1

Index
1. What is Virtual Reality and how to use it in psychotherapy 3

2. Advantages and disadvantages of virtual reality:

what your patients should know before they start 6
2.1. Primary benefits of virtual reality 7
2.2. Disadvantages: Warnings for the use 8

3. General recommendations for the therapeutic process 10

3.1. Key moments of the use of the VR in consultation 11
3.2. A thorough evaluation is the basis of an effective intervention 14
3.3. Dynamics of intervention during the consultation 17
3.4. Establishing a Sense of Presence 18

4. Specific recommendations for the therapeutic process based

on the technique used 20
4.1. Exposure therapy 21
4.2. 4.2. Systematic desensitization (and variants) 26
4.3. Activation control techniques 28
4.4. Cognitive restructuring 34
4.5. Mindfulness 37

5. What to say when the patient says... 43

6. Clinical Cases 49

Related / Recommended bibliography 55

2
1. What is Virtual Reality and how can
you use it in psychotherapy

3
Virtual reality (VR) and augmented reality (AR) can be defined as sets of
three-dimensional environments with which a person interacts in real time,
generating a sense of immersion similar to real life. Immersion and interaction are,
in fact, characteristic components of this kind of technology.

In psychotherapy, virtual environments both reproduce relevant stimulation

configurations for mental health intervention, and also allow for the manipulation of
certain variables in order to control and adapt the intervention to the patient’s
characteristics. This technology allows us to work in a way that cannot be
reproduced in real life. It immerseoffers us the option of evaluating and intervening
with the patient “within” a specific situation (for example, in the subway) without the
need to leave the consultation office. It also allows us to repeat certain conditions (for
example, a takeoff) as many times as necessary to work on a therapeutic goal
(habituation, reciprocal inhibition of an anxious response, relaxation...). And it helps us
to plan in a personalized way, manipulating configuration variables and the moments
at which certain events are initialized, the intervention’s stages, etc. (Gutiérrez J., 2002).

In other words, VR facilitates the application of evaluation and intervention in

psychology. However, it is crucial to clarify that ICTs alone do not produce a
therapeutic change. Amelia's environments are empirically supported tools within

4
psychological evaluation and intervention. (for an overview, see, for example, Daset,
Lilian R. and Cracco, Cecilia, 2013). Research in psychology already has a broad
empirical base that includes virtual reality or augmented reality protocols, which have
proven their therapeutic efficiency (see, for example, Botella et al., 2012).

In Amelia, we develop virtual environments for healthcare professionals to have

accessible, flexible, customizable and attractive tools to apply therapeutically
effective interventions. All our environments are based on bibliographic review of
validated studies and the clinical experience of mental health professionals.

We currently have environments in which you can work through exposure,

systematic desensitization, diaphragmatic breathing, muscle relaxation,
visualization/imagery and mindfulness techniques. Likewise, you can use these
environments to work on cognitive strategies, such as cognitive therapy and rational
emotive therapy. Below, we offer supporting details.

Finally, remember that each environment has a Specific Manual (fear of flying,
claustrophobia, fear of heights...), and that you can find additional materials in the
Knowledge Base of our platform, which can clarify the use of virtual reality and
augmented reality in your consultation.

5
 2. Advantages and disadvantages
of virtual reality: What your patients
should know before they start

6
2.1 Primary benefits of virtual reality
VR is a non-invasive, safe technology that projects interactive 3D graphics through headsets
and headphones. The placement of the helmet isolates external stimuli, transporting the user
to an environment that is different to the one they are physically in. This “virtual” environment,
designed by and for healthcare professionals, has different configurations to best fit each
patient’s needs.

Across the world, new technologies supported and facilitated certain processes. In the case of
psychotherapy, technology allows us to control the therapeutic process and personalize
psychological interventions to align with each patient’s characteristics and needs. For
instance, our fear of flying environments allow you to land before you take off, as many times
as necessary.

As Gutierrez (2002) suggests, there is a host of advantages, from which health professionals
and their patients can benefit from:

1. A greater degree of privacy in comparison with live exposure.

2. Lower costs because VR does not require location changes or co-therapists.
3. It allows you to carry out treatments in difficult-to-access stimulation configurations (take-offs,
storms...), and to easily solve problems associated with the patient’s imagination difficulties.
4. Greater control towards external stimuli and conditions. The therapist can decide whether it is day
or night, rainy or sunny - offering a way with which therapeutic processes can be adjusted for a
patient's needs.
5. It allows for situations that go beyond what can be found in reality. For example, recreating 10
consecutive take-offs or going up on a lift without stopping at any floor for 5 minutes.
6. It facilitates self-training and over-learning, as the patient does not have to wait for the events to
take place in real life, but can produce and reproduce them whenever they wish.
7. It allows the therapist to control and observe what the patient is seeing, which allows them to
easily detect which stimuli have greater clinical relevance.
8. It is possible to design therapeutic hierarchies in a personalized way, graduating each one of the
steps to follow in a very detailed way.
9. Safety. Therapists and patients can control what is happening at all times.
10. VR asks that the patient adopt an active and participative role (Bruner, Vygotsky, Piaget). In this
way, the patient can promote re-learning and behavior modification.

7
2.2. Disadvantages and Warnings
(We recommend that these be included in informed consent forms)

Does virtual reality have any side effects?

The most common possible side effects associated with the use of Virtual Reality or 3D
videos are slight dizziness, blurred vision, eye strain, headaches, or other visual effects. This is
what you may have already experienced if you have watched a 3D movie in a cinema. If
your patient experiences any of these symptoms, stop the use of the equipment, rest and
schedule shorter VR or AR exercises.

3D motion sickness can impact patients with specific tendencies or conditions. For instance,
some people are more prone to dizziness when they watch 3D movies than others. For the
most part, you can anticipate whether your patient will get dizzy by evaluating whether they
usually suffer from motion sickness or dizziness, especially when they are in cars, boats, or at
the cinema. If your patient fits these characteristics, we recommend:

a. Beginning with shorter VR exercises, 10-15 min, that include rest periods between
each exercise. You can use this to evaluate their sense of presence, cognitions, and
habituation.
b. Avoiding sudden head movements. Most of our environments use interaction targets
to minimize these problems.
c. Accompanying what they see visually with bodily movements. For instance, if their
environment involves movement, such as walking, but they are sitting, they can
move their legs without advancing to minimize feelings of dizziness.

Are there any risks?

Are there any risks?

A low percentage of patients (approximately 0.025%) may experience seizures, nausea, or
disorientation when using VR. It should be noted that seizures caused by flashing lights are
more common in epileptic patients, meaning that this tool is not ideal for them. If they do
choose to use VR, they should be made aware of the risk involved. To minimize these risks,

8
Amelia has controlled the use of scintillating lights in its virtual experiences. Again, if you
experience any of these symptoms, notify your therapist.

What if the headset doesn't fit well?

It is important to adjust all the fastening strips, unfasten the Velcro, tighten the strap around
the head, and refasten it. Try not to tighten the strips too much, because they can get
uncomfortable during long sessions. It is also important to center the headset at the
average height of the patient's eyes.

Can patients wear prescription glasses under the helmet?

If they have a few diopters, it might be more convenient to take their glasses off before they
place the helmet on their head - if the glasses don’t fit the helmet’s cavity, they can cause
discomfort. Our hardware also offers a little wheel on the top of the helmet that can be
rotated until the image is clear to each person.

