Rational-Emotive and Cognitive-Behavior Therapy Using Virtual Reality (RE&CBT-VR): A Short Protocol for Social Anxiety Disorder

Abstract

The RE&CBT-VR protocol is targeting adult population diagnosed with Social Anxiety Disorder according to DSM-5 (APA, 2013) as main diagnosis, the performance specifier, or public speaking subtype. This program can also be useful for people who suffer from public speaking anxiety that does not necessarily meet the diagnostic criterion of SAD, but whose occupational or educational functioning is greatly affected. This program is not indicated when (1) the SAD diagnosis is secondary to another axis I diagnosis of psychiatric disorders, like psychotic disorders, bipolar depressive disorders, current substance abuse, dementia, or mental retardation; (2) the SAD diagnosis is secondary to another axis III diagnosis; (3) personality disorders predisposing patients to confusions between the real and virtual realities (paranoid, schizoid, schizotypal, borderline, antisocial personality disorders); or (4) suffered anytime during the past 6 months of panic disorder with or without agoraphobia. Participants included in some concurrent form of psychotherapy or receiving medication are also excluded.

Appendix: Forms and Handouts for the RE&CBT-VR

The ABC monitoring form (David et al., 2014; Ellis, 1956, 1991—reproduced with permission)

1.1 Subjective Units of Distress (SUDS; Wolpe, 1969)

The subjective units of distress scale specify 11 points on the scale, ranging from 0 (absolutely complete relaxation) up to 10 (extreme distress).

Anxiety level	Description	Situation
Zero	Complete relaxation. Deep sleep, no distress at all
One	Awake but very relaxed; dosing off. Your mind wanders and drifts, similar to what you might feel just prior to falling asleep
Two	Relaxing at the beach, relaxing at home in front of a warm fire on a wintry day, or walking peacefully in the woods
Three	The amount of tension and stress needed to keep your attention from wandering, to keep your head erect, and so on. This tension and stress is not experienced as unpleasant; it is “normal”
Four	Mild distress such as mild feelings of bodily tension, mild worry, mild apprehension, mild fear, or mild anxiety. Somewhat unpleasant but easily tolerated
Five	Mild to moderate distress. Distinctly unpleasant but insufficient to produce many bodily symptoms
Six	Moderate distress. Very unpleasant feelings of fear, anxiety, anger, worry, apprehension, and/or substantial bodily tension such as a headache or upset stomach. Distinctly unpleasant but tolerable sensations; you’re still able to think clearly. What most people would describe as a “bad day,” but your ability to work, drive, converse, and so on is not impeded
Seven	Moderately high distress that makes concentration hard. Fairly intense bodily distress
Eight	High distress. High levels of fear, anxiety, worry, apprehension, and/or bodily tension. These feelings cannot be tolerated very long. Thinking and problem-solving is impaired. Bodily distress is substantial. Ability to work, drive, converse, and so on is difficult
Nine	High to extreme distress. Thinking is substantially impaired
Ten	Extreme distress, panic- and/or terror-stricken, extreme bodily tension. The maximum amount of fear, anxiety, and/or apprehension you can possibly imagine

1.1.1 “Psychological Pills” for Public Speaking

Based on the PsyPills app (Gavita, 2013)

• I want very much to make a good presentation, but I realize that things do not necessarily have to be as I wish.

• I want very much to make a good impression and not embarrass myself during my presentation, but I realize that things do not necessarily have to be as I wish.

• I want very much to perfectly master the topic, speak fluently, and find the adequate answers during the presentation, but I realize that it does not necessarily have to be as I wish.

• I want very much not to feel anxious, blush, or have trembling voice during the presentation, but I do realize that it does not necessarily have to be as I wish.

• It would be very uncomfortable if I would make a weak presentation and I am making all the efforts not to happen, but this would not be awful.

• It would be very uncomfortable if, despite my efforts, I would not be appreciated by the audience or I would embarrass myself during the presentation, but it would not be awful.

• It would be very uncomfortable not to find my words during the presentation and/or the audience to realize that I do not perfectly master the topic, but not the worst thing.

• It would be very unpleasant to feel anxious, blush, or have trembling voice during the presentation, but it would not be awful.

• In case I cannot answer properly questions from the audience, I can accept the people in the audience as human beings.

• In case people in the audience are not approving or are criticizing/despising me, I think this does not impact their worth.

