Virtual Reality in Psychotherapy: A Commentary on Strategies, Interventions, and Perspectives From Five Clinical Reports

ABSTRACT

Virtual reality (VR) applications have shown significant potential in enhancing psychological interventions by evoking vivid emotional reactions and creating immersive environments. This commentary provides an overview of five clinical case reports illustrating the advantages and pitfalls of VR‐enhanced psychotherapy in social anxiety disorder, PTSD due to military trauma, auditory hallucinations, depression, and chronic pain. The case reports are analyzed with a dimensional framework designed to evaluate VR applications to be used in psychotherapy. The framework is based on three key dimensions: Strategy (e.g., Exposure, Training, Exploration), Focus (Symptom, Attitudes, Identity and Flourishing), and Perspective (Self, Other, Witness, Multiperspective). For example, the use of VR‐based body scan exercises in chronic pain management can enable the training of body‐related attentional skills helping individuals to not only focus on pain sensations, while VR exposure therapy helps clients with social anxiety or PTSD to confront feared situations, reprocess traumatic experiences, and develop coping skills. VR Avatar Therapy, on the other hand, enables individuals with auditory hallucinations to actually have a dialogue with the voices they hear since these are embodied in avatars controlled by therapists, promoting symptom externalization and self‐identity exploration. Finally, the Explore Your Meanings tool enables immersive multi‐perspective exploration of self‐identity in 3D immersive spaces where it is easy to visualize the differences between the perceived and ideal self. The cases demonstrate VR's unique ability to provide real‐time, dynamic treatment personalization, aligning with the trend toward individualized care in psychotherapy.

As discussed in each case report of the issue, numerous studies have demonstrated the potential of VR applications to enhance the effectiveness of psychological interventions (Bell et al. 2024). This enhancement is partly attributed to VR's ability to evoke vivid emotional reactions, which can in turn lead to significant attitudinal and behavioral changes. VR's capacity to create a strong sense of presence and plausibility—making users feel as if they are truly inside the virtual simulation where events are occurring (Slater 2009)—confers high ecological validity to this technology, thus unlocking unique and powerful possibilities for clinical psychology.

In this issue, we include five clinical case reports illustrating how VR can augment existing evidence‐based psychological interventions for treating social anxiety disorder, posttraumatic stress disorder (PTSD) due to military sexual trauma, auditory hallucinations, depression, and chronic pain. Our aim with this issue is to bridge the gap between research and clinical practice by bringing together clinical case reports that demonstrate step‐by‐step how therapists can integrate specific VR applications into broader psychological interventions. Moreover, these case reports also showcase the diversity and richness of the clinical tools that can be created with VR. In this final commentary we discuss the main clinical potential of the VR scenarios included in the issue, as well as analyze how each case fits into the dimensions of the VR framework for psychotherapy proposed by Montesano and Seinfeld (2025) and illustrated in Figure 1.

Figure 1.

Dimensions of VR as a tool for psychological intervention. Adapted from Montesano and Seinfeld (2025). Virtual reality in psychotherapy: expanding therapeutic horizons. Journal of Clinical Psychology. Within the figure: CLEVER 1 refers to the VR “body scanning exercise” and CLEVER 2 refers to the “unwanted neighbour” experience used by Loucks et al. (2025) and Garcia‐Gutierrez et al. (2025); BRAVEMIND is the VR application used by Loucks et al. (2025) for the treatment of military‐related posttraumatic Stress Disorder (PTSD); EYME represents the “Explore Your Meaning” application used by Garcia‐Gutierrez et al. (2025) to explore self‐identity; CLEVR.NET stands for the VR social scenarios used by Meyerbröker and Emmelkamp (2025) for the treatment of social anxiety disorder. Finally, AVATAR refers to the Avatar Therapy application used by Loucks et al. (2025) and Garcia‐Gutierrez et al. (2025) focused on helping clients who suffer auditory hallucinations.