Can the patient stand or walk while wearing the helmet?

Amelia's environments are designed to be experienced while sitting or, if indicated by the
therapist or if the patient prefers it, standing, without moving and always touching a
physical reference with part of the body (for example, calves or calf muscles). It is important
that they do not move while wearing the helmet to avoid accidents.

9
3. General recommendations
for the therapeutic process

10
3.1. Key moments of the use of the VR in
consultation

Inform Motivate Evaluate & Plan

What is virtual reality (AND Test a virtual environment Do we have to prepare a

WHAT’S NOT) hierarchy?

There are three key moments in VR treatment:

1. Before beginning treatment:

Inform
Explain what virtual reality is and what it is not, emphasizing the idea that
i. Realism is not necessary to effective therapy. You can find more information under “what to
say when my patient says...”
ii. They will not immediately feel like they are in the environment, the moment they put the
headset on
iii. For more than 15 years, virtual reality environments have been scientifically validated as
effective
The Knowledge Base offers more information that can be offered to patients.

Motivate
Let the patient test a virtual environment that impresses or intrigues them. This could be the
“Exterior Glass Elevator” environment or “Underwater in the Ocean.” In doing so, the patient will
become predisposed to VR and may develop an interest in the technology.

Evaluate
Evaluation is an important part of the therapeutic process. For phobias, this evaluation can
support the development of a “therapeutic hierarchy”.

11
2. First session:
For the sake of motivation, it is crucial that the first VR experience be a therapeutically
successful one. For example, you can begin with a relaxation session, using electrodermal
response sensors to record anxiety and relaxation levels. If the patient leaves feeling relaxed,
they will be more motivated to continue using VR.

In addition, if you are using VR for exposure therapy, it might be best to start with environments
that only generate 20 - 40 Subjective Units of Distress (on a scale of 100) and register a
habituation curve using Amelia.pro. Note that you can use Amelia's physiological features to
track your patient’s anxiety descent and view their habituation curve.

12
3. Intervention sessions:
For intervention sessions to be effective, it is crucial that you:

a. Are well aware of how your choice of virtual environment functions. We highly
recommend that you read our manual before the intervention, with specific focus on
the functionality of each button, whether they work at all times or certain times and so
on. It can also help to practice using the environment - allowing you to engage with its
functions at a hands-on level. This may also support your skill development.

b. Are detail oriented. Attention to detail can ensure that sense of presence and
immersion is as realistic as possible. The more sensory channels we stimulate, the
more the patient connects with the environment. Furthermore, information obtained
during evaluation sessions will allow you to establish emotional activation. You can find
more recommendations of this nature under “What to say when a patient says…”

c. Focus on post-session reports. Showing reports at the end of each session allows both
you and the patient to make note of the progress.

d. Note that Amelia's virtual environments have multiple uses for multiple conditions.
There is no need to hold back based on the titles of the virtual environments. We
encourage you to be creative! For example, while the airplane environment is explicitly
connected to fear of flying, it can also be used for patients with claustrophobia. In the
same way, the subway environment that is explicitly connected to claustrophobia can
also be used for post-traumatic stress, social anxiety and many others. Amelia's
Knowledge Base offers a document that outlines multiple uses for different
environments.

e. Check the device’s battery before the patient arrives, confirm that the internet
connection is working well and see that there are no pending updates.

13
3.2. A thorough evaluation is the basis of an
effective intervention
A thorough evaluation supports the conceptualization of an effective intervention. Amelia
offers specific guidelines for specific conditions and their corresponding environments, such
as the Manual on Claustrophobia. In this you can explore strategies, self reports and
bibliographies. These environments can support:

a. Evaluation of patient’s sense of presence

i. It is important to remember that all patients do not have the same imagination capabilities.
Some may have to learn how to be imaginative
ii. When activating an environment, a patient’s degree of interaction must be observed, with
specific focus on exploratory behavior, stillness, silence or speech
iii. At the end of the VR scene, you can ask your patient how involved they felt (1 to 9), what
they focus on and what their thoughts were when experiencing the environment.

b. A baseline electrodermal response:

i. You can use a neutral environment, such as an island, to obtain 5 to 10 minutes of
electrodermal response.
ii. You can use this information to analyze your patient’s response. Remember that
electrodermal responses can vary within a patient and from one patient to another
iii. You can access more information about the electrodermal response sensor in Amelia's
Knowledge Base.

14
 c. A behavioral approximation or avoidance test:
i. The information you obtain can be useful in developing a therapeutic hierarchy,
especially in cases of gradual exposure, systematic desensitization, emotional
staging...).
ii. A test can also help you assess whether you may move forward with Amelia's
default configuration or if you have to adjust it. Generally, the default is a configuration
with a low discomfort level.
iii. You can evaluate subjective discomfort units associated with your patient’s
behavior and obtain an electrodermal response record.
iv. You can assess variables such as:
1. The distance at which your patient stays away from phobic stimulus. For example,
how far from the basement room (claustrophobia environment) are they able to get.
2. The time that they are able to remain in the presence of phobic stimuli. For example,
how long can they withstand heights, in the fear of height environments.
3. The intensity of stimuli that the patient is able to tolerate. For example, the amount of
rain your patient is comfortable with, in the fear of the dark environment.
4. How much of the environment’s activities can the patient complete. For example, how
far is the patient able to leave the house, take a taxi and wait at the departure gate, in
the fear of flying environment?

d. Evaluation of situation- specific cognitive distortions.

When activating the generalized anxiety environment, you may ask the patient to verbalize
their thoughts.

e. Evaluation of social skills

Certain environments carry avatars that can offer insight into how your patient interacts with
others, engages with conversation or initiates requests, such as asking a waiter to lower the air
conditioning. They can also indicate whether your patient is assertive when presented with
negative stimuli, such as in conversation at a bar or how your patient interacts with an
audience, such as in an auditorium.

f. Evaluation of psychological processes

These environments can also support the evaluation of processes such as attention or
memory. In the fear of the dark environment, for instance, you can ask the patient to count

15
and recall the number of photos in the living room. Alternatively, you can use the mindfulness
environment and ask the patient to notice how the leaves fall off the trees.

16
3.3. Dynamics of intervention during the
consultation: What will the sessions be like?
Your patient will be curious and uncertain about the nature of these sessions. While the
therapeutic process rests on the therapist’s choices, we can generally suggest:

● Initially, it will be important to collect information and establish objectives.

● Depending on the type of technique used, the next stage will involve some working
time where the patient will interact with the device.

● A feedback session will follow.

● Between sessions, therapists may assign some “homework” that strengthens and
generalizes VR therapy to real life.

COLLECTION OF → WORKING WITH → FEEDBACK OF → TASK AT HOME

INFORMATION VIRTUAL REALITY WHAT WORKED IN BETWEEN
SETTING OBJECTIVES VR SESSIONS

17
3.4. Establishing a Sense of Presence
The following aspects can support sense of presence:
1. Amelia's virtual environments include stimulation, configuration variables, and events
that are adjusted to therapeutic needs. To achieve these, Amelia conducts
bibliographic research before developing and adapts this research to the latest
technology.

