oVRcome VRET for psychologists
Clinical Guide
This guide is designed to help you prepare for your first oVRcome VRET session with your clients. You can also use it to give them helpful information and answer common questions. Where information is meant to be shared with your clients, we’ve worded it as if you were speaking to them directly so you can answer them quickly.
Should you have any questions that have not been addressed in this guide, please feel free to reach out to us at support@ovrcome.io.
oVRcome Virtual Reality Exposure Therapy
Benefits of oVRcome VRET for Psychologists
As a psychologist who prescribes exposure therapy, you’ll know that in vivo exposure doesn’t come without inconveniences. oVRcome VRET has been designed to break down the barriers of space, time, location, and technology, while allowing you to scale your business.
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Here’s how:
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Exposure Therapy Anywhere
Your clients can still undergo exposure therapy regardless of lockdowns or social distancing restrictions. You get to connect to their live home sessions without ever leaving your office.
Give Your Clients the Convenience of VR
Your clients get to do VRET at their own pace. It works with their schedule. They’ll never have to go searching for hard-to-find situations. Happier clients are always wonderful for business.
Help Your Clients do More
Your clients can do more exposure sessions in different environments than they could ever do through in vivo exposure. They can repeat simulations until they’re more comfortable with them. Because you can see what they’re doing, know how much exposure they’ve done, and have access to all the environments they’re immersed in, your presence becomes a source of motivation and a driving force for them to keep going.
It’s Easy to Use
oVRcome VRET is an all-inclusive solution made for everyday people. If you know how to use a computer, you’ll be right at home with our psychologist dashboard. If your client can operate a smartphone, they’re good to go. With our customer service team on standby, you can rest assured that any issues are quickly solved.
Grow Your Business
The oVRcome dashboard lets you keep your exposure therapy sessions going remotely, even during lockdowns. Our technology lets you monitor multiple clients at the same time. You’ll be able to manage more clients with a smart solution, in less time than ever before.
Industry standard privacy and data protection
Feel secure in the fact that we’ll never sell your data. We comply with best industry practices regarding all matters concerning your privacy and that of your clients’.
It’s Proven
oVRcome VRET is currently being clinically trialed, with some very promising results due December 2021.
Benefits and Risks of VRET for clients
If your clients would like to know why you have recommended oVRcome VRET for them, here are 6 reasons to share.
To keep them as safe as possible, we would also like you and your clients to be aware of 4 potential risks while in VR.
We have worded these benefits and risks as if you were speaking to your clients directly to make it easy for you to share this information with them.
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Benefits of VRET
VRET is the preferred type of exposure therapy for the majority of people looking to desensitize themselves to fears and phobias *
Here’s why:
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It’s Effective.
Research shows that VRET is not significantly different to in vivo exposure therapy when it comes to efficacy** It’s also actually more effective at maintaining results over a 6-month period than in vivo exposure therapy***
It’s Convenient.
You won’t need to spend time traveling or searching for exposure scenarios. You can also do as little or as much exposure as you like - anywhere, any time.
It’s Accessible.
We have simulations from all over the world that you can access from the comfort of your own home. You won’t need to visit a doctor’s office for a blood test just to get that exposure. It’s all on your smartphone.
It’s Private.
VRET happens in a headset, not out in public places. This means no one will see your reactions or judge you for them. You can focus on the actual exposure without feeling worried about the awkwardness of seeking exposure outside of the home.
It’s Affordable.
Things like flying on planes, traveling to bridges, and skydiving all cost money. oVRcome makes VRET affordable so you can have a large range of situations in your hierarchy with one low, very competitive monthly payment.
It’s Virtual.
So you’re perfectly safe and not in any actual danger.
Before you start: Warnings
Although there are a whole host of benefits you can get from VRET, being aware of the disadvantages will keep you safe, comfortable, and able to persevere.