• In case someone asks me difficult questions and I get blocked, I understand this does not impact their worth.

• In case I am feeling very anxious, blush, or have trembling voice during the presentation, I understand this does not impact the worth of my audience.

• In case I am making a weak presentation, I can accept myself having the same value as a human being and to improve my behavior.

• In case I am making a bad impression or the public is uninterested on my presentation, I can accept myself having the same value and to improve my behavior.

• In case I do not perfectly master the topic, find my words, or not know the answers to the questions coming from the public, I understand that this does not impact my worth as a person.

• In case I feel very anxious, blush, or have trembling voice during the presentation, I understand that this does not impact my worth as a person.

• It would be very unpleasant to make a weak and flawed presentation, but I could stand it in case it would happen.

• It would be very unpleasant if the audience would make a bad impression of me during the presentation, but I could stand it in case it would happen.

• It would be very uncomfortable to get blocked/not find my words during the presentation or to not be able to answer to the questions from the public, but I could tolerate it in case it happens.

• It would be very uncomfortable to feel anxious, blush, or have trembling voice during the presentation, but I could tolerate it in case it happens.

• In case someone asks me difficult questions and I get blocked, I understand this does not impact their worth.

• In case I make a bad presentation, I can accept life with its ups and downs and I can keep improving my skills.

• In case people in the audience are not approving or are criticizing/ despising me, I can accept life with its ups and downs and I can keep improving my skills.

In case I do not perfectly master the topic, find my words, or not know the answers to the questions, I can accept life with its ups and downs and I can keep improving my skills

In case I feel very anxious, blush, or have trembling voice during the presentation, I can accept life with its ups and downs and I can keep improving my skills

1.2 Measures

1.2.1 Public Speaking: Rational and Irrational Beliefs Scale

Name: Today’s Date: / /  Age: ___ Sex: Male or Female

When making a presentation or a public speech in front of an audience, some people tend to think that situation absolutely must be the way they want (in terms of absolute must). In the same situation, other people think in preferential terms and accept the situation, even if they want very much that those situations do not happen. In light of these possibilities, please estimate how much the statements below represent the thoughts that you have when by yourself in public places.

Please think about a situation when you were making a presentation or a public speech in front of an audience or preparing one . Try and recall the thoughts that you have had in such situations.

Using the following scale, indicate in the space provided how true each of these statements is for you.

• 1. Strongly agree

• 2. Somewhat agree

• 3. Somewhat disagree

• 4. Strongly disagree

3.3.2.1 Part 1—Performance RIBS

		Strongly agree	Somewhat agree	Somewhat disagree	Strongly disagree
1	I absolutely must make a good presentation, and I cannot conceive otherwise	1	2	3	4
2	I want very much to make a good presentation, but I realize that things do not necessarily have to be as I wish	1	2	3	4
3	It would be awful and terrifying if, despite my efforts, I would make a weak presentation	1	2	3	4
4	It would be very uncomfortable if I would make a weak presentation and I am making all the efforts not to happen, but it would not be awful	1	2	3	4
5	If I am making a weak presentation, this shows that I am worthless and a loser	1	2	3	4
6	If I am making a weak presentation, I can accept myself having the same value as a human being and to improve my behavior	1	2	3	4
7	If I cannot answer properly questions from the audience, this is because people in the audience are bad and worthless beings	1	2	3	4
8	If I cannot answer properly questions from the audience, I can accept the people in the audience as human beings	1	2	3	4
9	I could not stand to make a weak and flawed presentation	1	2	3	4
10	It would be extremely unpleasant to make a weak and flawed presentation, but I could stand it in case it would happen	1	2	3	4
11	If I make a bad presentation, it means life is unfair and not worth the effort	1	2	3	4
12	If I make a bad presentation, I can accept life with its ups and downs and I can keep improving my skills	1	2	3	4