2. Amelia also allows you to choose from a range of environments based on what best
suits your patient’s needs. For instance, if you are using relaxation techniques but your
patient prefers mountains to the beach, you can choose the “diaphragmatic breathing
in the meadow environment” rather than the “Imagery for relaxation” or “Underwater in
the Ocean” environments. Alternatively, if you are using exposure techniques, you can
begin with low anxiety environments (20-40 SUDs) and gradually integrate more
challenging environments. If you are working on fear of flying, some patients may fear
the boarding gate while others may fear landing. This range is especially useful
because it allows you to target different stimuli for different patients.

3. It is also important to establish clear intervention objectives. For instance if the

objective is to increase duration of abdominal breathing, you can focus on breathing
techniques that involve longer inhalations than exhalations. In doing so, the patient can
achieve higher levels of relaxation and stronger abdominal breathing. If you are using
a sequence of environments, it is crucial to communicate the details of this order with
the patient such that their expectations match yours.

18
4. Before beginning to work with virtual reality, you can briefly describe to your patient
what the environment entails, with specific focus to the visual and auditory
experiences. Your information can also direct the patient’s attention. For instance, in the
fear of flying take off environment, you can ask the patient to focus on where they are
going or how long the flight will last. Our Environments' Specific Manual carries more
information.

5. Generally, we recommend that you do not interact with the patient during the
simulation. Talking to you or establishing a dialogue can remind them that they are in
a consultation and interfere with their sense of presence. Rather, you can instruct your
patient to voice their questions after the simulation is over. If you are trying to gauge
relaxation or discomfort levels, you can also use short and pre-established questions
(e.g., I will ask you every 5 minutes “What is your level of discomfort from 0 to 10?,” try to
answer considering what you feel at that moment.)

6. We do recommend that you observe the patient as they undergo VR therapy. Their
behavior can be useful for evaluation processes, specifically when it comes to
therapeutic changes. For instance, if your patient is undergoing exposure therapy,
initial behavioral observations may indicate a lack of activitiation or sense of presence.
If a patient demonstrates activation, they are usually tense, rigid and do not explore. If
this behavior is accompanied by a decrease in self-reported discomfort, they will
reflect habituation.

7. At the end of the simulation, you can ask questions about what they did while in VR,
what they saw, how they remember the environment and where their attention was
focused. These questions can inform the extent of their sense of presence.

8. It can also help to encourage live and imaginative in vivo sessions. In some cases,
especially in anxiety and avoidance behavior cases, the patient has been avoiding
what he fears for a long time, and has no recent memories of what it implies. In vivo
sessions will help them apply their learning to real life.

19
4. Specific recommendations for
specific kinds of therapeutic
processes

20
4.1. Exposure therapy
Essentially, exposure therapy is a psychological intervention technique that uses a gradual
and systematic confrontation of feared stimuli to eliminate conditioned emotional responses,
substitute avoidance responses and emotionally reprocess expectations.

Evaluation → Planning → Objectives → Exposure

dynamics

- BAT - Hierarchy - Objectives of the - Conceptualization

- Self-reports first session and & presentation task
following sessions - Duration
- Exposure
- SUDS rating
- Decision: continue
on the same item or
change to the next
- End session

Gradual Exposure Through Virtual Reality and Augmented Reality

General steps of the procedure:

Evaluation
Remember:
➔ Use the environments to perform a behavioral approximation/avoidance (BAT) test
and build a hierarchy.
➔ Use Virtual Reality and the electrodermal response sensor to establish a baseline.
➔ Observe the patient to notice their motor behavior within the environment they fear,
and record it in the comments of the Amelia platform.
➔ Ask them questions, at the end of the VR simulation, to detect distorted cognitions and
dysfunctional beliefs.
➔ Evaluate the patient’s imagination ability (it may require some training). To do so, you
can use the instructions in section 3.4.
Elaboration of exposure hierarchy
Remember:
➔ The behavioral approach/avoidance tests carried out in consultation using VR, can be
used to establish the exposure hierarchy starting point.

21
 ➔ Virtual reality environments will allow you to create hierarchies of between 10 and 40
items (from 0 to 100 SUDs). Use the configuration variables and environment events to
define the items in the hierarchy.
➔ In the specific “Environment” Manuals you will find self-reports with examples of items
configurable by means of the variables and events of the Amelia platform.

Set session objectives

Remember:
➔ In the initial session look for items of low activation, between 20-40 SUDs to generate a
low-moderate anxiety and, in that way, reach habituation to discomfort more easily.
The patient will be able to experience that change is possible and this will benefit
motivation.
➔ In the following sessions, use the exposure hierarchy to establish the objectives of the
session. The configuration variables of the environments will allow you to adjust the
exposure gradient to your patient’s characteristics and needs.

Gradual exposure therapy

Remember:
➔ It will be better if you schedule sessions of between 30 and 45 minutes of exposure. In
them, you can work on a variable number of items in the exposure hierarchy
depending on the patient’s characteristics and the intervention’s moment (more or
less aversive items).
➔ Make an introduction:
◆ define the intervention objectives (e.g., landing)
◆ make a brief description of the content of the environment in which he/she is
going to work (flying, information about the next arrival, approaching the airport
and characteristic sounds, wheels contacting the track and intense sounds...). In
this way, you will benefit induction of the sense of presence.
➔ Use Virtual Reality so that the patient is exposed to the stimulating configuration that
generates the phobic emotional response. The use of hierarchies obtained in the
evaluation will make the process more gradual and less aversive for the patient.
➔ You can use the Amelia platform to register, by means of SUDs, the discomfort
experienced.

22
➔ It is recommended in general not to ask questions while the patient is being exposed
himself (wearing the headset and being within the VR’s environment), as these could
interfere with the patient’s sense of presence. Wait for the stimulation to end before
you ask questions. You can also request the patient, before the start of the intervention
through VR, to indicate relevant changes in his/her discomfort levels (increases or
decreases), and you can register them. Sometimes patients seek therapeutic
interaction as a disguised avoidance response (talking to the therapist reminds them
that they are not inside the virtual environment but in the consultation and thus, they
avoid discomfort).

➔ It is recommended, as a general guideline, that there is a significant reduction in

self-inflicted discomfort in order to end the exposure exercise or advance from one
item to the next: a decrease to more than half the maximum level of discomfort
registered. For example, if the maximum indicated was 10 (on a scale from 0 to 10), do
not finish the exposure until you reach a 4. If you have time during the session, it is
better to reduce it to 0-2. In case the patient does not tolerate the discomfort level, the
exposure can be stopped: positively reinforce the coping behavior, provide
explanations regarding the emotional response, allow emotional expression, identify
trigger stimuli). Once the anxiety diminishes:
◆ re-evaluate the exposure hierarchy to, if applicable, decrease the stimulation
level (you can do this using the hierarchy obtained during the evaluation, the
configuration variables, the general volume of the platform).
◆ re-expose the patient until you reach a significant reduction of anxiety.

➔ In case the patient gets tired, even if the scheduled time has not been reached, it is
advisable to stop the exposure, pause (reinforce the coping behavior, talk about how

23
 the process is going, show the changes achieved) and, if possible, re-expose the
patient.
➔ End the session always after having significantly reduced the discomfort associated
with one of the phobic conditions. In this way, you will maintain your patient’s
motivation.
➔ Use the possibility of writing comments on the Amelia platform to record the
verbalizations, the thoughts of the patient during the exhibition, etc. Also, make notes
regarding their behavior (for example, whether they remain quiet, with arms tensed,
whether he/she carries out more or less exploratory behaviors).
➔ You can use the electrodermal response sensor to record anxiety changes using the
physiological channel. Remember that you can find more information on how to use
the sensor in the Knowledge Base and the specific Biofeedback Guide.
➔ In case you detect the presence of cognitive beliefs and/or distortions, use pauses
between the exposure exercises (for example, scene repetition, changes on items) to
work on cognitive restructuring.
➔ If feasible, establish live exposure exercises between sessions that include the items
worked in consultation.
➔ In the “Specific Environment Manuals”, you can find examples of intervention.