First, we discuss the case report by Navarro‐Moreno et al. (2025) which focuses on improving the management of chronic pain. They employ the CLEVER‐BODY treatment protocol, which involves four therapy sessions designed to promote a positive body image and the acceptance of pain in John, a client suffering from chronic low back pain due to a work‐related injury. CLEVER‐BODY includes two VR scenarios: one designed to increase body awareness through an immersive adaptation of a body scan exercise and a second scenario where the client is immersed in a scene representing the “unwanted neighbor” metaphor to promote pain acceptance.

In relation to the VR body scan scenario, it is important to consider that in these types of exercises, clients are instructed to pay attention to different body parts and sensations with the objective of training attentional processes that enable the person to not only focus on negative bodily sensations, but also on positive and neutral ones. Traditionally, this type of body‐related attentional exercises is facilitated by a therapist who asks the client to focus on different body parts with closed eyes. In VR, the immersive nature of the scenarios facilitates that clients concentrate solely on the body scan exercise, since they are fully surrounded by the sensory information displayed through a head‐mounted display, including visual, auditory, and proprioceptive cues (Arpaia et al. 2022). Moreover, when performed in VR, Body Scan exercises may further enhance focus on various body parts by providing richer visual and auditory feedback on a virtual body that the person may also experience as their own real body given congruent multisensory stimulation (Döllinger et al. 2021).

The second VR scenario included in CLEVER‐BODY utilizes the “unwanted neighbor” metaphor, often used in therapy to promote body and pain acceptance. Commonly, therapists convey such metaphors through spoken narratives. However, VR immersive scenarios enable clients to not only imagine the metaphor but also to engage in a realistic, first‐person interactive experience which makes it possible to directly experience the metaphor as if it was happening. Such experiential learning in psychotherapy has the potential to improve engagement, critical thinking, and information retention, as evidenced by several studies (Hwang et al. 2022). In the present clinical case report, living a metaphor in VR helped the client to learn new coping strategies for chronic pain, enhanced his pain acceptance, and he also gained insights into the importance of pursuing life goals despite persistent pain.

On the one hand, the main strategy of the body scan application was Training, as it helped the client learn to pay attention to positive bodily states rather than focusing solely on pain sensations. The focus was to reduce pain‐related Symptoms by diverting attention away from it. On the other hand, the main strategy of the unwanted neighbor scene was Exploration, as John was able to discover a new facet of himself. Through a metaphor, he learned to cope with an unwanted situation differently (e.g., the neighbor representing pain), realizing that he can still enjoy pleasurable experiences despite the persistence of pain. Therefore, in this case, the focus of the experience was Attitudinal Change. Both VR applications promoted experiential hand‐on learning, since they were experienced from the first‐person perspective of a Self‐Avatar.

Although VR has been proven effective in the management of acute pain, one of the innovative aspects of the CLEVER‐BODY app is its demonstration of how VR can also be used to better manage chronic pain and improve body image. Furthermore, an additional novel feature of the present case report is how VR is exploited to vividly and powerfully represent therapeutic metaphors, as is the case of the “unwanted neighbor” immersive scenario.

Meyerbröker and Emmelkamp (2025) case report is centered on the use of Virtual Reality Exposure Therapy (VRET) for treating social anxiety disorders. They present the case of Carolin, a young woman with high anxiety and avoidant behaviors in nearly all social contexts. The case report shows how VRET performed in various simulated social environments of a VR app named CleVR.net enabled Carolin to confront several feared situations—such as making eye contact with a cashier in the supermarket, asking for a product in a shop, and engaging in small talk with a stranger on a bus. VRET was carried out as part of Carolin's therapy sessions and under the constant real‐time guidance of her therapist. This helped Carolin to gradually feel more comfortable and confident in these simulated social situations, which then transferred to real‐life scenarios. By the end of treatment, she could handle similar real‐life situations without avoidant behaviors and with significantly reduced anxiety.

