Your First VRET Session: A Step-by-Step Clinical Protocol
By Equipo clínico VRET
The first VRET session is not the first exposure. It's a session structured into six blocks (pre-session assessment, framing, neutral acclimatization of 5 to 10 minutes, low-intensity first exposure with SUDS ≤4, measurements every 2-3 minutes, session closeout, and between-session homework) whose goal is not symptom reduction but stabilizing the alliance and the headset. Treating it as full exposure tends to produce dropout.
The Real Goal of the First Session: It's Not Exposure, It's the Headset
A common mistake among psychologists starting out with VRET is treating the first session like just another exposure session. The usual result is a patient who leaves exhausted, with high SUDS, and doesn't come back.
The clinical goal of the first VRET session is threefold, and it does not include meaningful symptom reduction.
1. Verify the patient's tolerance of the headset: Does it cause dizziness? Added claustrophobia? Visual fatigue?
2. Calibrate the SUDS baseline both inside and outside the clinical scenario.
3. Consolidate the therapeutic alliance with the procedure itself (not with the psychologist, which was already established during the prior assessment).
If, by the end of the first session, the patient wants to return and the psychologist has a clear initial measurement, the session has been a clinical success — even if the scenario's peak SUDS was only 3.
Pre-Session Assessment: What You Need Before Putting on the Headset
Before the first VR session — ideally by the end of the assessment session — you should have the following elements documented.
1. An operational clinical diagnosis under DSM-5-TR or ICD-11. ‘Fear of public speaking’ is not operational; ‘social anxiety, formal presentations’ is.
2. An exposure hierarchy built together with the patient, ideally with eight to twelve levels, each with an estimated SUDS. The hierarchy is built on paper — it is not discovered inside the headset.
3. A standardized anxiety scale (STAI trait and state, BAI, or equivalent) with a baseline score.
4. A disorder-specific questionnaire (FQ for specific phobias, LSAS for social anxiety, PCL-5 for PTSD, as applicable).
5. Screening for VR contraindications: photosensitive epilepsy, prior severe motion sickness, active positional vertigo, pregnancy, active psychosis, severe dissociation, cognitive impairment. This blog has a dedicated article on contraindications worth reviewing.
6. A signed VRET-specific informed consent form, explaining what data is recorded (SUDS, events, duration, biometrics if applicable) and how it is processed in compliance with GDPR.
Without these six elements, it's better to postpone the first VR session. The headset cannot make up for a missing assessment.
Block 1: Verbal Framing (5-10 minutes)
After the initial greetings and a review of prior homework, the psychologist spends the first 5-10 minutes on a verbal framing specific to today's session. This is not the introduction to VR itself (that happened in the previous session), but the operating script for the next two hours.
1. A reminder of today's goal. 'Today isn't about intense exposure. Today we're trying the headset and seeing how it feels for you. We'll start with a scenario with no phobic stimulus, then move up to a very basic level of the hierarchy, and talk about it afterward.'
2. A reminder of the SUDS scale. 'Every two or three minutes I'll ask how much distress you're feeling, from 0 to 10. 0 is completely calm, 10 is the worst you've ever felt. There's no right answer; whatever you say, I'll record it as is.'
3. Stop signals. 'If you want to stop, say so. If you feel dizzy, say so. If anything about the headset bothers you, say so. You don't have to wait for me to ask. And if you can't speak, raise your hand.'
4. Position and physical setup. Seated in a chair with armrests, no wheels, with the surrounding space free of obstacles. Confirm there is nothing on the floor within a 1.5-meter radius, and that the room temperature is comfortable.
5. Hygiene and headset fitting. Show the patient the clean hygienic cover, adjust the strap, set the diopter correction if the headset allows it, and confirm the image is sharp using a calibration screen before loading the scenario.
Block 2: Acclimatization in a Neutral Scenario (5-10 minutes)
Acclimatization is the block most underestimated by psychologists new to VRET, and the one with the greatest impact on treatment adherence.
Load a neutral, pleasant scenario: a mindfulness forest, a meditation room, a beach at sunrise. The scenario must be free of phobic stimuli for that specific patient (if the patient fears water, the beach won't work — use the forest instead).
Ask the patient to look around: up, down, side to side. To identify three visible objects. To listen to the ambient sound. To take two or three slow breaths. This guided exploration serves two purposes: it defuses anticipatory anxiety about the headset and lets the psychologist watch for early signs of dizziness.
Measure SUDS at minute 2 and minute 5 of the neutral scenario. The expected baseline is 0-2. If the baseline SUDS in the neutral scenario exceeds 4, do not advance to exposure; work on regulation using the relaxing scenario until it drops.
Check tolerance: does the patient report dizziness, visual fatigue, head pressure? If the answer is clearly yes, end the session here and reassess whether VR is suitable for this case. Do not push through.
Block 3: First Low-Intensity Exposure (10-15 minutes)
After acclimatization, moving to the first level of the hierarchy must be deliberately conservative. The operating rule is to choose the level whose estimated SUDS on paper is 3 or 4, never higher.
Examples by presentation: dog phobia, a small dog behind a fence 5 meters away, not moving. Acrophobia, a first-floor balcony. Claustrophobia, a spacious elevator with open doors and natural light. Fear of flying, an airport waiting area with no plane visible. Social anxiety, an empty room with ambient audio of people in the distance.
Ask the patient to describe what they see in one short sentence. This verbalization anchors attention on the stimulus and lets the psychologist confirm the patient is processing, not dissociating.
Measure SUDS every 2-3 minutes without breaking immersion: 'Without opening your eyes, what's your SUDS right now?' Log each measurement with a timestamp.
