Virtual reality in psychotherapy: expanding therapeutic horizons

This issue explores the evolving field of Virtual Reality (VR) as a transformative tool in psychotherapy through the presentation of five clinical case studies and a framework for their analysis. As technological advancements increase accessibility to VR and a growing body of scientific evidence supports VR-based psychological interventions the potential for innovative VR applications in psychotherapy continues to expand. We propose a framework for conceptualizing VR psychotherapeutic interventions along three key dimensions: Strategy, Focus, and Perspective. The goal of this conceptual framework is to provide guidance for clinicians and researchers in designing effective interventions and broadening the scope of therapeutic possibilities. The five clinical cases featured in this issue span a wide range of psychological conditions, including chronic pain, PTSD, social anxiety, depression, and psychosis. The VR interventions draw from diverse theoretical approaches, including cognitive-behavioral therapy, acceptance and commitment therapy, systemic therapy, and personal construct therapy. Each contribution demonstrates how VR can enhance therapy, offering clients immersive and emotionally intense experiences that might foster personal growth, symptom reduction, and therapeutic breakthroughs. By presenting both well-established and innovative uses of VR, this issue provides valuable insights into how virtual environments can extend the boundaries of psychotherapy, addressing complex psychological issues in novel, impactful, and unique ways. Virtual reality in psychotherapy: expanding therapeutic horizons

This issue explores the evolving field of Virtual Reality (VR) as a transformative tool in psychotherapy through the presentation of five clinical case studies and a framework for their analysis. As technological advancements increase accessibility to VR and a growing body of scientific evidence supports VR-based psychological interventions the potential for innovative VR applications in psychotherapy continues to expand. We propose a framework for conceptualizing VR psychotherapeutic interventions along three key dimensions: Strategy, Focus, and Perspective. The goal of this conceptual framework is to provide guidance for clinicians and researchers in designing effective interventions and broadening the scope of therapeutic possibilities. The five clinical cases featured in this issue span a wide range of psychological conditions, including chronic pain, PTSD, social anxiety, depression, and psychosis. The VR interventions draw from diverse theoretical approaches, including cognitive-behavioral therapy, acceptance and commitment therapy, systemic therapy, and personal construct therapy. Each contribution demonstrates how VR can enhance therapy, offering clients immersive and emotionally intense experiences that might foster personal growth, symptom reduction, and therapeutic breakthroughs. By presenting both well-established and innovative uses of VR, this issue provides valuable insights into how virtual environments can extend the boundaries of psychotherapy, addressing complex psychological issues in novel, impactful, and unique ways. Key words: Clinical psychology, Digital mental health, Case studies, VR-enhanced psychotherapy, Digital Personalization in Therapy

Most therapeutic processes, at some stage, involve supporting the client in developing emotionally intense experiences or higher-order cognitive, emotional, or even metacognitive skills. Therapists strive to facilitate this advanced processing during sessions with different purposes, like enhancing clients’ readiness for change, increase their sense of control and mastery, symptom reduction, foster personal growth, promote self-reconceptualization or facilitate deeper insights. However, facilitating these impactful experiences and higher-order processes can be challenging when relying solely on the client’s own imagery and skills (and on the therapist’s). This is particularly true for clients facing chronic or treatment-resistant problems, which often diminish their capacity for abstraction and high-level cognitive and emotional processing. But what if Virtual Reality (VR) could bridge the gap and amplify the impact and intensity of interventions, particularly when engaging critical higher-order mechanisms? This question has been explored since the early nineties (Rothbaum et al., 1995) and has gained attention over the decades based on technological advancements and the emergence of more sophisticated VR scenarios applied to psychotherapy. Traditionally, cognitive-behavioral models and exposure therapy have been the pioneering paradigms shaping the creation and exploration of VR applications in psychotherapy. These established approaches have demonstrated remarkable success in treating conditions such as phobias, post-traumatic stress disorders, and anxiety disorders, among others (Bell et al., 2024; Rizzo & Bouchard, 2019). However, the evolving landscape of VR applications has given rise to innovative psychological interventions, expanding