From a clinical perspective, VRET and imaginal exposure are the only methods that allow a client like Carolin to be exposed to social situations within therapy sessions rather than out of a therapeutic context. However, imaginal exposure can be problematic for clients with limited imaginative capacity or severe avoidant behaviors. VRET carried out with the CleVR.net application addresses these limitations by providing highly realistic social scenarios where clients feel as if they are truly present, regardless of their ability to imagine hypothetical situations. Unlike imaginal exposure, VRET allows therapists to control and design the content of an exposure session precisely. Meyerbröker and Emmelkamp (2025) highlight that In Vivo exposure is often less effective for social anxiety disorders compared to other phobias due to the unpredictable nature of social situations, which complicates the creation of a hierarchy of gradually more challenging scenarios. In this regard, VRET has enormous clinical potential for exposure therapy since it can simulate specific feared situations, that then the therapist and client are able to sequence according to the therapeutic needs, allowing repeated practice until the client feels confident.

The main strategy of the CleVR.net virtual scenes used in Meyerbröker and Emmelkamp (2025) was Exposure. The intervention aimed to reduce the clients' degree of experienced social anxiety in everyday situations, therefore the experienced Symptoms. Finally, the different VR exposure scenarios used in this social anxiety case were experienced from the client's perspective, to create the sense that she is actually exposing herself to the feared situation, thus from a Self‐perspective.

Loucks et al. (2025) describe a clinical case in which Bravemind, a VR‐based exposure therapy tool designed for the assessment and treatment of post‐traumatic stress disorder (PTSD), is used to treat William. William is a military veteran with PTSD resulting from military sexual trauma. Bravemind is leveraged to help William to emotionally reprocess a traumatic experience by exposing him to virtual scenarios that match several details of the sexual abuse he suffered when he was in military service (e.g., time of the day, location, other people present, etc). The use of this VR tool helped William to effectively reprocess the trauma and think of himself differently. At the end of the intervention, there was a significant reduction in distress and avoidance behaviors towards harmless everyday situations that reminded William of the trauma.

In this regard, In Vivo and VR‐based exposure therapy aims to activate feared structures to help clients emotionally reprocess pathological aspects of feared stimuli. Repeated exposure is expected to reduce anxiety through habituation and help clients learn new coping skills, as in the case of William and Carolin. However, unlike certain phobias or social anxiety disorders, in PTSD is frequently unethical, impractical, and even impossible to expose the client to the traumatic event in real life. For instance, asking a military veteran to relive a combat or sexual abuse situation in real life is not possible and ethical. In contrast, it would not be unethical or impossible to ask a person with social anxiety to expose herself to talk with some stranger on the bus. This is why Bravemind, as well as other digital tools focused on VRET, are unique and valuable tools for PTSD treatment since they can complement the client's narrative by providing realistic and immersive stimuli that enhance the reprocessing of traumatic events (Eshuis et al. 2021). This is specially relevant because several patients with PTSD find it difficult to recall the traumatic event through imaginal exposure due to emotional blockage.

Loucks et al. (2025) case report also emphasizes the clinical relevance of Bravemind adaptability. It is very interesting that in this case the therapists can easily modify the VR content in real.time using a “Wizard of Oz” control panel. This enables the therapist to quickly adjust parameters such as the number of avatars, types of avatars, time of day, sounds, objects, and actions of the VR scene based on the client narrative. Such flexibility makes this type of VR tools highly useful in psychotherapy, allowing therapists to tailor standard VR scenes to individual clients' needs without requiring to develop unique scenarios for each person, which would be time‐consuming and costly. Advances in generative artificial intelligence and automated 3D content generation may further streamline this process in the future.

Following the framework proposed by Montesano and Seinfeld (2025), the strategies used in Loucks et al. (2025) were mainly focused on Exposure to stimuli related to the traumatic event to promote emotional reprocessing and habituation. In this particular case, Bravemind helped the patient to reduce his Symptoms (anxiety) when confronted with stimuli that reminded him of the trauma. Similarly to previous cases, William was exposed to this VR scenario from a first‐person Self‐Perspective.

