Using Step Out: A Guide for Clinicians

Overview

Step Out is a prescription-only virtual reality (VR) program designed to support patients who experience anxiety or distress related to leaving their home or participating in everyday social situations. It delivers Cognitive Behavioral Therapy (CBT) techniques through immersive virtual environments, guided by an automated virtual therapist named Nic.

Step Out is intended to be used as an adjunct to standard care, under the supervision of a healthcare professional. It does not diagnose, treat, or prevent any medical or psychiatric condition.

For the patient-facing version of this guide, see How to Use Step Out.

Setting Up the First Session

1. Launch Step Out.
   There are two ways to start the app:
   1. Patient (independently): The patient selects Step Out from the XR Portal Library, found under Behavioral Space.
   2. Clinician (remotely): The clinician can launch the app on the patient's device directly from the Clinician Platform.
2. Let the virtual therapist, Nic, introduce the program.
   Upon launching, the patient is taken to Nic's virtual office. Nic introduces herself, explains the program, and walks the patient through how to use the VR headset.
   
3. Guide the patient through the initial feedback questions.
   Nic asks the patient to provide input on their current ability to manage everyday social situations. This establishes a baseline assessment that will be used to track progress over time.
   
4. Help the patient select a scenario and level.
   The patient is asked to choose the scenario and level they feel most comfortable starting with. Encourage them to start with whatever feels manageable — there is no pressure to begin at the most challenging level.
   

The 5 Social Scenarios

Step Out includes 5 virtual social environments. Each scenario has 5 levels that increase in difficulty based on the number of people present, the noise level, and the degree of required social interaction. As a clinician, you can help your patient choose the scenario most relevant to their real-life challenges.

Café

The patient orders a drink in a café that becomes progressively busier. Involves interactions with a barista and other customers in the queue.

Doctor's Office

The patient waits in a queue at a reception desk and is asked to speak with the receptionist. Higher levels involve longer waiting times and more interactions with people in the waiting area.

Shop

The patient completes a shopping list, which encourages them to drop hypervigilant safety behaviors (e.g., keeping their back to others) and refocus their attention on the task. Higher levels include waiting while the shopkeeper scans items.

Street

The patient opens the door of an apartment and waits on the street for a taxi. The environment becomes noisier and busier at higher levels. One task involves washing graffiti off a wall while keeping their back to other people, helping to address hypervigilance.

Bus

The patient waits at a bus stop, boards a bus, and pays for a ticket. Most levels involve standing at the front of the bus in increasingly close proximity to other passengers.

How Tasks Work Within Each Scenario

Each scenario requires the patient to complete pre-determined tasks in the virtual environment. Tasks are designed to invoke graded levels of anxiety and mirror common real-world situations.

Task Timing

Patients have approximately 15–30 seconds to complete each action. If the task is not completed in that time, Nic provides a verbal prompt or encouragement. The patient then has an additional 15–20 seconds to complete the task.

How Task Completion is Measured

• Microphone input or voice activation for verbal responses.
• Virtual interaction with objects (e.g., picking up an item, walking through a door).
• Remaining in the situation for a required amount of time without exiting.

If a Task is Not Completed

If a task is not successfully completed within the allowed time, an exit sequence is initiated and the patient is returned to Nic's virtual office. From there, the patient can reflect on the experience and decide whether to re-attempt the level.

Task Breakdown by Scenario

Monitoring Progress

Throughout the program, Nic periodically asks the patient the same initial feedback questions to assess how they are progressing compared to their baseline. As a clinician, you can use these check-ins as a discussion point in your sessions to reflect on changes in the patient's confidence and anxiety levels.

• Review the patient's scenario and level choices over time — moving to higher levels indicates growing comfort.
• If a patient repeatedly fails to complete a level, consider discussing the specific task with them and exploring the underlying anxiety in your clinical sessions.
• Encourage patients to reflect with you on what felt easier or harder in VR compared to real life.

Week-by-Week Overview

Step Out is designed for one 30-minute session per week over approximately 5 weeks. Each session focuses on completing all 5 levels of one scenario (~5 minutes per level). Patients may use the device more frequently if desired. The minimum recommended dose is three 30-minute sessions over the 5 weeks.

Clinical Notes

• Nic uses CBT techniques throughout, including encouraging patients to drop safety behaviors, providing positive reinforcement, and prompting self-reflection to disconfirm perceived threats.
• The VR experience is designed to be gradual and patient-led — patients always choose their scenario and starting level.
• Consider integrating VR session content into your clinical conversations: what did the patient notice about their thoughts and feelings during the scenario?
• Patients who stand during the VR experience should be in a clear, open space. Seated use is also supported.
• All audio in Step Out is narrated in English.