Here are some known disadvantages of VR that you should be aware of and get familiar with before you start:
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Discomfort
All new activities take some getting used to. Initially, the VR headset may feel heavy or uncomfortable strapped to your head and face. Being in VR may also feel disconcerting or surreal if you’ve never experienced VR before. Both these issues can be tackled by using your headset for short periods of time. Soon, your headset will not feel so obvious and you will also become more familiar and comfortable with the feeling of being in virtual reality.
Feeling sick
Extended use of VR can lead to virtual reality sickness which causes dizziness, disorientation, nausea, eye soreness, and trouble focusing. If you
start feeling sick while in VR, this means your eyes haven’t gotten used to the feeling yet. You will need to slowly build up tolerance to VR. We recommend starting with 5 minutes every other day for a week. Then building up to 10 minutes at a time. Please take a 10 to 15 minute break every 30 minutes. You can do this by taking off your headset and looking at objects far away to reduce eye strain. Even if you don’t think you need it. If symptoms persist, do not try to “power through” the content. Just stop using the headset and try again in 24 hours.
Bumping into surroundings
When you’re in VR, you won’t be able to see the world around you. To avoid bumping into things, make sure you use your headset away from walls
and furniture. Keep a 1.5 meter radius around yourself so you’re clear from any potential hazards.
oVRcome VRET has been designed so you won’t need to move or walk. You can do oVRcome VRET sitting in a chair, leaning against the wall while in your bed, or while standing still.
Feeling faint
With a needle phobia, some people may experience a sudden decrease in heart rate and blood pressure. This may result in dizziness, wooziness,
or feeling faint. If you feel like you might faint, first, take off your headset and take some deep breaths.
If possible, lie on your back and raise your legs up by propping them on a chair or against the wall.
If you can’t do this, then sit down and put your head between your knees. When you feel a little better, drink some water or eat something to raise
your blood pressure. If you know you are prone to feeling faint when encountering needles, make it a point to undergo exposure in the presence of someone who can help in the event it happens.
Staying Comfortable in
the Headset
Your client has received an email and video to teach them how to use their VR headset.
However, if they mention they’re uncomfortable or report blurriness, here are some quick
trouble-shooting tips to improve how they feel in the headset.
The headset is blurry:
There are two wheels to adjust. First, slowly adjust the interpupillary distance wheels that sit between
your eyes in the center of the headset. This is to make sure the lenses are properly situated in front of the eyes. Next, slowly adjust the focal length
wheels to improve clarity. You’ll find these wheels on top of each eye.
The headset is too loose/tight:
The headset’s bands are adjustable. Pull the buckles along the straps until you feel like the headset feels nice and snug. You should be able to move your head without it feeling like it’ll fall off. The headset should sit firmly against your face without being uncomfortable.
It feels weird in glasses
oVRcome’s VR headset has been designed to be used by people who wear glasses as well. If your glasses feel like they’re squashed to your face, try adjusting the bands to give them a little more room.
If you use contact lenses, consider using them for a potentially more comfortable VR experience.
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It doesn't close properly:
Make sure you’ve removed your phone cover. Align
your phone so the center line on your smartphone
when it’s in VR mode, matches the division line in
the center of the headset.
Still having problems?
What phone are you using?
The headset is compatible with most smartphones with screen sizes ranging from 4.7” to 6.53”.
This includes the iPhone models X, XR, XS, 8, 8 plus, 9, 9 plus, 10, 7, 7 plus, 6, 6s, 6s plus, 6 plus, 6, 5, 5 plus, 5c, 5s, SE; the Samsung Android Galaxy s8, s7, j3, s7 edge, s6, s6 edge, note5, a8+, note 3, note 4, note 5, note 7, note 8, note 9, s5 s6, s7, s8, s8 plus, s9, s9 plus, s10; and all similar sized phones of different makes and models
Using the App
If you're using an iPhone:
Multimedia audio won't play when the iOS device is on mute. All iOS users need to turn the sound on prior to going into the VR session.
Better with headphones:
Listening to the sounds played in VR and cancelling out any background noises will help increase the immersiveness of each environment
Notifications
It’s recommended that all notifications are disabled for the duration of the VR session. Muting your phone will stop the audio from playing on iOS
devices, so consider enabling the ‘Do Not Disturb’ mode for the duration of your session.