Despite that the case reports by Meyerbröker and Emmelkamp (2025) and Loucks et al. (2025) are based on one of the most extensively studied and validated applications of VR—exposure therapy—they incorporate innovative elements, such as demonstrating how it is becoming increasingly feasible to personalize VR experiences in real time based on clients' needs. In both cases, therapists maintain a high degree of control over the VR scenarios presented to the clients, allowing them to customize scene elements according to the goals of each session and to introduce interactive components that enhance engagement.

Rus‐Calafell et al. (2025) clinical case represents one of the most recent and novel uses of VR in psychotherapy. The authors are pioneers in creating a VR version of an intervention known as AVATAR Therapy for the treatment of auditory hallucinations (Craig et al. 2018). In this intervention clients who suffer auditory hallucinations due to a psychotic disorder are able to establish a dialogue and confront the voice they hear in VR. Interestingly, the voice is embodied in an avatar that the patient can see in an immersive VR environment, and it is the therapist who controls the dialogue of the avatar after exploring the type of distressing comments experienced by the client. The voice is also artificially modulated to match the tone and pitch of the voice patients hear. A series of studies have shown that this is a very promising intervention to reduce auditory hallucinations, which can even make auditory hallucinations disappear, as well as help the patient acquire effective coping skills to deal with the distressing voice (Craig et al. 2018).

In their clinical case report, Rus‐Calafell et al. (2025) present an extended version of the VR AVATAR Therapy where the client, Laura, is first provided with standard treatment based on confronting a hallucinatory voice through dialogues. Importantly, the voice is embodied in an avatar and controlled by the therapist. Currently, there is no other technology that allows a patient to see, hear and talk with a symptom (hallucinatory voice) in such a realistic manner, with the important advantage that the therapist can embody the voice represented as an avatar and control the content of its discourse depending on the desired therapeutic outcomes.

Compared to the traditional AVATAR intervention, in this case report three additional VR sessions are provided where Laura not only learns how to better cope with the voice she hears, but also how to deal with it in simulated virtual social situations. These further illustrate how VR enables the creation of virtual scenarios with high ecological validity in which the patient can practice strategies to effectively deal with the distressing voice not just in neutral scenarios, but also in everyday social situations, possibly having a stronger impact in the patient's real life. Overall, this case report nicely exemplifies the power of VR for symptom externalization, since with this technology it is possible to represent symptoms in an immersive and realistic manner to help clients face them and regain control over them.

Based on our framework for analyzing VR applications used in psychotherapy, the primary strategy in Laura's first AVATAR therapy sessions was Exposure. The goal was to help Laura confront the feared stimulus (hallucinatory voice) with a focus on reducing her anxiety Symptoms. However, in more advanced stages of therapy, once a significant reduction in anxiety toward the voice had been achieved, AVATAR therapy was also used with a target of Exploration, by putting the focus on enabling Laura to explore how the hallucinatory voice affected her self‐identity. During this process, she was able to explore and reconstruct negative perceptions of her Identity related to the distressing comments of the voice. In AVATAR therapy, clients deal with the voice in VR from a Self‐Perspective, but interestingly in this case the therapist changes his perspective to Other, since he embodies and controls the avatar that represents the voice that the patient hears, allowing for multi‐perspective within the same application.