the scope of therapeutic horizons and optimizing treatment personalization. Emerging VR-enhanced psychological interventions leverage unique features that only VR can provide. Beyond its ability to create a sense of presence (the subjective feeling of being in a virtual environment as if the user is truly present within it), VR offers several specific advantages. First, it allows for the creation of personalized and interactive environments, often informed by a case formulation tailored to an individual’s unique background, to design VR experiences that capture their individual circumstances and needs. Second, VR enables the generation of entirely fictional scenarios, making it possible to simulate situations that are not feasible in the real world, such as interacting with exaggerated or impossible objects and environments (e.g., sticking one’s head out of an airplane window or having a conversation with Sigmund Freud). Third, VR facilitates body ownership illusions, giving users the subjective experience of owning a virtual body, which might be relevant for clinical applications (e.g., eating disorders, family therapy, meditation, etc). Finally, it harnesses the plasticity of the virtual self, meaning that individuals can try out various roles, personal characteristics, or identities in a more loosening way that in the physical world. This flexibility, or plasticity, allows for playful and transformative experiences where a person’s virtual identity can shift, enabling them to explore new behaviors, attitudes, and perspectives. This experience in virtual spaces can lead to real-world effects, such as changes in how people think, act, or even feel physically (Slater & Sanchez-Vives, 2022). In summary, VR initially demonstrated great potential in creating immersive illusions of changing one’s location, transporting users to simulated feared (e.g., making a person who is afraid of heights feel like they are on a high bridge) or stimulating environments (e.g., making persons who love nature feel that they are meditating in a beautiful forest). However, the scope of VR has since expanded, revealing an even greater capability: not only can it alter the sense of place or the stimuli, but it can also transform the self (Slater & Sanchez Vives, 2016; Slater & Sanchez-Vives, 2022). By leveraging these features when designing VR apps, individuals can experience and practice new personal characteristics, abilities or sensations about themselves, others and the world through their virtual selves, bringing forth a certain change of perspective (Gabarnet et al., 2023). In a way, VR might serve as a shortcut that takes clients to a more favorable position for change, by-passing limitations and rigidities imposed by chronic psychological problems. Therefore, the potential of VR-enhanced interventions extends far beyond simply recreating environments with phobic stimuli or for training specific skills. It opens up a wide range of possibilities to foster psychological improvement and personal change. For instance, clients can experience positive or relaxing stimuli, embody different avatars pretending to be another person (e.g., their partner, their brother, an assertive person, etc.), even embodying different racial or gender identities. Clients can also embody and interact with conflicting parts of themselves in VR, facilitating a dialogue between different aspects of their identity. Additionally, VR enables the externalization of symptoms, turning abstract experiences into tangible forms that individuals can see, engage with, and ultimately reshape their relationship with. Many key techniques from the various therapeutic approaches can be adapted to VR settings, allowing clinicians to harness its power to accelerate therapeutic processes, particularly when a transformative emotional experience is required. The primary goal of this In session issue is to detail some of the most leading-edge applications of VR in the field of psychotherapy. We believe the field is currently at a pivotal moment due to the increased accessibility of VR equipment, technological advances in the creation of complex multisensorial immersive environments, and the growing potential to integrate artificial intelligence into VR simulations. Considering these recent advancements, this issue presents five exemplary clinical case report that illustrate both the ”what” and the ”how” of VR usage in therapy, addressing a wide range of health problems, including chronic pain, sexual abuse, social anxiety, depression, and psychosis. To further understand these applications and the potential of VR for psychological intervention, we provide in this introduction to the issue a conceptual framework to help researchers and clinicians navigate how VR can be applied in psychological interventions. Thus, in the following section, we present a three-dimensional conceptual framework for classifying and designing VR-based interventions in psychotherapy. A framework to analyze VR-based applications in psychotherapy In this section we describe in a structured manner (i.e., dimensional map) different aspects that might