feeling anxious or even presenting panic attacks. In these cases, treating the patient is essential since this shows a high level of acrophobia and the patient may try to avoid any place not situated at ground level. The avoidance response intensity depends on the patient’s particular condition, but it is particularly important to understand how the avoidance response intensity manifests itself through a continuum, which is a scale of high positions going from climbing up stairs to situating the patient on a cliff. This is an important indicator, and it has to be taken into account not just when analyzing the impact and the relevancy of the disorder but also when analyzing the stage of the disorder.
Finally, it is worth mentioning that Virtual Reality is a good alternative compared to traditional exposure techniques in the treatment of acrophobia because of several reasons. Firstly, the healthcare professional holds greater control of exposure variables, as opposed to the difficulty of obtaining an optimal environment to treat this phobia.
Secondly, it is less expensive in terms of logistics, treatment time and effort because it does not require the patient and healthcare professional to move around to find suitable places for in vivo exposure: the situation is modeled in a virtual environment . And, last but not least , there are fewer probabilities of the patient not wishing to be exposed to this treatment. Moreover, the use of VR exposure as a technique is at least equally efficient as in vivo exposure treatment (Emmelkamp, & cols; 2002).
Amelia Virtual Care also has a video that includes various events of a public bathroom, recorded in 360º.
EVENTS
LOW DIFFICULTY
Far away from the toilets In this scene the patient is in front of some public toilets, a bit far from the entrance.
Exit bathrooms In this scene the patient is inside the bathrooms, just in front of the exit door.
MEDIUM DIFFICULTY
In front of the bathroomsentrance In this scene the patient is just in front of the door of the public bathrooms.
MEDIUM-HIGH DIFFICULTY
In front of the closed WC door In this scene the patient is already inside the public toilets, just in front of the door of a WC, with said door closed.
In front of the open WC door In this scene the patient is inside the public toilets, just in front of the door of a WC, with said door already open.
In front of the toilet In this scene the patient enters the toilet and is standing about 10 cm from the toilet.
In front of the sink In this scene the patient is standing in the bathrooms, just in front of the sink.
Open bathroom door In this scene the patient is right in front of the exit door and opens it.
HIGH DIFFICULTY
Opening WC doors In this scene the patient is inside the public toilets, just in front of the door of a WC, opening the door with his hand.
In front of WC touch environment In this scene the patient is standing about 10 cm from the toilet and begins to touch the environment (walls, toilet paper dispenser and the cistern button).
Sitting WC In this scene the patient is sitting on the toilet.
Sitting toilet touching walls In this scene the patient is sitting on the toilet and begins to touch the walls of the toilet.
Sitting toilet touching paper In this scene the patient is sitting on the toilet and begins to take pieces of toilet paper and touch the dispenser.
Washing hands in a sink In this scene the patient is in front of the sink and begins to wash his hands: he rolls up his sleeves, takes soap from the dispenser, rubs his hands with the soap, turns on the water tap while rinsing his hands, shake it, put it under the hand dryer and pull down the sleeves.
SEQUENCE
Duration: 5 ‘ In this option you can see all the previous events followed one after the other.
Stress is a process that begins when a person judges a situation as threatening to them, and starts a cognitive evaluation of how to handle it. The situation can be perceived as a threat, damage/loss or challenge.
The primary evaluation is followed by a secondary one in which the individual takes into account their own resources and the repercussions of facing the situation. If the person perceives that the actual demands exceed their resources, a complex physiological mechanism is activated that prepares the individual to fight, flight or endure. This model is based on the particular relationship that is established between a person and a specific situation.
General strategies
Correctly interpret your body’s signals such as palpitations, muscle tension, sweating is essential to manage your stress. Remember that activation of your sympathetic nervous system allows you to adapt better to situations that require a quick response. Feel how your body takes over through the emotions that you are feeling to prepare you to confront a task or professional situation. Use this activation to face your challenges!
Organise your work well, establish realistic goals, prioritise the important things, delegate what you can…
Have hobbies in your routines, moments when you focus on carrying out those activities that are pleasant in your life.
Your social network
We have seen that cortisol is one of the hormones involved in the stress response and its presence can be, in the long run, dangerous. Cortisol has an antidote: oxytocin, a pituitary hormone that is generated in pleasurable situations and which causes more confidence, improves relationships and decreases stress. Oxytocin is the hormone of social instincts: it prefers us to look for relationships and makes us feel good when we have them. It uses social support as a form of managing stress. Asking for and giving help in stressful situations increases the generation of oxytocin and it helps us to prevent and improve our stress.
Specific strategies
In the management of stress within the working world we can use activation control techniques that allow us to adjust our level of attention to the characteristics of work demands, as well as recover our well-being after a prolonged and intense effort.
We have already seen that momentary increases in our body’s levels of activation, both physiologically and cognitively, have an adaptive function. In the working world, this allows us to meet the demands of the environment, tasks. However, if, as we have shown, these increases are produced in a massive, intense, long-lasting and/or repetitive way, then it can produce effects damaging to both physical and psychological health.
Regular and systematic training that provides us with skills and abilities to manage our levels of activation can be beneficial, as much in the personal sphere as in the working one, and it encourages a rise in quality of life and a better working atmosphere as well as prevention of behavioural disorders, for example: professional strain syndrome, burnout syndrome or “burnt worker syndrome”, occupational stress syndrome (OSS), etc.
Currently virtual reality is a means of highly effective technology that can make this goal easier and allow access to learning and practice of these techniques such as breathing control, different types of relaxation and training to focus attention through simple and effective Mindfulness exercises that allow us to identify, strengthen and maintain a state of well-being with the resulting benefits for the user who is involved in sustained practice.