Getting Started
Before Treatment
Information
Knowledge is power. The more we know about how phobias develop and the steps we have to go through to unlearn this anxiety, the less we fear. Knowing we have effective tools to quell the fear when it arises, helps us keep moving forward.
Therefore, simply ensuring your client has all the information they need about the technical and practical aspects of VRET so they know what to expect can be very helpful in preparing them for their first VRET session.
Motivation
If your client has never used VR before, it can be quite an enjoyable experience. Having them try some fun VR environments that have nothing to do with their phobia can pique their interest in VR technology and VRET. This can help remove some of the apprehension surrounding VRET and have them curious to try more. We have include “Swimming with the dolphins” as the first demo video for this reason. If this is not a suitable “fun” simulation, you can also suggest that your client tries one of the “Calming scenes” in their toolbox.
Professional guidance, assurance, and encouragement
As a therapist, you represent a safe space for your client. Simply knowing you’re there to reach out to is one of the most comforting assurances while undergoing VRET. This is especially true during the first few times they’re experiencing VRET, or when trying to tackle a particularly challenging VR simulation. The ability to be present so you can encourage your client to keep going is a powerful motivator. Consider offering your client the option for you to connect into their session so you can see what they see. You can do this through your dashboard.
After Treatment
Evaluate
During VRET, your client will be self-reporting their fear levels. Over time, this gives you a clear indication of what VR environments they’ve immersed themselves in, trends in terms of fear levels, and which environments need more work.
All this data can be accessed on your dashboard.
You can also download reports to share with your client. Sharing, interpreting, and discussing progress is an important part of their overall evaluation because the more they see themselves improving, the more motivating VRET will be for
them, and the easier it will be for them to continue.
First Session
The Feeling of Success
Feeling successful in VRET is imperative to wanting to continue, and consequently, actual success. Including very low anxiety VR simulations in their hierarchy will help them move through the hierarchy and see progress as each simulation is
ticked as complete. As well, each VR simulation has been labeled with a fear ranking and trigger tags.
The fear ranking is based on average user ranking. This helps keep the rankings realistic so you’ll have a sound indication of how anxiety inducing each simulation should be to the typical user with that phobia. The trigger tags are there to cater to specific individual fears. For example, some people will be more afraid of small dogs than they are of big dogs.
You’ll be able to truly customize your client’s graded exposure hierarchy with the help of these labels, and thus allow them to progress at a comfortable, individualized, and sustainable pace. This will help increase their feeling of success and desire to keep going.
Checklist
My client understands the theory behind phobia development and exposure therapy.
My client knows the benefits of VRET and its efficacy.
They understand the risks and know how to stay safe during VRET
I've reminded them of the skills they've mastered and to remember to use them during VRET
My client knows how to use the headset and the app
They're comfortable in the headset, their vision is clear, and they have their headphones on.
They've tried a fun VR environment unrelated to their phobia to get a better idea of what VRET will be like.
I've given my client the option of having me connect into their sessions should they need my assistance.
I've included low level VR environments into my client's hierarchy to keep them successful
I've shared my client's progress with them and my interpretation of their collected data
Patient FAQ
Here is a list of common questions and scenarios that may show up during a client’s VRET journey.
We have worded the replies to these questions and statements as if you were speaking to your clients directly to make it easy for you to respond to their concerns.
I don't feel like I'm really there
Immersion or the feeling of “really being there” helps generate anxiety which is needed for
exposure therapy to work. When clients report a sense of disconnect, this could be due to
two reasons: Hardware or Imagination.
Hardware
Blurriness
Blurriness can reduce the feeling of immersiveness. If your headset is blurry, try adjusting the pupil distance and focal length wheels for clearer vision.
Discomfort
If your headset feels like it is too loose or too tight, this can be distracting and affect immersiveness. Adjust the bands to the point where it feels firm but not overly restrictive. If you wear glasses and find them uncomfortable in the headset, consider using contact lenses if you have them. Don’t forget to calibrate your device by scanning the QR code.