be present in VR applications used in psychological applications. This provides a structured framework for understanding the design, implementation, and impact of VR interventions. More specifically, the proposed framework conceptualizes VR psychotherapeutic interventions along three key dimensions: Strategy, Focus, and Perspective. The purpose of this three-dimensional map is not merely to classify existing VR applications, but rather to provide guidance for clinicians and researchers in designing effective interventions and expanding therapeutic horizons (see Figure 1). In what follows, we will depict these concepts and offer some examples. INSERT FIGURE 1 ABOUT HERE Strategy The first dimension refers to the main therapeutic strategy employed within the VR experience. So far, we have identified three main common strategies used among existing VR applications such as Exposure, Training and Exploration . • Exposure : This has been the first and most widely used strategy for VR applications developed to be used in psychological interventions. Within these VR applications, clients are exposed to fear-inducing, phobic, or emotionally sensitive stimuli in an immersive virtual environment. For example, VR can help individuals with phobias to confront feared objects or situations or to assist individuals with PTSD in reliving traumatic memories in a controlled and safe space. The goal of exposure is to gradually reduce the intensity of the emotional or physiological response to these stimuli through repeated and controlled encounters. One of the key advantages of VR exposure is its ability to provide a highly controlled and gradual approach to desensitization. Unlike traditional exposure therapy, VR allows for the precise manipulation of stimuli, ensuring that the level of exposure is tailored to the client’s needs. Furthermore, VR can simulate an unlimited range of scenarios, not only in a highly realistic manner but also with enhanced, intensified, or even fictional elements that would be difficult or impossible to recreate in real life. The papers from Mayerbröker & Emmelkamp (2024) and Loucks et al. (2025) in this issue are clear examples of this strategy. • Training : In VR training, the focus is on facilitating behavioral change and the learning of new skills through practice within the virtual environment. For instance, this could involve the training of soft skills in situations such as giving a public talk, going to a job interview or trying to be assertive with a friend. VR’s immersive nature provides a unique setting for clients to rehearse and refine new skills, preparing them for real-world application. The paper by Navarro Moreno et al. (2025) in this issue contains some VR applications that can be categorized under this specific strategy on the strategy axis. • Exploration : This is a broad strategy that encompasses various possibilities for interaction and personal discovery. This approach allows individuals to immerse themselves in virtual environments to explore different aspects of their identity, engage in meaningful interactions with others, or connect with specific emotional states. For instance, clients may engage in conversations with their future selves or ideal selves, or conflicting positions, engage with emotions linked to personal loss (e.g., grief therapy), or focus on mindfulness practices to explore their mental and emotional states. Through exploration, clients gain insight into internal experiences, relationships, and emotions, facilitating a deeper understanding of themselves or their circumstances. In this issue, this strategy is used in Garcia-Gutierrez et al. (2025). In general, a VR application typically follows a primary strategy, but some scenarios allow for a combination of strategies or a shift depending on the therapeutic process. For example, an exposure-based strategy may evolve into training once anxiety reduction has been achieved, provided the scenario is sufficiently rich to support this transition. These categories are not mutually exclusive; rather, the strategy can adapt according to the dynamics of the therapeutic process. However, most applications, due to their technical characteristics, may be restricted to a single strategy. Focus The second parameter refers to the main focus of the intervention within the therapeutic process, ranging from focusing on various psychopathological aspects, attitudes, and/or more complex concepts such as identity and flourishing. Therefore, the Focus dimension illustrates a continuum that spans from addressing pathological symptoms to fostering personal growth, well-being, and flourishing, aligning with a dual model of mental health (Bohlmeijer & Westerhof, 2021; Keyes, 2005) • Symptoms : The interventions that focus on this level aim to directly alleviate symptoms of mental health conditions. For instance, they may target the reduction of pathological fear or avoidance behaviors, acute pain sensations, auditory hallucinations, violent behaviors, depressed mood, body image, etc. These interventions are often structured around symptom-specific therapeutic approaches and are