Interoceptive exposure therapy

Remember::

➔ To work exposure to body sensations generating fear, you can use the button located
below the webplayer.

➔ In general, you can use interoceptive exposure in patients with panic disorder with or
without agoraphobia, some cases of claustrophobia (especially those with marked
fear of suffocation), health anxiety, etc.

➔ In case the patient is afraid of the physical sensations a certain situation can generate,
you can opt for different intervention forms:

a. Launch a certain environment in a configuration you have identified as one

generating anxiety for the patient. If the physical sensations that generate fear
appear, allow habituation to occur. In case they do not appear, you can
activate the INTEROCEPTIVE button to induce the physical sensation of
discomfort and then work on the habituation.

24
 b. You can launch a neutral environment for the subject (if he/she is afraid of
closed spaces, activate the park environment) and then activate the
INTEROCEPTIVE button and expose him/her specifically to sensation that causes
fear. In this case, the objective will be to solve the fear of sensations before an
exposure to a virtual or real environment (being on the subway, for example).

➔ Choosing one or another option will depend on the evaluation process:

Option a will be appropriate for subjects with less fear of physical sensations (more
time with them, for example) and more associated with specific situations (especially
the agoraphobic ones).

Option b will be appropriate for patients with high sensitivity to physical sensations
(recent panic attacks, for example).

➔ We recommend that, in general, you complement the interoceptive exposure with

psychoeducation and cognitive restructuring and/or re- labeling of physical
sensations.

➔ Interoceptive exposure should not be used or should be applied with medical

supervision in people suffering from cardiovascular disorders (hypertension,
arrhythmias), respiratory diseases (asthma, emphysema), metabolic or hormonal
disorders, pregnancy, epilepsy, seizures, or any serious physical disorder. In all these
cases, it is convenient to contact the patient’s doctor, explain the procedure and the
exercises involved, and ask which ones can be carried out. On the other hand, it is
advisable to request a medical examination for patients who have not undergone
check-up in the last 12 months.

25
4.2. Systematic desensitization (and variants)
Systematic desensitization is a psychological intervention technique rooted in
counter-conditioning of emotional responses. It incorporates relaxation techniques,
such as Jacobson’s relaxation, with activity, such as eating, to inhibit conditional
emotional responses. This is most commonly practiced with anxiety patients.
Reciprocal inhibition is used to counter-condition the fearful emotional response with
relaxation.

Gradual Exposure Through Virtual Reality and Augmented Reality

General steps of the procedure:
Evaluation
➔ Use the environments to perform a behavioral approximation/avoidance test and
build the hierarchy.
➔ Use Virtual Reality and the electrodermal response sensor to establish a baseline.
➔ Observe the patient to notice his/her motor behavior within the environment he/she
fears, and record it.
➔ Ask him/her to detect distorted cognitions and dysfunctional beliefs.
➔ Evaluate the patient’s imagination ability (it may require some training sometimes).

Elaboration of Exposure Hierarchy

➔ The behavioral approach/avoidance tests carried out in consultation using VR, can be
used to establish the exposure hierarchy starting point.
➔ Virtual reality environments will allow you to create hierarchies of between 10 and 40
items (from 0 to 100 SUDs). Use the configuration variables and environment events to
define the items in the hierarchy.
➔ In the specific “Environment Manuals” you will find self-reports with examples of items
configurable by means of the variables and events of the Amelia platform.

26
The Relaxation Response
➔ Use Amelia's relaxation environments (Diaphragmatic breathing under the sea or
meadow and/or Progressive muscle relaxation) to train the inhibitory response. Once
the answer is taught, you can start with the counterconditioning.
➔ Remember that, in children, you can use games as a relaxation response and that you
have specific environments, such as fear of the dark, that include the “gamification” for
coping.

Set Session Goals

➔ In the initial session, look for low activation items, between 10-20 SUDs, to benefit the
appearance of low anxiety.
➔ In the following sessions, use the exposure hierarchy to establish the objectives of the
session. The configuration variables of the environments will allow you to adjust the
exposure gradient to your patient’s characteristics and needs.

Systematic Desensitation
➔ Once the environment is started in a certain configuration and when the patient
indicates the appearance of anxiety, you can:
◆ Tell the patient to close their eyes and launch the relaxation with which you
have trained in audio format, from the RELAX buttons located below the
webplayer: progressive muscle relaxation or diaphragmatic breathing. Once
relaxed, the patient will be able to open his/her eyes and face the objective
counter-conditioning item once more.
◆ Stop the environment, go to the relaxation environments and apply the one
used during the training. Once relaxation has been achieved, you can restart
the environment that includes the item you are working with.

➔ Remember that this dynamic will be repeated until the patient does not show anxiety in
that stimulating configuration, at which time you can go to the next item in the
hierarchy; that is, restart the environment, and/or change the configuration variables,
and/or launch some environmental event.
➔ It is advisable to start the sessions with the environment’s last configuration (item)
solved by the patient in the previous session.

27
4.3 Activation control techniques
Activation control techniques provide patients with skills that will help them regulate their
activation levels, generally and physiologically. Historically, Jacobson (1938) offered a muscle
relaxation structure, Wolpe (1936,1982) disseminated this structure, and Borkovec (1973)
protocolized it for clinical and research purposes. It is also important to note Schultz and Luthe
(1969), Upper and Cautela (1979) and Meirchenbaum (1985) for their contributions to the
autogenic training of covert conditioning as well as stress inoculation. Amelia offers four types
of virtual reality environments to support these techniques:

● Diaphragmatic breathing: in the Meadow and Underwater in the Ocean

● Muscle relaxation: Jacobson Relaxation
● Imagery: Imagery for Relaxation and Underwater the Ocean.
● Mindfulness: Attentional Focus, Emotional Regulation, and Body Scanning

General Procedure

Evaluation
These environments can be useful to introduce patients to VR, before moving on to more
specific objectives. They are incredibly pleasant environments that can demonstrate the
intricacies of VR and AR to the patient.

They can also be employed to assess your patient’s sense of presence. Section 3.4 offers more
information on the importance of this. Other general aspects that can be assessed include:

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 ➔ Perceptive ability: at the end of the simulation, you can ask them whether they
noticed the breeze or smell of salt water. This can assess the extent to which a person
imagined perceptive characteristics of the environment.
➔ Attention capacity: You can assess the extent to which a patient is able to focus on
the visual and auditory aspects of the environment. You may ask them about
environment-specific details such as the kind of trees they saw or whether they
recognized any of the marine animals.
➔ Aspects related to memory: You can also establish objectives before the simulation,
such as remembering the amount of palm trees. At the end of the simulation, you can
assess how much they were able to remember.