Imagination
Think
You are what you think! Use the power of your imagination to transport yourself into the simulation so you’re living it, not just watching it. Our bodies react to our thoughts as if they’re real. The same way you might cringe when thinking about a spider or feel your heart race when imagining the turbulence you felt on your last flight; unleash your
imagination and allow it to freely explore the VR environments and connect you to them.
Focus
If you’re thinking about other things while in VRET, this can disconnect you from the feeling of being there. Mindfulness skills can help you to stay in the moment. Remind yourself to keep paying attention to details in the simulations to help you latch on to it. If you can’t stop thinking about other things, come back to VRET when you’re feeling more focused.
Use all 5 senses
Increase immersiveness by using all your senses. Use the headphones so you can hear the sounds of the VR environment. Imagine tactile sensations like stepping on damp leaves in the forest or the sand at the beach. Even your sense of smell and taste can further immerse you in a simulation. Think about what that dog might smell like or the strong smell of disinfectant in a clinic while observing a blood test. Doesn’t that sea water taste salty? Having pizza with total strangers? What does it taste like?
This environment makes me feel extremely uncomfortable
VRET requires some discomfort so you can get used to the feeling of being uncomfortable around your phobia.
If you feel uncomfortable to the point where you believe you might “freak out” or lose control, select the [stop] button and you will be taken to your chosen safe place to calm down.
When you’re ready to resume VRET, select a lower ranked simulation instead. Remember, you need to work your way up to the most uncomfortable simulations for long term benefits. Throwing yourself “into the deep end” must be avoided as it can end up having a reverse effect and making you even more fearful.
0-25
26-50
51-75
76-100
Easy
A bit uncomfortable, but still do-able
Uncomfortable
Awful
I'm not sure how I should rate this environment
If you’re having trouble rating a simulation, it can help to segment the 1-100 scale into sections and focus on your physiological reactions.
For example, you might think of a simulation as:
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1. Easy - I didn’t break a sweat
2. A bit uncomfortable, but still do-able - My heart rate went up a bit!
3. Uncomfortable - I felt kind of queasy
4. Awful - I’m shaking, sweating, and my skin is crawling. I feel like throwing this headset off! (Don’t do that though!)
From there, you can divide up the scale according to your “typical” reactions so you have ratings of:
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0 - 25: Easy
26 - 50: A bit uncomfortable, but still do-able
51 - 75: Uncomfortable
76 - 100: Awful
Segmenting the scale into more obvious feelings and reactions should make it easier for you to pinpoint your overall state. From there, you’ll have an easier time estimating how you feel within a particular range.
This isn't working
Remember that it takes at least 16 VR simulations (approximately 25 minutes of VR) to start feeling a difference with VRET (Donker, 2020). Permanent change will take time.
Improvement is also cumulative. With VRET, we need to work off the theory of “slow gains.” Think of it like going to the gym. You won’t see any difference in a day. You might not even notice that much has changed after a month. But change is happening and you could very well be improving without even realizing it.
I'll never get through this
Research reports that exposure therapy has a success rate of up to 90% even after four years has passed from working through an exposure program (Kaplan & Tonlin, 2011). Logically, this means the chances of you getting through this are very high.
In the beginning, it is easy to feel discouraged because you are facing a fear that is deeply rooted in your body and mind. Do expect that the first few “high” rated simulations you experience will be difficult. This is where you’ll want to lean on the coping skills you’ve learnt from your psychologist.
This feeling of being overwhelmed is temporary. Remember this isn’t a race and there is no time limit for recovery. Allow yourself to re-enter each simulation as many times as necessary until the initial feeling of anxiety decreases.
My fear is very specific, these environments are missing something
We are always willing to take a look at specific requests if they are possible to address. Please email us at support@ovrcome.io with your specific request.
I feel worse after VRET, not better
Exposure therapy needs some anxiety for it to work. This is one of those cases where, “it
needs to get worse before it can get better.” All individuals are unique. Therefore, the amount of time and number of different VR environments needed to feel improvement during exposure is going to vary from person to person. How adaptable you are in getting used to using your coping skills during exposure is also going to affect how long you feel “worse” in VRET before it starts feeling better.