designed to provide clients with controlled exposure to challenging situations or stimuli. A key advantage of VR-based symptom-focused interventions is their ability to create highly customizable and repeatable therapeutic experiences, offering a bridge between therapeutic exercises and real-world applications. For instance, a client with social anxiety might use VR to engage in simulated social interactions to build personal confidence and reduce fear as in the paper by Mayerbröker & Emmelkamp (2025). • Attitudes: Here the focus of the intervention is on shaping attitudes and implicit cognitive processes related to a wide range of behaviors and perceptions. This can include fostering prosocial attitudes (reducing prejudice, racism, ageism, or sexism); improving readiness to change; promoting goal setting; or facilitating acceptance of key clinical issues (body image, chronic pain). VR can create immersive scenarios that encourage perspective-taking, empathy, and self-reflection by allowing clients to experience life from different perspectives. For example, studies have used VR to facilitate shifts in implicit biases by inducing embodiment in avatars of different races or genders (e.g., Banakou et al. 2020). Similarly, VR can be applied to support the acceptance of one’s own body or condition by allowing individuals to explore alternative perspectives on their own experiences as described in Navarro-Moreno et al. (2025). • Identity and Flourishing : These interventions focus on the exploration and reconstruction of the self, or on creating experiences that promote subjective well-being and personal growth. Through immersive experiences, clients can explore new identities or reconsider their relationship with their current self, facilitating growth and self-reconstruction (Montesano et al., 2017). For example, clients may engage in experiences that encourage self-reflection, enhance self-esteem, or foster a sense of flourishing and relational well-being, as in our issue is explained in Garcia-Gutierrez et al. (2024). This dimension represents the primary focus through which change is intended to be facilitated, but it does not imply that only one aspect of human experience is being affected. We assume that therapeutic change is a co-constructed, dynamic, and interdependent process, and changes in one area will resonate in other aspects of human experience. For instance, changes in symptomatic behavior can influence implicit attitudes and cognitive schemas, and vice versa. Moreover, VR is often used as a tool within a broader therapeutic process where multiple mechanisms of change may be activated simultaneously. Thus, this dimension helps identify which aspect of experience is being prioritized to promote meaningful transformation at a given moment. As with Strategies, some advanced VR applications allow for multiple foci depending on the needs of the therapeutic process, although in general, the design prioritizes one as the main focus for intervention. Perspective The third dimension involves the perspective that the client (or even the therapist) adopts within the VR experience. This influences how the therapeutic process unfolds, depending on whether the client is viewing the world through their own eyes, from an external viewpoint, or even from multiple perspectives. This capability is unique to VR, as it allows clients to adopt perspectives other than their own through body ownership illusions (Slater & Sanchez-Vives, 2022). These immersive methods enable clients to experience different identities or viewpoints, potentially fostering deeper emotional and cognitive insights that would be difficult to achieve through traditional therapeutic approaches (e.g., role playing, or role exchange). So far, we can consider four main possibilities: • Self (1st Person Perspective): In this scenario, the client interacts with the virtual environment from the first-person point of view, typically using an avatar that represents their own identity. This perspective is essential for interventions that require personal embodiment, such as confronting one’s fears, practicing relaxation techniques, or engaging in a role-playing exercise that involves personal identity or decision-making processes. Most of the applications being reviewed in this issue adopt this perspective. • Other (1st Person Embodiment in Another): In some therapeutic contexts, the client may embody another person within the VR environment, experiencing the world through someone else’s eyes. This can be particularly effective for fostering empathy, perspective-taking, and challenging rigid cognitive or emotional patterns with respect to outgroup members or other persons. For instance, a person could embody a virtual body with a different race, gender, or age to gain insights into how these differences affect interpersonal interactions and attitudes. However, it is also possible to embody the avatar of a family member, a friend or any significant other, for instance, to engage in a difficult conversation as in the empty chair paradigm. Examples of this are provided in Peck et al. (2013) where virtual embodiment