Some specific aspects that can be assessed include:

➔ Breathing: you can observe the movement of their abdomen to assess whether their
breathing is more thoracic or clavicular. You can also judge whether they can adjust
their breathing to a pre-established rhythm, whether inhalation or exhalation is more
difficult, or whether they need “recovery breaths.” It can be helpful to establish a
baseline habitual respiratory rate and register the inhalation and exhalation frequency
at which a person feels comfortable. Remember that Amelia's web comments tool can
support this kind of evaluation.
➔ Tension areas: you can also assess your patient’s ability to detect their own tension
areas through body scan.
➔ Ability to follow instructions: in relaxation environments, your patient must adjust their
breathing according to external guidance. This offers the opportunity to observe and
make notes in the comment section.

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IMAGERY
Imagery for relaxation and Underwater the ocean environments can support sensory focus
and relaxation objectives, by::
➔ Teaching the patient to carry out covert-conditioning. This can include word repetition
➔ Redirecting attention towards pleasant stimuli
➔ Using imagination as a distraction in low anxiety situations, such as the appearance of
unpleasant thoughts
➔ Generating the patient’s own mental environment that will allow them to apply their
practice to diverse situations
➔ Combining various activation control techniques, such as muscle relaxation or
diaphragmatic breathing. This is especially useful for thought intrusions. Amelia's
technology offers RELAX buttons (below the VR viewer on the platform) to activate
diaphragmatic breathing (Figure 1, button 2) and progressive muscle relaxation.

DIAPHRAGMATIC BREATHING
The Diaphragmatic Breathing in a Meadow and Underwater in the Ocean Diaphragmatic
Breathing environments allow for breathing-related training. The objective will be to regulate
its frequency to low with focus on the abdomen to promote deactivation through
parasympathetic nervous system mediation and regulation of carbon dioxide in blood
(hypercapnia). Remember to introduce the general objectives of diaphragmatic breathing.
Likewise, it's important to establish specific objectives such as breathing from the lower
abdomen area.

It is also important to demonstrate abdominal movement and intensity of breathing to offer a

visual and auditory model of abdominal breathing.

Before starting the environment, you can select a virtual guide. Amelia offers the opportunity
to pick a guide that supports the needs of the patient and does not generate intrusive
thoughts, such as “will the jellyfish come near me or will it sting me?” Neutral guides usually
work best. Once you pick a virtual guide, you can connect to the electrodermal response
sensor. With Amelia.pro, you can monitor changes and provide feedback to your patient. For
example, you can verbally reinforce activation descents seen in the graph.

Once you do start the environment, you can observe the breathing frequency of your patient
when they are at rest. You can make note of the baseline parameters in the Amelia.pro

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comments section. As you adjust the parameters to their usual frequency, you can obtain a
behavioral baseline.

Once the patient demonstrates an inhalation and exhalation rhythm, you can use
environmental events to decrease the frequency of parameters. This can especially support
the learning process.

During relaxation, you can use yes or no questions to evaluate your patient’s progress. You can
also use SUDs to record your patient’s response and include comments.

Remember to encourage real-life application of these techniques. You can ask your patient to
perform consultation activities at home, in the subway, while driving, etc. You can facilitate this
process by using relevant virtual environments and the RELAX platform buttons to activate
diaphragmatic breathing exercises.

MUSCLE RELAXATION
The Progressive Muscle Relaxation environment abbreviates procedure as per muscle groups.
You can teach your patient to identify muscle tension group by group. The combination of
proprioceptive information and reduced muscle tension can reduce general activation.

Remember that psychoeducation is crucial to help the patient understand the therapeutic
process, establish objectives and put an effort in their practice. Before beginning, we
recommend that you visually demonstrate the general procedure of Progressive Muscle
Relaxation. For instance, you could tense and relax your dominant hand.

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Also remember that physiological records can be useful to monitor therapeutic changes and
extent of relaxation. They can also provide feedback to the patient during and after the
session.

Based on self-reported evaluation (through Caution’s (1977) “Inventory of tension) and

therapeutic objectives, you can establish target muscle groups. For example, if your patient
demonstrates tension in their cervical area, you can target head, neck, limbs and trunk related
exercises. You can also assess the need to perform exercises with other muscle groups.

During relaxation, you can use yes or no questions to evaluate progress. Scale-based
questions, such as “indicate your degree of relaxation from 0 to 10” can also be useful. SUDS
are helpful in recording patient responses and adding comments.

Remember to encourage real-life application of these techniques. You can ask your patient to
perform consultation activities at home, in the subway, while driving, etc. You can facilitate this
process by using relevant virtual environments and the RELAX platform buttons to activate
diaphragmatic breathing exercises.

BODY SCAN
The Mindfulness body scanner can support evaluation and guide patients towards
recognizing their muscular tension areas. This technology also trains patients towards
developing attentional focus and discriminative learning. Alternatively, a body scan can be
useful at the end of diaphragmatic breathing or Jacobson’s relaxation.

Establish therapeutic goals with your patient, such as focusing attention or detecting tension
levels. Once the scan is complete, you can ask your patient to recall their attention and detect

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their tension areas. Remember that you can always make annotations in the comment
section before changing the environment or ending the session.

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4.4. Cognitive restructuring
Cognitive restructuring is a cognitive-behavioral strategy used to modify maladaptive
thoughts and beliefs through re-labeling, identification and change of distorted thoughts,
Socratic dialogue and reality tests. Rational Emotive Therapy (Ellis, 1958) and Cognitive
Therapy (Beck 1967) are the two main models with high empirical evidence. Amelia's
environments offer evaluation and intervention tools aligned with the intervention model.

General steps of the procedure:

Evaluation
All virtual reality environments can apply cognitive restructuring techniques for evaluation and
intervention.
If your initial evaluation demonstrates presence of automatic, distorted thoughts and
dysfunctional beliefs, it is likely your patient needs cognitive intervention. You can:

➔ Use an emotionally activating environment and instruct your patient to verbalize what
they are thinking while experiencing different environments such as taking off, driving,
going down a subway corridor, listening to television news, etc.
➔ Tell them to refrain from interacting with you in order to avoid interferences and
damage their sense of presence. You can use the platform’s comments section to
make notes.
➔ Register situation-specific distorted thoughts and then begin the process of cognitive
restructuring.

Intervention
You can support cognitive restructuring in a complementary or specific way. In both cases, we
recommend that you introduce your patient to the basic steps of restructuring before

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beginning the process. We further recommend that this introduction explain the identification
of distorted ideas, labeling or catastrophizing and the idea of excessive generalization

a. Complementary:
If you have a broader intervention strategy in mind, such as exposure or DS, you can apply
cognitive restructuring in a way that complements the main objective. You can begin the
restructuring process after the patient is habituated or counter-conditioned but while the VR
environment is still active.
You can encourage the patient to identify their distorted thoughts by verbalizing them. In case
they cannot do so, remind them of their evaluation. Expressing these ideas out leads for the
patient to activate and manage them.

If you have already taught your patient how to identify these thoughts, encourage them to
label the thought and generate more functional alternatives. As always, we recommend your
intervention to take place later on if you want the sense of presence to prevail. Take notes,
using the Amelia.pro comments section, to provide feedback once the VR exercise is finished.

b. Main strategy:
For the disorders that require cognitive restructuring to be a central strategy (i.e. generalized
anxiety, adaptive disorders, mood disorders, etc.) you can:

- Direct your patient towards identifying distorted thoughts by thinking out loud, for
example. Choose virtual reality environments in which you have detected, during the

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 evaluation, that it is easier for distortions to appear. For example, if someone is
experiencing health-related anxiety, they can benefit from the “concern for diseases”
generalized anxiety environment.
- In this case a sense of presence will not be as relevant as it is at the exposition.
Accordingly, you can interact with the patient and guide them in identifying distorted
thoughts, categorizing distorted thoughts and offering alternative thoughts through
modeling.
- If the distortions do not appear spontaneously, remind the patient of the ones you
obtained during the evaluation. Express them out loud and work with them while the VR
is active.
- By working with VR, recordings and activities between sessions can allow patients to
automate and apply cognitive restructuring.