Finally, the clinical case of Garcia et al. (2025) describes the use of Explore Your Meaning (EYME), a VR application designed to explore self‐identity and internal conflicts in an immersive way. EYME is a VR visualization therapeutic tool that allows patients to explore their “maps of meanings.” More specifically, with the guidance of the therapist, patients can explore how they define their ideal‐self, their self‐now, and significant others in an immersive 3D environment, as well as the poles of these definitions. The visualizations are built based on the results obtained in the Repertory Grid Technique (Fransella et al. 2004). The paper presents the case of Mary, a young woman meeting criteria for major depressive disorder and social phobia. In this case EYME was used as part of a wider treatment protocol (10 weekly sessions) focused on changing personal constructs, cognitive schemas, and internal conflicts. The authors found that EYME helped Mary to identify how she perceived herself before therapy (naive, negative), her strengths (empathetic, good person), as well as her internal conflicts (becoming smart entailed being selfish for the person). Moreover, EYME also helped Mary to attribute new meanings to herself based on the insights acquired in therapy, as well as detect future areas of improvement in relation to her personal identity. The development and use of EYME further shows the potential that VR has for visualization in clinical psychology. In terms of innovation, EYME might make it easier for clients to visualize the poles of psychological constructs (personal meanings) and understand abstract concepts, because individuals can see all this information in a 3D immersive environment that allows spatial exploration, while at the same time these constructs are discussed with the therapist.

In accordance with our proposed VR framework, the present case report's strategy was Exploration, with Self‐Identity being the main target of the intervention. In EYME, Mary was able to explore her personal “maps of meaning” in a 3D immersive environment. This exploration in VR was performed from a Multi‐Perspective, since she was able to see how significant others and relatives were represented in the 3D space while also making it possible to adopt their perspective based on the therapist's guidance.

Building on the insights from the clinical cases included in this issue, it is important to consider the current trends and future directions of VR in psychotherapy. This includes the growing emphasis on treatment personalization, the advancements in monitoring clients' progress during VR‐based interventions, and some areas that were not addressed in this issue due to space limitations but are important to briefly discuss such as counselors' perceptions in relation to VR adoption in psychotherapy and its use in different therapeutic contexts. Finally, we briefly comment on how the evolving commercial landscape influences how therapists access and implement VR tools in their clinical practices.

Personalization of treatments has become one of the most significant areas of development in contemporary psychotherapy to optimize treatment outcomes (Nye et al. 2023). Usually, this personalization involves determining the appropriate treatment package, selecting treatment components, identifying therapeutic targets, or matching clients to specific therapists. In this context, VR offers a unique advantage: it enables real‐time content personalization, allowing the therapy to adapt dynamically to the client's needs and responses as they arise. Moreover, some VR applications are specifically designed to facilitate high levels of personalization. For example, certain tools create unique scenarios for each client based on initial interviews (as seen in the work of Garcia‐Gutierrez et al. 2025), enable therapists to interact directly with the client within the virtual environment (as described by Rus‐Calafell et al. 2025), or incorporate various personalized elements for a highly tailored experience (as in Loucks et al. 2025 or Meyerbröker and Emmelkamp 2025). In the past, achieving this level of content personalization in VR was a complex challenge due to all the technical expertise required for the implementation of virtual scenarios. However, with the advent of AI and more advanced programming techniques, it is becoming increasingly feasible to easily implement 3D environments. Overall, the capacity for such customization appears to be one of the primary paths for VR development in psychotherapy in the coming years. This adaptability not only enhances the therapeutic process but also aligns VR with the broader trend towards individualized care in mental health.

In monitoring clients' progress during VR‐based treatment, research indicates that using a variety of measurement tools yields the most accurate assessment (Wiederhold and Wiederhold 2000). These tools range from subjective self‐reports to objective physiological measures which play a crucial role in identifying emotional and high‐level cognitive processing during therapy. For example, heart rate variability, skin conductance, and gaze behavior can provide insights into the client's emotional state and engagement level. For instance, eye‐tracking research has categorized user emotions with an accuracy ranging from 60% to 90%, while devices like smart bracelets that monitor heart rate can help identify mood states with clinical relevance (Lim et al. 2020; Shu et al. 2020). Automated procedures, such as pupillometry or smart watches that assess physiological states, are expected to become increasingly integrated as real‐time signals for therapists, offering a more nuanced understanding of the client's in‐the‐moment responses and enabling timely therapeutic adjustments.

