lAnxiety disorders are probably the most frequent reasons for consultation for clinical psychologists – we are referring to the group of diagnoses that includes phobias, generalized anxiety, obsessive-compulsive disorder, post-traumatic stress disorder, panic disorder, social anxiety, among others. There is no therapist who does not have to deal with some of them on a daily basis.
There are numerous treatments to work with these diagnoses, but the most commonly used approach (and generally the one with the most research support) is some form of cognitive behavioral therapy (CBT). CBT is not a treatment but rather a family of treatments, which have a similar theoretical framework, and which use different procedures or treatment components, which vary depending on the type of problem being treated. In the particular case of anxiety disorders, practically all CBT approaches use some form of .
The essence of exposure is a simple idea: it is about the therapist guiding and helping the patient to interact with what they fear, safely and gradually. If the fear is of spiders, let’s say, after a few preparation sessions, the exposure can begin by placing a box with a spider on the other side of the room, and allowing the distance to be progressively reduced until the patient can touch the spider. spider and hold it in your hand. It is the same procedure that we instinctively use when we teach a child who is afraid of water to swim: first we encourage him to be in the water in the shallowest part, with support, until he becomes familiar and feels safe with the situation, and then we progressively encourage it to move towards the deepest part and we withdraw the help.
In therapy, the best known example is its use in the treatment of simple phobias (fear of animals, for example), in which 3 to 6 hours of treatment with exposure are usually sufficient, but also in other anxiety disorders. exposure, with some procedural modifications, is a central component: Exposure with Response Prevention is used for obsessional disorders; Prolonged Exposure for post-traumatic stress; , etc. The evidence supporting exposure as a treatment axis is tremendously solid, with half a century of research behind it. However, the application of exposure in some cases can be difficult.
Take for example exposure in simple phobias. If these are phobias of animals that are considerably easy to access (such as dogs, pigeons, or spiders), it is relatively simple to put the patient in contact with what they fear. But what happens when the phobia is, for example, of storms? In these cases, unless the therapist has superpowers, there is no possibility of organized contact with the stimulus that causes the phobia. Something similar happens when there are certain aspects of the feared situation that cannot be controlled. Creating a public speaking exposure situation for social anxiety, for example, is something accessible, but what happens if the audience is too hostile, or if on the contrary it is too accommodating and friendly, and does not present any difficulties to overcome?
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Of course, there are many solutions for these types of situations. Psychologists who work with exposure routinely use photos and videos to initiate contact with the avoided stimulus; stories and similes can be used. One of the most used resources is imaginary exposure, which consists of approaching the situation in question by mentally going through it with the guidance of the therapist. Often, imaginary exposure is the only way to contact the feared stimulus. Or at least, it was the only way to contact the feared stimulus.
In the last decade and a half, a new tool for working with exposure began to appear in scientific literature, and it has quickly become one of the most fluid and interesting collaborations between technology and psychotherapy.
FROM IMAGINATION TO IMMERSION
lThe imaginary exhibition, although it is an excellent resource, has several limitations. On the one hand, it requires the patient’s ability to generate and connect emotionally with a mental image or story, which is not always easy. On the other hand, the therapist has no control over the imagined situation, which may be too difficult for the patient, or lack crucial details.
Overcoming these difficulties, in recent years the application of Virtual Reality (VR) began to be tested as a technical resource for exhibition. It basically consists of a helmet or glasses, with screens that emit an image in front of the user’s eyes, while the device records the movement of the head and allows one to see in all directions. Since the images cover the entire visual field, and the device allows you to see in all directions by simply moving your head, a feeling of immersion is generated in the user; the feeling of being in the situation in question.
To have an approximate experience, you can watch this 360-degree video that NASA put together with images collected by the Curiosity probe on the surface of Mars. If you watch it on a cell phone you can move the cell phone to see around it, if you are on a computer you can use the mouse over the video:
This particular video does not have movement, but if you search YouTube you will see several that do. If they were using a VR device, they would see that image covering their entire field of vision, and it would be enough to move their head to look around.