I've been skipping my VRET sessions at home
Consistency is key. It’s easy to want to “give up” if you feel like you’ve missed a few sessions. However, like riding a bike, keep getting back on the program and continue through your hierarchy. Even if you’ve missed a week of sessions. The important thing is to keep going.
Follow the 5 minute rule if you feel like VRET is daunting. Here’s how it works:
1. Make a commitment to do just FIVE minutes of VRET on a given day.
2. Bite the bullet and “just do it”.
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The idea is that 5 minutes is such a short amount of time that even if it’s an activity you dislike, you’ll be able to get through it.
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Once you’ve started and committed to doing 5 minutes of anything - VRET included, it’ll be easier to anchor yourself to that activity and to keep going. You’ll be amazed at how much more exposure you’ll find yourself doing at the end of your “5 minute” session.
As well, each environment takes only around 2-3 minutes to complete, so even if you persevere and do a little bit of exposure at a time, you’re still helping free yourself from fear!
Transition to in Vivo Exposure
In this section, we've provided resources that may help you facilitate a client's transition to real life exposure. We have worded the information here to be as if you were speaking to your clients directly so it is easy to share it with them. As well, you will see mentions of a fear of dogs throughout this sections. This serves as an example of a potentioal phobia.
Exposure is the single most effective treatment for phobias. By now, we hope you’ve built up your confidence using oVRcome’s VR process to work your way up your hierarchy and conquer your top level.
If so, you might feel ready to try some exposure to actual dogs. If not, we recommend that you circle back and continue to work through the levels of your hierarchy until you can do these with minimal anxiety.
The next step is facing your fear in real life – getting up close and personal with actual dogs!
Real-life exposure is done following the same procedure you’ve used in the VR stage:​​
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Start with something that feels manageable
Something where you’re likely to feel anxious, but you feel like you can probably handle it. A situation that is similar to the bottom level of your VR hierarchy.
2
Stay in your situation as long as it takes for your fear to drop
This will eventually happen, even if it takes a little while.
3
Use your skills to help you with this
Use your skills exactly like you did when in VR.
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Move up step-by-step
When you’ve achieved your first challenge, you’re ready to move up to something that feels a bit more anxiety-provoking.
Real-Life Exposure
Goal Setting
Just like you did for the VR phase, clearly define your goal. What would constitute being fully
recovered from your phobia? Do you want to be able to pat a large dog that’s off its lead? Be sure to make it specific.
Step 1
Building your real-life exposure hierarchy
Think about opportunities you have around you to have contact with dogs. List three situations you could work through over the coming week or so. Rank them from least anxiety-provoking to most.
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Step 2
Recording your results
Fill out an exposure record whenever you complete your challenges. This step is important, because it helps you to really see the results and keep track of where you’re at.
Step 3
How to Manage Setbacks
The recovery trajectory graph
When we enter into a course of treatment, we usually hope that we’ll recover in a linear fashion.
With each day, we’ll keep getting better bit by bit, right? Not quite. Here’s how it usually looks:
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A setback does not mean failure
Recovery doesn’t proceed in a linear fashion – there will be plateaus and regressions as well as times of moving forward. Not being able to tolerate as much exposure to a situation as you did previously is a normal part of recovery.​​
Week 1
During three out of five exposure sessions you can tolerate being around a dog, and stay in the situation.
Week 2
Four out of five sessions you just can’t be around
dogs and get up and leave the situation.
Week 3
For two out of five practice sessions you can be present with dogs of different sizes. During the other two sessions, you’re able to pat a dog that’s on a leash. One day you feel you can’t be around a dog at all.
Week 4
Due to illness you can only get in two practice sessions. On one of those days, you manage to pat a large dog off its lead.