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4.5. Mindfulness
Mindfulness refers to the consciousness that emerges from purposeful attention and living in
the moment. (Kabatt-Zinn, 2003, cited in Boettcher et al., 2014 ). The concept of mindfulness is
essentially transdiagnostic (Boettcher et al., 2014). Accordingly, mindfulness is relevant to a
broad theoretical framework of psychological therapy, within which mental disorders are
considered to share behavioral processes and specific cognitive factors which contribute to
the development and maintenance of said disorders (Barlow et al., 2004 and Mansell et al.,
2009; cited in Boettcher et al., 2014).

These processes refer to selective internal and external attention, attentional avoidance,
interpretation biases, distorted and/or recurrent thoughts, and avoidance and safety
behaviors (Harvey, Watkins, Mansell, & Shafran, 2004; cited in Boettcher et al., 2014). Though
mindfulness is not intended to treat specific aspects of a specific disorder, it can be used to
work on certain aspects common to different disorders.

Amelia's environments include tools that allow for transversal evaluation and intervention.
Different environments include:

Attentional focus:
Walk through a meadow while practicing mindfulness exercises aimed at different perceptual
modalities. Duration: 15 minutes. Level: beginner.

Emotional Regulation:
A walk while practicing full attention, thought management, and gratification exercises in two
environments corresponding to spring and summer. Duration: 22 minutes. Level: beginner.

Body Scanning:
Tour through different parts of the body, paying full attention to your body sensations. It can
be used as a precursor for Jacobson's relaxation exercise because the patient must focus on
the body parts where they feel tension, and work towards relaxing those parts. Duration: 5
minutes Level: beginner-intermediate.

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 Attentional Focus
General steps of the procedure:

Evaluation
➔ The Attentional Focus environment can
be very useful in evaluating your patient’s
perceptual abilities. Are they able to focus their
attention on each of the different sensory
modalities? Is there one in which they are more
skilled than others? Is it easy for them to focus
their attention on one modality? Do they know
how to change their attention focus from one
perceptual modality to another? Can they focus
on their breathing, on their own perception?

➔ It is important to establish specific objectives and evaluate the patient’s performance

during VR. For example, you can use the lemon tree exercise to assess their ability to
focus on taste and smell. You can also evaluate the level of salivation response (using
the SUDs scale) by observing your patient’s non-verbal behavior (how they move their
mouth during exercise, swallows, etc.)

Intervention
➔ You may use chaining as a way to gradually learn mindfulness. Evaluation results can
help determine the order in which you can involve perceptual modalities through VR
exercises. Once these modalities are individually learned, your patient can attempt to
carry the activity out completely.
➔ You can complement mindfulness environments with activation control, in the form of
both diaphragmatic breathing and muscle relaxation. Remember that you can use the
Play event to stop the mindfulness exercise and the RELAX buttons (below web player)
to activate activation control audios.
➔ Once this attention training is completed, you can encourage applications to real life.
For instance, the acrophobia environment offers the chance to generalize this skill to a
new situation. You must also encourage activities that are similar to those carried out
during VR in order to further support application.

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 Emotional Regulation
General steps of the procedure:

Evaluation
The Emotional Regulation environment consists
of different activities that allow for the
evaluation of mindfulness (Spring: nature
meditation), management of thoughts (Spring:
Cascade of thoughts), conscious attention
(Summer: Conscious observation and
proprioception) and capacity to use pleasant
emotions (Summer: gratitude exercise).

Each of these environments can be used to

evaluate different aspects of the VR environment. We recommend that you:

➔ Establish evaluation objectives such as thought management

➔ Detect unpleasant thoughts and write them down in the patient’s file using the
Amelia.pro comments section.
➔ Evaluate the user’s ability in relation to their therapeutic objective (remember that you
can use the SUDs scale as a guide: 1 - few skills and 10 - many skills) Is their attention
focused on these thoughts? Do these generate a high intensity of emotion? Does such
a fact generate a cascade of unpleasant thoughts that the patient cannot manage?

Intervention
➔ Define intervention objectives. You can use conscious attention to manage unpleasant
emotions during, for example, a job interview.
➔ Make sure that VR activities allow you to work on the therapeutic objective. For
example, you can use conscious attention exercises from the Summer environment to
practice voluntary and directed observation. This observation can focus on VR details
of oneself and of the process.
➔ Let the patient complete the activity, and once completed, jointly evaluate their
attention level, what they saw and other details.
➔ Remember to use observation to assess the behavior of your patient during VR
(whether they are immobile, show exploratory behavior, focus on a specific object, use
diaphragmatic breathing correctly, etc.)
➔ Once they have practiced this, you can encourage them to use these skills during job
interviews in the Office VR Environment.

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 ➔ As always, we recommend that you establish exercises in between sessions with the
goal of applying their learning to real life. Particularly, you can use imagination to
promote covert practice. Ask the patient to imagine themselves in a job interview and
to practice attentional focus in that imagination.

Body Scanning
General steps of the procedure:

Evaluation
The body scan environment consists of a single
activity that will allow you to evaluate the
patient’s ability to focus on parts of their body
and associated physical sensations. Are they
capable of focusing on every part of their body
for a while? Can they notice which areas are in
tension and relax them later? Do they have the
ability to recognize physical sensations? You
should evaluate whether the patient is able to
develop attention, in this case, towards their
body and associated sensations. As in the previous environments, we recommend
establishing specific objectives.

Intervention
After the evaluation, establish objectives such as refraining from tightening the back muscles
before a lecture or conference.

You can use this environment as practice before working on the final exercise of Progressive
muscle relaxation. Once the patient has learned to focus on different parts of their body, this
environment will allow him/her to perform the activity independently and therefore, acquire
greater control.

If you are using the environment for mindfulness training, you can facilitate its real life
application by practicing in a virtual reality environment, such as public speaking, driving, etc.

Once again, encourage patients to practice activities similar to those carried out during VR in
their natural environment as they learn how to apply these techniquest to real life situations.

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Other non mindfulness Amelia environments that allow you to work
transversally

Through Amelia environments, you can evaluate aspects associated with:

a. Perceptive abilities: To what extent does the patient feel present and immersed in the
activities? Have they noticed visual details and can they recall these details? Have they
heard the environment’s different sounds? Have they felt the breeze, the smell or
perceived the taste of something related to the environment? Ask your patient
questions regarding these aspects after completing the VR activity. It may be
interesting to set goals before it. For example, ask your patient to pay attention to what
they perceive (what they see, hear, smell, etc.) while walking on the subway platform.

b. Attention avoidance: observe and record your patient’s behavior while in an

environment. For example, what are they looking at when they are in the elevator? do
they show an exploratory behavior and if their gaze is fixed to a specific place? Are they
avoiding looking at some area of the environment? You can use the Amelia.pro
comments section to make the annotations and notice changes between sessions.

c. Presence of distorted thoughts: As already indicated in previous sections, especially in

the one dedicated to cognitive restructuring (section 4.4), you can use the
environments to evaluate the presence of dysfunctional thoughts and beliefs. Use the
indicated guidelines to obtain a better result.

d. Avoidance behaviors: propose different activities to your patient to evaluate their level
of avoidance. How, in a behavioral avoidance test, can you activate an environment
and graduate its presentation? For example, you can activate the environment of fear
of storms with rain, and ask the patient about their level of discomfort. If it is low, ask
them whether they are ready for a low intensity thunder and lightning storm.