Despite a growing body of evidence demonstrating the applicability and efficacy of VR applications in psychotherapy, their adoption in mainstream clinical settings remains very limited (Wray et al. 2023). Research exploring psychotherapists' perceptions of VR has revealed that, although numerous practitioners acknowledge benefits of using VR such as enhanced treatment effectiveness, increasing clients' motivation, and providing new possibilities in therapy, significant barriers to adoption persist (Sebri et al. 2020). As noted by Felnhofer et al. (2025), these barriers are mainly professional (e.g., lack of knowledge, training, time, or personal hesitancy), financial (e.g., high costs, unfavorable cost–benefit ratio), therapeutic (e.g., concerns about clinical applicability or the authenticity of the therapeutic relationship), or technological (e.g., underdeveloped systems, cybersickness, or lack of access to equipment). Therefore, to promote the broader adoption of therapeutic VR, efforts should focus on comprehensive education, specialized trainings programs (e.g., in‐person and online), development of clinical guidelines, professional mentorship, institutional and financial support, and further software developments to ensure successful and easy implementation in clinical practice (Jeon et al. 2025; Felnhofer et al. 2025; Wray et al. 2023). The conceptual framework provided by Montesano and Seinfeld (2025), as well as the case reports included in this issue, represents an initial contribution for helping practitioners understand, select, and integrate VR applications in psychotherapy.

Interestingly, it is currently possible not only to incorporate therapeutic VR scenarios into therapy sessions under the guidance of a counselor, but also to develop automated psychological interventions in VR, in which a pre‐programmed virtual coach guides the client through the various steps of a treatment program. For instance, randomized controlled trials have demonstrated the effectiveness of such automated interventions in reducing fear of heights (Freeman et al. 2018) and agoraphobic avoidance in patients with psychosis (Freeman et al. 2022). Analogous to internet‐based interventions, these developments expand the possibilities for between‐session assignments, allowing therapists to encourage clients to practice therapeutic skills at home using immersive and engaging VR environments. Moreover, they pave the way for the creation of fully automated, stand‐alone VR‐based interventions, enabling individuals to complete all or most of their treatment independently. The rapid growth of large language models and artificial intelligence is further broadening these horizons, as it is now feasible to develop AI‐powered virtual reality therapists. Of course, such possibilities raise several ethical concerns, but they also offer the opportunity to promote mental health on a large scale and make psychological interventions accessible to a wide range of populations who might not otherwise have access (Grodniewicz and Hohol 2023).

Due to space limitations, this issue has not covered certain areas where there is significant accumulated evidence and well‐developed applications of VR. Notable examples include its use in eating disorders, addiction, autism, and neurorehabilitation (Matamala‐Gomez, 2021). Additionally, we did not discuss the evidence showing that treatments incorporating VR tend to be well‐accepted by individuals, with low dropout rates. We also did not explore the current commercial landscape of VR applications and how clinicians can access these tools. While frequently the most advanced applications often reside within university laboratories with limited opportunities for large‐scale dissemination and exploitation, there has been a proliferation of companies offering VR solutions. These companies provide packages of VR scenarios and applications that clinicians, both in hospital settings and private practices, can implement with their clients through a monthly subscription model. It will be important to monitor how these commercial offerings are received and adopted by clinicians and therapists in the near future to identify the specific demands and needs practitioners may have. To ensure the scalability and sustainability of VR solutions, fostering stronger collaboration between researchers and industry is essential. Additionally, partnering with clinical service providers is crucial to creating models that integrate VR‐based treatments into everyday clinical practice.

Finally, we would like to highlight that, although all the case reports included in this issue present innovative features to varying degrees, our goal was not only to showcase novel VR applications, but also to provide therapists with a practical guide on how VR can be integrated into therapy—even when using well‐established, long‐standing VR tools. As previously discussed, there remains a significant gap in the adoption of VR technologies in real clinical practice, partly due to the lack of proper training and educational resources, such as those offered by the case reports and accompanying commentaries in this issue. Therefore, we hope that these materials will be of great value to the community of therapists interested in applying VR within psychotherapy.

Conflicts of Interest

The authors declare no conflicts of interest.