The block ends on one of three criteria: (a) SUDS drops by at least one point and stays stable for 4-5 minutes; (b) the patient reaches 10-15 minutes of continuous exposure with stable SUDS; (c) the patient asks to stop, or SUDS exceeds the threshold agreed on during framing.
If SUDS rises above 7 in the first session, withdraw the stimulus (switch to the neutral scenario, don't remove the headset) and allow 2-3 minutes for regulation. End the session without returning to the stimulus.
Block 4: Session Closeout (10-15 minutes)
Remove the headset and dedicate the final 10-15 minutes to session closeout. This is the block that distinguishes a clinical session from a tech demo, and the one that consolidates the patient's learning.
1. Operational questions. 'What was the highest SUDS you remember? When did it happen? What thoughts crossed your mind? What physical sensations did you notice?' Take verbatim notes of the relevant answers.
2. Review of the objective record. Share the measured SUDS values with the patient: 'You started at 4, rose to 6, stayed at 6 for six minutes, and dropped to 4 before finishing.' Let them see the data.
3. Light cognitive restructuring. Identify at least one automatic thought that came up during exposure and work through it briefly using CBT techniques the patient already knows. This is not the time for deep restructuring — it is the time to validate what came up.
4. Emotional validation. 'You did twelve minutes of exposure without pulling back. That's exactly what we need to happen. The discomfort you noticed is the target, not a side effect.'
5. Anticipating the next session. 'Next time we'll move up one step in the hierarchy (or repeat today's level for longer, depending on how this went). We'll talk through the plan once you confirm you're feeling okay.'
Block 5: Between-Session Homework and Documentation
Before ending the session, leave the patient with two or three concrete tasks for the period between sessions, and complete the documentation in the clinical record.
Typical homework after a first VRET session.
1. Thought log. Ask the patient to write down, over the next seven days, any thoughts about today's session or the next one. This reduces anticipatory anxiety and provides clinical material.
2. Self-monitoring of avoidance. Have the patient record real-life situations where the stimulus appeared and what they did. This confirms or adjusts the hierarchy built in session.
3. Minimal behavioral task. For mild-to-moderate presentations, a micro in-vivo exposure (getting within 30 meters of a park with dogs, going up to the first floor, taking an elevator with company). Without this, VR remains disconnected from the real world.
The clinical record for the session should include: scenario used, hierarchy level addressed, total time with the headset on, baseline SUDS in the neutral scenario, peak SUDS during exposure, final SUDS, incidents (dizziness, fatigue, withdrawal), relevant automatic thoughts, and the clinical decision for the next session. This blog has a dedicated article on GDPR-compliant documentation of the VR session.
A well-executed first session ends with a patient who wants to come back, a calibrated hierarchy, a SUDS baseline, and a complete clinical record. If any of those four is missing, it's worth course-correcting before moving forward.
This article is for informational purposes for psychology professionals. It is not clinical advice for any individual case and does not replace the judgment of the licensed psychologist in charge. VRET is professional clinical-support software, not a CE-marked medical device.
Frequently asked questions
How long should the entire first session take?
Between 60 and 75 minutes total: 10 minutes of framing, 5-10 of neutral acclimatization, 10-15 of first exposure, 10-15 of closeout, and 5-10 of homework and goodbyes. The standard 50-minute session runs short for a first VRET session; it's best to block out an hour and fifteen minutes and let the patient know in advance.
What should I do if the patient reports dizziness or nausea in the first five minutes?
Stop the scenario, remove the headset, offer water, ventilate the room, and log the incident. Do not put the headset back on for that session. In the next session, start with fully static scenarios, extend the acclimatization phase to 15 minutes, and consider brief breaks with the headset off. If dizziness recurs across two consecutive sessions, assess whether VRET is the right modality for that patient.
Is it normal for SUDS not to drop during the first exposure?
It's common and does not indicate failure. Within-session habituation is usually observed from the second or third exposure to the same level onward. In the first session, what matters clinically is that the patient tolerated the stimulus without withdrawing and that SUDS did not escalate to panic. Habituation builds up across sessions.
Can I use two different scenarios in the same first session?
Using two different phobic scenarios in the first session is not advisable. It is reasonable and useful to use a neutral acclimatization scenario plus a single exposure scenario. Jumping between two phobic contexts in the first session saturates the SUDS baseline and makes calibration harder.
What peak SUDS should I consider excessive for a first session?
Above 7 in a first session, it's best to withdraw the stimulus and not return to it that day. A peak SUDS of 9 or 10 in a first session usually indicates the chosen hierarchy level was too high — not that the patient is a 'poor candidate.' The next session should drop a level, not move up.
Do I need to give the patient a written record at the end of the first session?
It's not mandatory, but handing over a brief summary (scenario, duration, baseline/peak/final SUDS, plan for the next session) reinforces the sense of serious treatment and reduces the dissonance of a patient still unsure whether VR is 'legitimate.' A printed A5 sheet or an email is usually enough — without identifying data in the email if the patient has not signed specific consent for electronic communication.
Keep reading
VR Headset Hygiene Protocol: What No One Tells You
A practical VR headset hygiene protocol for clinical practices: disinfection, hygienic covers, hair and glasses management, and airing times between patients.
Practice managementVRET Contraindications: When Not to Use It With a Patient
Absolute and relative contraindications for VRET — epilepsy, psychosis, dissociation, pregnancy, BPPV, cognitive impairment — plus the pre-session screening checklist.
Practice managementDocumenting a VRET Session: GDPR Best Practices in Spain
How to document a VRET session in the health record: GDPR rules for health and biometric data, consent, and retention periods under Spanish law.
VRET is professional clinical-support software, not a CE-marked medical device. Clinical supervision remains with the licensed psychologist in charge.