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 i. In case they indicate a high intensity, write down their answer to elaborate the
exposure hierarchy.
ii. In case they indicate an intensity below 30 SUDs, restart the environment with
the storm variables in mind and ask once more.
As we mentioned in section “a”, you can also observe what the patient's attention is directed
towards. For example, do they constantly look out the window while on the plane? At the end
of the VR, ask them whether they noticed it and to explain the reasons for their behavior.

e. Safety behaviors: as mentioned in previous sections, observation will be your greatest

ally. Is the user capable of carrying out an activity, but does so in a very rigid way or
only in certain conditions? For example, sitting at the front of the plane. Do they carry
them out with some object or thought that generates safety in a dysfunctional way?
For example, carrying a bottle of water in your bag, the cell phone battery at full
charge, always accompanied by someone, etc.

Remember that Virtual Reality is a tool to use together with an evaluation

psychological intervention technique or protocol. Well used, it will allow you to
adapt the modality of presentation and/or use of the intervention strategy,
facilitating the therapeutic process.

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5. What to say when
your patient says…

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In this section you will find information on how to manage the patient’s doubts regarding their
interaction with virtual reality, the psychological intervention processes, and the intervention
dynamics.

I do not feel immersed in the VR situation

With the exception of accident related scenes, it is very important you imagine that you are
in the situation represented through VR. We encourage you not to look at it as if you were
watching a movie. Instead, strive to imagine that you are actually living it. Make sure that
there are no distractions in the room. Think about your actions. And if you can’t stop thinking
about other things, stop the activity and resume at a more appropriate time.

I still cannot imagine myself in the situation

Some of the following guidelines can help you live the situation more realistically:
Always imagine that you are there. Think about how you are dressed, where you are going
(for example “To the city, coming back from a meeting”), who is sitting next to you, or what
you can smell. Think about what tactile sensations you notice. Close your eyes momentarily,
paying attention to the sounds coming through the headphones. In short, look for the best
way to make the scene you are watching a realistic and vivid one.

This is not the same as reality...

It is certainly not. But it is the closest thing we have. If this was a real situation, do you think
you could do it? Remember, our goal is to gradually break the associations between the
discomfort we feel and concrete aspects of the situation we fear. When it is time to
experience this situation in real life, the discomfort will be much less because these
associations will no longer exist or will have been greatly weakened. Focus on what you are
doing at present, and do not anticipate what may come later.

It is also important to note that psychological research in new technologies (Information

and Communication Technologies, ICT) points out that an excess of realism can be, in initial
intervention situations, harmful to the process of therapeutic change. Quoting Dr. Gutierrez
Maldonado, of the Universitat de Barcelona, expert in virtual reality-based psychological
interventions:

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“We can initially think, as Thorndike proposed in 1931, that the more similar to reality the
learning environment is, the greater the probability that what is acquired in the virtual
environment will be transferred to the real situation. However, this assumption may require
qualifications. It is possible that a very realistic virtual environment is even detrimental to
learning and that, on the other hand, more schematic reproductions, such as those now
available because of technical limitations, are capable of focusing the subject’s attention
more on the relevant aspects of the task, promoting better learning.”

The Amelia platform allows the therapist to reduce or extend the administered stimulation
(configuration variables and events), depending on the stage of the therapeutic process
and the patient’s characteristics and needs.

Only certain stimuli cause me a lot of discomfort

If you experience significant discomfort when you watch certain images or hear certain
sounds, this means the intervention is working. The natural reaction would be to think about
something different, get distracted, take off your headset, get up or leave. DO NOT DO IT! The
only way to make the stimuli neutral is to let the discomfort reduce in their presence, and
this will happen after repeatedly working on different scenes. What you can do, exceptionally
just because a particular scene is much more difficult for you, is to graduate the exposition.

Only part of the scene causes me discomfort

Each scene is formed by many different stimuli, and it is usually easier to get used to some
more than others. When you identify a specific moment in the scene that causes you the
most discomfort, watch it again, focusing especially on that moment, as many times as you
need to lower the anxiety. Your therapist will tell you when you can move to the next
environment. If a particular stimulus causes you discomfort, pay special attention to it and
introduce details, that is, facilitate the sense of presence. If you find it difficult to get used to
a particular sound, try to isolate it by exposing yourself to it in a more direct way. For
example, close your eyes to concentrate better. You will see that the sound will gradually
stop generating discomfort and that you will have become accustomed to it.

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I cannot lower a certain level of discomfort

Do not anticipate anything that is not present in the scene you are watching. Focus on the
present goal (for example, remaining in the terminal before boarding). The higher the
anxiety score, the easier it is to notice a change when it is reduced. That is why it may be
harder for you to notice you are calmer. In any case, do not worry if it is difficult for you to
lower the score. The intervention is individual and you must carry it out at your own pace,
without speeding the process up. Even if you have to repeat a scene many times, there will
come a time when you will hardly experience any anxiety.

It's hard for me to rate my level of discomfort

The best way to assess discomfort level is through your body’s response. As you see the
images and hear the sounds, you will notice that the tension, heart beats, sweat on the
hands, dryness in your mouth, change. Evaluate and rate the level of discomfort according
to those changes. Train yourself to use scales from 1 to 9 with simple exercises such as
rating how cold you feel when you go out. If you give it a 7, this means it is quite cold and it
would be best to go back in and grab a coat. These questions can also help you: If this is the
first time you are watching the scene, at what time did you notice the most discomfort?
What score would you give that discomfort? If you have already watched the scene, is the
discomfort you feel this time less or greater than before? If the level of discomfort is low, is
this discomfort tolerable? Can it be managed? So you consider yourself capable of doing
what you fear with that level of discomfort?

When I saw the scene again, my discomfort increased

What has probably happened is that you are more focused now, consciously or
unconsciously. THIS IS GOOD. This means you are attentively involved in the situation. If your
anxiety rose when you watched a scene that still created discomfort for you, you should
know that this is normal and it is precisely for this reason that we recommend you not to
abandon the exposure to a scene before it has ceased to cause discomfort. What you
should do is to watch the scene again and identify what causes you the most discomfort.
Do it as many times as necessary. You will see that the discomfort will be reduced little by
little.

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I’m tired...

If you are very tired and are not capable of becoming involved in the situation, it is best to
take a break. First, pause for five or ten minutes. If you still cannot get involved, finish the
session for the time being. However, do not delay the following session. Carry it out exactly
when you had originally planned. Remember, it is important that before starting any session
you have ensured that you have the ideal conditions to do it (planning time, eliminating
distractions, etc.)

I will never complete this scene

DO NOT BE DISCOURAGED! It is normal for the last few stages of your VR therapy to be more
difficult than the initial ones. As you overcome each scene, it may be more difficult to move
forward. Watch the scene again as many times as necessary. Anxiety, in the end, will be
reduced.

Can I take tranquilizers?