Although VR technology has been around since the 1970s, it has only started to become truly available to the average user in the 2000s, and in recent years a plethora of devices have hit the market, from more sophisticated models like the which costs $600, to simple devices like the , which is used with a smartphone and costs about $15.
Although its main use is recreational, as technology has become more accessible, its developments for psychotherapy have been refined. Initially, simulated environments were developed for some phobias and post-traumatic stress, but the range of applications has gradually increased.
The advantages it offers for exhibition are multiple. On the one hand, it is not necessary to rely on imagination, since detailed and specific environments can be generated for each type of anxiety. On the other hand, and unlike using imagination, with VR the therapist can control the difficulty of the exposure by varying the environment and details.
VIRTUAL REALITY IN THE CLINIC
hSome time ago we got in touch with , a company that offers a virtual reality platform for psychotherapy, to review the service and its scope. Psious, founded in 2013, is a company based in Barcelona and the United States that offers a virtual reality system for psychotherapy, a complete platform so that a therapist can use VR in the psychological office.
“The idea for Psious arose from a curious story,” says Víctor Casellas, communications director at Psious. “In 2013, the two founders, Xavier Palomer and Dani Roig, who had gone to college together in the past, met again. Roig suffered from fear of flying and went to therapy to try to remedy it. The process was long and did not help him much. It was then that the idea arose to treat the fear of flying through something more effective: Virtual Reality. “It all started here, with the aim of providing everyone with an economical, effective and quick way to overcome a phobia.” That moment marked the starting point for the design of the platform, which would only begin to operate commercially in 2015.
Psious invited us to do a review of their platform, and since I routinely work various forms of exposure therapy with my patients in the office, it was my turn to do the review, which means that some of my patients and I have had some fun. I’ve had a great time with the system over the last few weeks.
To operate, the system consists of three elements: a web platform that is controlled from a computer browser, a biofeedback meter, and a Virtual Reality kit. The VR device that Psious uses is the , one of the most popular VR devices on the market, which was developed by the Oculus company for Samsung. The Gear VR is actually an accessory for Samsung’s high-end cell phones, so you need one of those phones for it to work – the cell phone operates as the “brain” of the Gear VR, so to speak.
TESTING THE PSIOUS SYSTEM
QTo install the system I went through the entire process that its users carry out. Well, not all users: if you buy the device from Psious (in Europe and the US), the applications come already installed on the cell phone, so it is not necessary to install anything. If the equipment is purchased elsewhere, however, it is necessary to install the Psious software.
In itself, installing the system is a process similar to installing a couple of applications on your cell phone. It is necessary to download a plugin for mobile virtual reality, download the application itself and install it, and finally create a username and password. This process took us about an hour and we carried it out guided by a Psious assistant via Skype.
Once that is done, it is necessary to download the virtual environments with which you are going to work within the Psious application. There are twelve different environments, ranging from fear of flying to claustrophobia, including public speaking situations, fear of injections and more.
Once the scenarios have been downloaded, you can start using the system. To do this, it is necessary to launch the application on the cell phone, place the glasses on the patient (along with the biofeedback device), and open the web platform in the computer browser. Both the cell phone and the computer must be connected to the Wi-Fi network.
This is necessary because from the computer the therapist can launch and manipulate the different scenarios that the patient will experience with the VR kit.
Upon entering the system the therapist sees this screen:
This screen is where the environment to use is selected, and in turn each environment can encompass several different scenes. In the case of the fear of flying environment, for example, there is a scene in which he is at home waiting for transportation to the airport, another traveling to the airport, another in the departure lounge, and another on the plane with the flight itself. . In turn, each scene has different parameters that the therapist can control.
Suppose we wanted to work on a patient’s fear of flying, and we started directly with the airplane scene. In that case, what the therapist would see would be this:
The image that can be seen above and to the left is a…