Two relaxation techniques exist that we will use and coordinate fundamentally in this virtual training protocol:
● Training in diaphragmatic breathing
● Jacobson progressive muscle relaxation
This learning is internalised through practice and is generalised to personal and working environments, providing the user with abilities that prepare them for greater satisfaction and work performance.
Through the virtual application, Amelia virtual Care, this learning can take place in an independent and personal way as well as receiving psychological and interactive assistance for any query, doubt or question.
Under conditions of tension or stress, many people tend to breathe too quickly, essentially thoracic and shallowly or too deeply. If this form of breathing is prolonged, there may be irritating somatic sensationssuch as breathing difficulties, palpitations, pain or discomfort in the chest, dizziness, sweating, shaking. Instead, a correct way of breathing helps to make you feel better physically and mentally.
The majority of people breathe only by widening and contracting their chest (thoracic respiration). Sometimes, they even lift their shoulders to fill the upper section of their lungs (clavicular respiration). In these types of respiration, the diaphragm does not intervene practically and it may be insufficient.
Instead, diaphragmatic or abdominal respiration is what allows the most efficient exchange between the oxygen that we breathe in and the carbon dioxide that we exhale, with the least effort. The diaphragm is a muscle in the shape of a dome that is located at the base of the lungs and separates the thorax from the abdomen. When breathing abdominally, the arch formed by the diaphragm is greatly flattened during inspiration, which permits more air to enter the lungs. When exhaling, the diaphragm returns to its original position.
The average person breathes 12 to 16 times per minute when they are not excited or deeply relaxed. Controlled breathing techniques are aimed at achieving slow, regular diaphragmatic and optimal breathing.
This technique can be used to cope with anxiety and, in general, to reduce the physiological activation of it, so we can obtain a sense of relaxation and serenity.
When we find ourselves anxious, stressed, some of the muscles of our body tense involuntarily. If we learn to identify these muscles and we are capable of relaxing them, we then feel relaxed by being able to control many of the physiological variables of anxiety.
What we intend to learn is a relaxation technique that subsequently has a practical application as a technique to manage stress and self-control, applying it before, during and after a situation that causes anxiety and regularly produces avoidance behaviours.
We are going to learn to tense and then voluntarily stretch and relax various groups of muscles in a sequential way, at the same time asking that you pay a lot of attention to the sensations associated with stress and relaxation.
With this we intend you to learn to relax yourself and keep recognising and differentiating tension from relaxation as it appears in daily life, finally being able to reduce muscle tension whenever the user wishes to do so.We can combine this with relaxation techniques and practices gaining beneficial effects.
Mindfulness is understood as full attention and awareness, attentive and reflective presence. One of the clearest references of mindfulness is Zen Buddhist meditation.
It cannot be understood in a generic way (as a life philosophy or a feeling of life), but it is always referred to as a precise moment, the present.
This attention, awareness and reflection are non-judgmental in nature, accepting the experience as it is given. It is an open and ingenuous observation, absent of criticism and valence.
A way of being in the world without prejudice, open to the sensory experience, attentive to it and without assessing or rejecting this experience in an active and meticulous way.
It lays out in positive terms how to direct attention and activity, openly adapting to each situation, and implicitly pointing out the problems that can result from not focusing on the present moment in the indicated conditions.
The goal of mindfulness is to see that the person can observe and feel in a natural way, letting go of their behaviour and at the same time engaging with the activity. The goal is to be open to the activity itself.It is not incompatible, at all, to choose experiences, activities, etc., and at the same time to be available to experience and feel things as they happen. In this way flexibility and variability in behaviour is favoured, an essential characteristic of its adaptive and creative capability.
Face stressful work situations from the perspective laid out by mindfulness and use the techniques of activation control as a way of managing unpleasant physiological responses.
On a psychological level, cognitive and behavioural functions can be habitual: Difficulty in concentrating and making decisions, emotional variation, anxiety, sadness, excessively frequent irritability, insomnia, changes in eating and sexual appetite.
Also, it has been demonstrated that among individuals who suffer from work stress, the risk of behaviours damaging to health, such as smoking, alcoholism or drug consumption, increases considerably. When this behaviour existed prior to the stressful situation, the consequence is usually an increase in consumption. There also seems to be a significant increase in eating disorders such as obesity, anorexia or bulimia.
Another consequence of stress is the progressive deterioration of personal relationships,with family, friends or a partner.
On a physiological level, cardiovascular changes can appear, such as high blood pressure, arrhythmias, migraines; dermatological changes such as alopecia, dermatitis; sexual changes such as erectile dysfunction and vaginismus; digestive changes such as diarrhoea and constipation; musculoskeletal changes such as spasms, chronic pains, headaches and immune system changes with greater likelihood of suffering from infectious diseases.
It should be borne in mind that presently there is a great range of experimental and clinical data that shows that stress, if its intensity and duration exceeds certain limits, can produce considerable changes in the brain. These include more or less mild and reversible modifications up to situations in which neuronal death may occur.
It is known that the damaging effect that stress can have on our brain is directly related to the levels of hormones secreted in the body’s physiological response. Although the presence of determined levels of these hormones is of great importance for the correct functioning of our brain glucocorticoid excess can produce a series of changes in different brain structures, especially in the hippocampus which is the brain structure that plays a critical role in many learning and memory processes.
Through different experimental projects it has been possible to establish that continued exposure to situations of stress can produce three types of damaging effects on the central nervous system: Dendritic Atrophy, Neurotoxicity and Exacerbation.
For this reason, the need exists to have useful tools to prevent and minimise the effects sustained from stress and anxiety in the short and long term and one of these is to acquire skills to manage it.