In general, we know that taking anxiolytics does not improve exposure treatment. On the
contrary, they can interfere with the process of re-learning. If you are already taking them,
inform your therapist and check with your doctor.
Exposure is a strategy that allows you to get used to the unpleasant sensations that cause
fear, reducing or eliminating it completely. Exposure gives autonomy and has no side
effects.
The effects of some drugs can be enhanced by the use of activation control techniques.
Check with your doctor. (note: the use of pharmacotherapy is recommended only under
medical supervision)

Some of the stimuli that cause me discomfort are missing

The objective of the images and sounds in the scenes is not only to expose yourself to them.
They aim to help you imagine and think of other stimuli, probably similar ones, to which you
are particularly more afraid of. Imagine those stimuli from what you see and hear in the
virtual environment, and try to make the situation as realistic and vivid for you as possible. It

47
is not possible to include all the stimuli that cause anxiety to all people; however, the scenes
can help you imagine them.

Can I close my eyes when I watch a scene?

Sometimes, closing your eyes can help you to better imagine a situation. However, you
should never close your eyes to avoid watching a certain part of the scene, no matter how
unpleasant it may seem. Remember, the way to get used to these challenging situations is
to watch them repeatedly.

Can I take breaks during exposure sessions?

We recommend that a session last between 30 and 45 minutes WITHOUT pauses of any
kind. Try to end the session only after having completely finished a scene, and do not leave it
if your anxiety has not disappeared or significantly decreased. For example, if the maximum
anxiety you’ve felt is at 8, do not stop until you get a 2 or a 3. If you have finished an item in
the hierarchy and believe you will not have time to complete the next, it is best not to start it;
leave it for another day.

What happens if I cannot complete any sessions during the week?

The effectiveness of the intervention depends on perseverance, and we recommend

completing two or three sessions each week. If you have not been able to complete any
sessions during the week, do not worry, but plan sessions for the following week carefully. If
you know you will not be able to complete some future sessions, you have two alternatives:
you can intensify the intervention now and complete more sessions (for example, one each
day), or wait until you have time availability for three or four weeks (application conditions).

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6. Clinical Cases

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6.1 Clinical Case: Treating fear of flying in two days

Date: 2017
Patient profile:
- Self employed.
- Mother of one child.
- Had a history of flying in all sizes of planes up until 8 years prior to seeing for therapy.
- She reported that her issues with flying started after she had a panic attack on a plane
that she could not explain.
- The patient sought other treatments for her problem but she found no relief.
- The patient drove from Colorado to New York for her VRT.

The patient called for help with her fear of flying. She has not been able to fly for about eight
years. She decided to solve her anxiety disorder because she had six flights scheduled for her
business in a short period of time.

First, the therapist provided the groundwork for the virtual reality therapy process. The patient
reported that she started to experience panic disorders at the age of 13. She indicated that
she has been in the emergency room at least three times a year due to panic attacks. Family
history was significant as her mother and her son also were reported to have panic attacks.

Physically the patient had problems with her hip and there other joints which were surgically
corrected. She reported that she has airborne allergies, high blood pressure, a small adrenal

50
gland tumor, and high levels of norepinephrine. The patient described herself as a social
drinker but a heavy caffeine user.

The therapist educated the patient on the source of anxiety and panic attacks. After the
educational portion of the session, I used VR for flying. Her hands become sweaty, her body
tense and stressed.

The second day she did much better in the virtual environment. She chose the aisle seat and
she realized that she does better there as opposed to a window seat. Also she recognized that
the engine sounds were triggers for her anxiety.

Since she was returning to Colorado the therapist suggested some VR homework so she could
increase the number of exposures before her flights.

In 2018 the patient was so thrilled that she could fly that she took a month off from work and
she had over 50 flights scheduled in her planned trips over Europe and Central America.

In 2019 she wrote to the therapist: ”I leave for Rome and Malta soon. Thanks to you I'm seeing
the world and living my best life.”

★ Learn more about this clinical case here.

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6.2 Clinical Case: Generalized anxiety disorder

Patient profile:
- 22 year old male
- Psychiatric referral
- An anxious family environment with multiple deep fears
- Very high levels of arousal
- Generalized fear especially with regard to his thoughts
- OCD beginning stages
- Depressive state intermittent
- Feelings of helplessness and locus of external control
- Pessimistic language, very decisively negative

The patient decided to incorporate Amelia into the therapy for relaxation techniques, and also
began to make records and perform the tasks. In subsequent sessions, Amelia was used to
perform acrophobic exposures. At first, it created such high levels of anxiety that the
exposures lasted no more than 5 minutes and he had to remove the VR headset right away.
Once progress was made with acrophobia, he got habituated to the environment and to
controlling his thoughts.

After progressive exposures, he had a significant improvement in practice. Mindfulness

environments were incorporated into therapy, and the patient seemed to be improving, both
within therapy and outside of it.

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Environments used:
RELAXATION: Initially, he rejected the idea of ​using VR because he thought it would not help
him, so the psychologist did not insist. After several attempts of being unable to train himself
to relax (neither progressively nor diaphragmatically) he then tested with VR. The immersion
helped him to follow the guidelines. Environment preference: Underwater in the ocean.

FEAR OF HEIGHTS: At first, seeing the image of the balcony scene gave him a lot of anxiety. In
that first session, he was dedicated to talking about how he felt and what thoughts and fears
came up. An exposure hierarchy was developed. At first, he was very nervous, but he remained
in the environment and learned to manage the situation progressively.

DRIVING IN THE CITY: After the success of heights he brought up his problem with cars. It
proceeded in the same way: working on what ideas he should focus on. Used the online chat
with the patient to remember what thoughts he should maintain. Previous sessions were
reviewed before the VR exposure. When he was in an environment, he was asked questions
that had to do with his thoughts.

WALK THROUGH THE PUBLIC SQUARE: Same procedure. Combination of VR with in vivo (a knife
in the hand that the psychologist brought to the practice).

MINDFULNESS: There was a mixture of past, present, and future. Due to the overprotective
behaviors of his mother (i.e., he never went on an excursion) he had memories of his childhood
that were established. It created agony in the present and he commented that he did not
want to be like that with his children in the future.

As a result, the patient became accustomed to the sensations of different environments. The
use of mindfulness was very positive, and the wide range of environments to treat different
fears was very supportive.

★ Learn more about this clinical case here.

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about Virtual Reality visit our web:

www.ameliavirtualcare.com

54
Related / Recommended bibliography

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InternetBased Mindfulness Treatment for Anxiety Disorders: A Randomized Controlled

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emocionales: una revisión. Anuario de psicología clínica y de la Salud, 8, 7-21

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Company, Champaign, Illinois.

- Daset, Lilian R. y Cracco, Cecilia (2013). Psicología Basada en la Evidencia: algunas

cuestiones básicas y una aproximación a través de una revisión bibliográfica

sistemática. Cienc. Psicol., 7(2), 209-220. ISSN 1688-4221.

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médica de psiquiatría, 4(2), 92-126

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práctica clínica basada en la evidencia. Papeles del Psicólogo. VL - 25IS - 87AB .SN -

0214-7823UR - www.redalyc.com/articulo. oa?id=77808701ER -

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- Tortella-Feliu, M. et al.(2016): Retos en el desarrollo de intervenciones psicológicas y la

práctica asistencial en salud mental. Clínica y Salud, 27(2),65-71, ISSN 1130-5274,

http://dx.doi.org/10.1016/j.clysa.2016.03.002.

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