is exploited to reduce racial biases, in Seinfeld et al. (2018) where virtual embodiment in a female victim improves emotional recognition in male intimate partner offenders, and in Falconer et al. (2016) where having a self-dialogue from the perspective of another avatar promotes self-compassion feelings in clients with depressive symptoms. • Witness (3rd Person Perspective): In the witness perspective, the client observes the virtual environment or their avatar from an external, third-person viewpoint. This detachment can help the client analyze their behaviors, emotions, and interactions from a more objective standpoint, encouraging reflection and insight. However, studies have found that physiological responses to threats in the first-person perspective are significantly greater than in the third-person perspective (Slater et al., 2010; Slater & Sanchez-Vives, 2022). Therefore, it is the least recommended perspective to implement, although it is the only option for VR applications based on 360 videos. • Multi-perspective: In this configuration, the client alternates between multiple perspectives within the same VR session. For example, a client might experience a scenario from both their own viewpoint and that of another person involved, allowing them to gain a broader understanding of interpersonal dynamics. Multi-perspective experiences can enhance empathy and insight by offering a fuller, more complex experience of the VR scenario. A good example of this is provided in Osimo et al. (2015) and Slater et al. (2019) where participants are able to provide counselling to their self-avatar from the perspective of Sigmund Freud. This framework is intended to serve as a roadmap for those looking to harness the potential of VR in psychotherapy. As interventions mature and undergo further research, they are likely to become more complex, integrating multiple elements from across the different axes. However, even with this increasing complexity, most interventions maintain a clear focus that can be situated within the space defined by the three axes of Figure 1. Given the rapid pace of technological advancements, it is important to note that this framework will likely need to be revised or expanded in the near future. The evolution of VR technology is enabling researchers and entrepreneurs to overcome current limitations and develop more sophisticated therapeutic tools. For researchers, the map provides a comprehensive way to classify and analyze VR-based interventions across different therapeutic contexts. By organizing VR interventions along the axes of Strategy, Focus and Perspective, researchers can more effectively evaluate which types of interventions work best for specific conditions or therapeutic goals. This allows for more nuanced experimental designs and can guide the development of future VR tools based on empirical evidence. Additionally, the model highlights areas that may require further exploration, such as emerging uses of VR for identity reconstruction or multi-perspective experiences, thus paving the way for innovative research and clinical practices. For practitioners, this model serves as a practical guide to selecting and tailoring VR interventions to meet the needs of individual clients. By considering the main strategy, the focus, and the perspective needed, clinicians can choose the proper VR experience to achieve specific therapeutic outcomes. We hope that the framework can simplify the integration of VR into ongoing psychotherapy processes, regardless of the approach, offering clinicians a clear pathway to apply cutting-edge technology in their practice. PAPERS IN THE ISSUE The five contributions in this special issue are distributed across the space defined by the three-dimensional model, showcasing both emerging applications and those that have evolved through extensive research over multiple generations of VR interventions. These papers address a wide range of psychological issues, including chronic pain, PTSD due to military sexual trauma, social anxiety, depression, and psychosis. The VR interventions presented are informed by diverse theoretical approaches, such as cognitive-behavioral therapy, acceptance and commitment therapy, systemic approaches, and personal construct theory. Together, these contributions demonstrate the versatility and potential of VR as a tool for addressing complex psychological challenges while highlighting both well-established and innovative uses of this technology in psychotherapy. The first article addressing military sexual trauma by Loucks et al. (2025), illustrates how pioneering studies from the 90s have advanced to provide a highly personalized, detailed, and safe approach to tackling some of the most challenging issues in psychotherapy: sexual trauma. The authors effectively convey, with clinical wisdom and clarity, how to implement the process of VR-enhanced progressive exposure therapy in PTSD. This paper presents a compelling case study of William, a military veteran who survived a sexual assault by a higher-ranking male service member. The authors demonstrate how VR can be used to activate traumatic