It’s important you don’t let these setbacks discourage you. Simply chalk it up as a bad day or bad week and learn from it. Nothing can take
away all the progress you’ve made during the VR phase up to now. You can use each setback as a learning experience to tell you more about how to best proceed in mastering your phobia.​​
Here are a few tips to help this process:
Practice regularly
Regular, consistent practice, whether it’s with VR or ‘real-life’, around 3-5 times a week, is the strongest predictor of success with exposure. There is simply no substitute for regular practice. People who practice regularly are the ones who recover.
There is no phobia that can’t be overcome with a steady and persistent commitment to practice exposure.
Keep using the diary to record your practice. Keep this going a few times a week. Use this to check and track your progress.
Use a support person
It’s often helpful when doing real-life exposure to have a support person (partner, friend) who can come along with you initially while you do your exposure work. Gradually, as you feel more comfortable, you can ‘drop’ the support of that person and continue on doing your exposure practice independently.
Be wiling to tolerate some discomfort
At times you may find the intensity of being around dogs in real-life situations more anxietyprovoking
than what you’ve experienced in VR. It’s also normal for your anxiety levels to continue to fluctuate during the VR exercises.
Make a commitment
I am willing to give [x] times per week to this. Commit to success by practicing your exposure exercises than many times a week.
Having issues?
Revisit your skills
Try linking back to some of your skills and practising these again. Make sure you’re using these throughout the real-life exposure challenges. Try your best to remember to use these while you’re in situations with dogs.
Be patient
Remember, your anxiety will eventually drop if you stay where you are and use your skills. Just like in the VR, your anxiety might rise at the start, but just like a wave, will peak, crest, and subside. Be willing to tolerate a bit of discomfort, and it’ll pay off.
Keep practising in VR
If it feels too much, go back to your VR videos and spend a bit more time working through these.
References
Bouchard, S., Dumoulin, S., Robillard, G., Guitard, T., Klinger, É., Forget, H., Loranger, C., & Roucaut, F. X. (2017). Virtual reality compared with in vivo exposure in the
treatment of social anxiety disorder: A three-arm randomised controlled trial. British Journal of Psychiatry, 210(4), 276–283.
Donker, T., van Klaveren, C., Cornelisz, I., Kok, R. N., & van Gelder, J.-L. (2020). Analysis of Usage Data from a Self-Guided App-Based Virtual Reality Cognitive Behavior Therapy for Acrophobia: A Randomized Controlled Trial. Journal of Clinical Medicine, 9(6), 1614. https://doi.org/10.3390/jcm9061614
Fodor, L. A., Coteț, C. D., Cuijpers, P., Szamoskozi, Ștefan, David, D., & Cristea, I. A. (2018). The effectiveness of virtual reality based interventions for symptoms
of anxiety and depression: A metaanalysis. Scientific Reports, 8(1). https:// doi.org/10.1038/s41598-018-28113-6
Garcia-Palacios, A., Botella, C., Hoffman, H., & Fabregat, S. (2007). Comparing Acceptance and Refusal Rates of Virtual Reality Exposure vs. In Vivo Exposure by Patients with Specific Phobias. CyberPsychology & Behavior, 10(5), 722–724. https://doi.org/10.1089/cpb.2007.9962
Kaplan, J. S., & Tolin, D. F. (2011). Exposure Therapy for Anxiety Disorders. Psychiatric Times, 28(9), 33–37.
Morina, N., Ijntema, H., Meyerbröker, K., & Emmelkamp, P. M. G. (2015). Can virtual reality exposure therapy gains be generalized to real-life? A metaanalysis
of studies applying behavioral assessments. Behaviour Research and Therapy, 74, 18–24.
Wechsler, T. F., Kümpers, F., & Mühlberger, A. (2019). Inferiority or Even Superiority of Virtual Reality Exposure Therapy in Phobias?—A Systematic Review and Quantitative Meta-Analysis on Randomized Controlled Trials Specifically Comparing the Efficacy of Virtual Reality Exposure to Gold Standard in vivo Exposure in Agoraphobia, Specific Phobia, and Social Phobia. Frontiers in Psychology, 10. https://doi.org/10.3389/fpsyg.2019.01758.
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