3.3.2.2 Part 2—Approval RIBS

		Strongly agree	Somewhat agree	Somewhat disagree	Strongly disagree
1	I absolutely must make a good impression and not embarrass myself during my presentation, and I cannot conceive otherwise	1	2	3	4
2	I want very much to make a good impression and not embarrass myself during my presentation, but I realize that things do not necessarily have to be as I wish	1	2	3	4
3	It would be awful and terrifying if, despite my efforts, I would not make a good impression or embarrass myself during the presentation	1	2	3	4
4	It would be very uncomfortable if, despite my efforts, I would be not appreciated by the audience or I would embarrass myself during the presentation, but it would not be awful	1	2	3	4
5	If I am making a bad impression or the public is uninterested on my presentation, this shows that I am worthless and a loser	1	2	3	4
6	If I am making a bad impression or the public is uninterested on my presentation, I can accept myself having the same value and to improve my behavior	1	2	3	4
7	If people in the audience are not approving or are criticizing/despising me, this shows what bad and worthless beings they are	1	2	3	4
8	If people in the audience are not approving or are criticizing/despising me, I think this does not impact their worth	1	2	3	4
9	I could not stand if the audience would make a bad impression on me during the presentation	1	2	3	4
10	It would be very unpleasant if the audience would make a bad impression of me during the presentation, but I could stand it in case it would happen	1	2	3	4
11	If people in the audience are not approving or are criticizing/despising me, it means life is unfair and not worth the effort	1	2	3	4
12	If people in the audience are not approving or are criticizing/despising me, I can accept life with its ups and downs and I can keep improving my skills	1	2	3	4

3.3.2.3 Part 3—Communication RIBS

		Strongly agree	Somewhat agree	Somewhat disagree	Strongly disagree
1	I must perfectly master the topic, speak fluently, and find the adequate answers during the presentation and I cannot conceive otherwise	1	2	3	4
2	I want very much to perfectly master the topic, speak fluently, and find the adequate answers during the presentation, but I realize that it does not necessarily have to be as I wish	1	2	3	4
3	I could not stand to get blocked/not find my words during the presentation or to not be able to answer all the questions from the public	1	2	3	4
4	It would be very uncomfortable to get blocked/not find my words during the presentation or to not be able to answer the questions from the public, but I could tolerate it in case it happens	1	2	3	4
5	If someone asks me difficult questions and I get blocked, this shows it is a bad and worthless person	1	2	3	4
6	If someone asks me difficult questions and I get blocked, I understand this does not impact their worth	1	2	3	4
7	It would be awful not to find my words during the presentation and the audience to realize that I do not perfectly master the topic I am talking about	1	2	3	4
8	It would be very uncomfortable not to find my words during the presentation and the audience to realize that I do not perfectly master the topic, but not the worst thing	1	2	3	4
9	If I do not perfectly master the topic, find my words or not know the answers to the questions coming from the public, this shows I am an incompetent and a worthless person	1	2	3	4
10	If I do not perfectly master the topic, find my words or not know the answers to the questions coming from the public, I understand that this does not impact my worth as a person	1	2	3	4
11	If I do not perfectly master the topic, find my words or not know the answers to the questions, this shows life is unfair and not worth the effort	1	2	3	4
12	If I do not perfectly master the topic, find my words or not know the answers to the questions, I can accept life with its ups and downs and I can keep improving my skills	1	2	3	4

3.3.2.4 Part 4—Comfort RIBS

		Strongly agree	Somewhat agree	Somewhat disagree	Strongly disagree
1	I absolutely must not feel anxious, blush, or have trembling voice during the presentation and I cannot conceive otherwise	1	2	3	4
2	I want very much not to feel very anxious, blush, or have trembling voice during the presentation, but I do realize that it does not necessarily have to be as I wish	1	2	3	4
3	I could not stand to feel anxious, blush, or have trembling voice during the presentation	1	2	3	4
4	It would be very uncomfortable to feel anxious, blush, or have trembling voice during the presentation, but I could tolerate it in case it happens	1	2	3	4
5	If I am feeling very anxious, blush, or have trembling voice during the presentation, this shows others are bad and worthless people	1	2	3	4
6	If I am feeling very anxious, blush, or have trembling voice during the presentation, I understand this does not impact others’ worth	1	2	3	4
7	It would be awful to feel very anxious, blush, or have trembling voice during the presentation	1	2	3	4
8	It would be very unpleasant to feel anxious, blush, or have trembling voice during the presentation, but it would not be awful	1	2	3	4
9	If I feel very anxious, blush, or have trembling voice during the presentation, this shows I am a weak and a worthless person	1	2	3	4
10	If I feel very anxious, blush, or have trembling voice during the presentation, I understand that this does not impact my worth as a person	1	2	3	4
11	If I feel very anxious, blush, or have trembling voice during the presentation, this shows life is unfair and not worth the effort
12	If I feel very anxious, blush, or have trembling voice during the presentation, I can accept life with its ups and downs and I can keep improving my skills