memories, facilitating emotional processing across sessions, leading to a significant reduction in symptoms. The paper also thoughtfully addresses common challenges encountered during VR exposure therapy and provides practical recommendations for clinicians. In the second paper, Navarro-Moreno et al. (2025) present the application of CLEVER-BODY, a VR-based intervention designed to improve body image and address chronic pain. This four-session intervention, aimed at John, a 48-year-old male with chronic low back pain, focuses on enhancing body awareness, acceptance, and appreciation of body functionality. Through immersive virtual environments John explored body-related information and how to react differently to unavoidable uncomfortable situations, which helped him to shift his focus from pain to more positive sensations. The intervention targeted key areas such as kinesiophobia, emotional distress, and pain interference. This study highlights the potential of integrating VR to complement traditional therapeutic approaches, particularly in fostering a more positive relationship with the body amidst chronic pain. The third contribution by Rus-Calafell et al. (2025) presents an evolution of the pioneering AVATAR Therapy (Leff et al., 2013), now enhanced with social scenarios in its new iteration named AVATAR_VRSocial. This therapy is specifically designed for individuals with schizophrenia who experience distressing auditory hallucinations. This innovative therapy creates a digital representation of the voice that the person hears, facilitating a dialogue between the individual and their perceived persecutory voice represented as an avatar. Over the therapy, the person confronts and gradually takes control of their experience by standing up to the avatar, whose behavior changes in response to the empowerment of the client. Importantly, the dialogue of the avatar that represents the persecutory voice is controlled by the therapist. In this case study, Laura, a woman who had been hearing a threatening voice for years, engaged in VR sessions where her negative voice was integrated into social scenarios such as a supermarket or a waiting room. These VR sessions allowed her to practice coping strategies, like assertively standing up to the voice and reducing safety-seeking behaviors, (e.g., avoid being alone or contacting others when distressed). Over the course of therapy, Laura experienced significant reductions in distress, social avoidance, and frequency of threat-related cognitions. Laura gained greater control over her life, showcasing how integrating VR into AVATAR therapy can enhance treatment outcomes and promote greater autonomy. The fourth contribution by Mayerbröker and Emmelkamp (2025) is a good example of how to use VR Exposure Therapy (VRET) for treating Social Anxiety Disorder. This paper explores how VRET offers a controlled, repeatable virtual environment for exposure therapy, helping individuals like Carolin, a 23-year-old woman with severe social anxiety to overcome her fear of negative evaluation. Carolin had avoided social interactions, leading to increased isolation. The treatment combined cognitive-behavioral therapy with VR, guiding her through virtual social settings, to practice making eye contact and managing interactions. Over time, she gained confidence in handling these anxiety-provoking situations, showing significant improvement in her social interactions without excessive distress. Garcia-Gutierrez et al. (2025) introduce a groundbreaking VR tool for self-identity exploration called Explore Your Meanings (EYME), the first of its kind. Unlike traditional approaches that rely on predefined personality categories, EYME is fully personalized, creating a unique virtual scenario for each individual based on their own personal values, perceptions, and significant interpersonal relationships. Using the repertory grid technique, EYME allows patients to navigate a multidimensional space that mirrors their personal meaning system and significant relationships, making the experience deeply immersive and tailored to each person’s inner world. The case of Mary, a 21-year-old woman with major depressive disorder illustrates the potential of EYME. Over 10 weekly sessions, Mary visualized her self-concept and internal conflicts, discovering her strengths and resolving personal dilemmas. This personalized approach facilitated deep self-reflection and identity reconstruction.

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Authors Metrics & Citations Metrics Article Usage 580views 363downloads Citations Download citation Adrián Montesano, Sofía Seinfeld. Virtual reality in psychotherapy: expanding therapeutic horizons. Authorea. 17 March 2025. DOI: https://doi.org/10.22541/au.174220930.04203839/v1 DOI: https://doi.org/10.22541/au.174220930.04203839/v1 If you have the appropriate software installed, you can download article citation data to the citation manager of your choice. Simply select your manager software from the list below and click Download. For more information or tips please see 'Downloading to a citation manager' in the Help menu.