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. 2025 Aug;22(4):320–326. doi: 10.36131/cnfioritieditore20250406

Virtual Meets Reality: A Psychodynamic Perspective on Immersive Technologies

Chiara Rossi 1,2, Fabio Frisone 1,2,3,4, Giuseppe Riva 1,2, Osmano Oasi 1
PMCID: PMC12453031  PMID: 40989042

Abstract

Objective

Virtual Reality (VR) is gaining increasing attention for its ability to support psychological interventions by offering immersive, interactive, and emotionally rich environments. While VR has been widely adopted in cognitive-behavioral treatments, especially for conditions like anxiety disorders, post-traumatic stress disorders, and phobias, its use within psychodynamic and insight-oriented therapies is still in its early stages. This paper explores how VR may serve as a valuable complement to psychodynamic work by enabling patients to connect with unconscious processes, relational patterns, and emotional experiences in new and innovative ways.

Method

Building on foundational psychoanalytic concepts, such as reality testing, unconscious fantasy, transference, and transitional objects, the paper examines how VR experiences can activate symbolic and affective dimensions of the psyche.

Results

In virtual immersive environments, patients can project inner conflicts, interact with avatars that represent aspects of the self or significant others, and engage in emotionally charged narratives that support insight and self-reflection. VR’s embodied qualities, like avatar identification and real-time bodily synchronization, further support this process by offering new modalities for exploring identity, body image, and dissociated self-states. However, realizing VR’s full therapeutic potential requires addressing a set of practical and theoretical challenges These include variability in individual responses, risks of disorientation or cybersickness, and the possibility that excessive environmental control could inhibit spontaneity and symbolic elaboration. Additionally, technical and financial barriers can also make the integration difficult. Along this line, VR should not be seen as a replacement for traditional psychotherapeutic methods, but rather as a flexible tool that, when thoughtfully embedded within a psychodynamic framework, can deepen the therapeutic encounter.

Conclusions

By offering new routes to emotional and symbolic exploration, VR expands the analytic setting into a dynamic and embodied space, inviting clinicians to engage with emerging modalities while preserving the depth and specificity of their practice.

Keywords: virtual reality, immersive technology, psychodynamics, self-reflection, intersubjective experience

Introduction

Virtual Reality (VR) is gaining prominence in psychological research because of its capacity to create multisensory and interactive environments that elicit authentic emotional responses. As an embodied, cognitive, and simulated technology, VR promotes a strong sense of presence and deep immersion within virtual scenarios (Riva, 2005). These qualities make VR a valuable tool for studying emotion and behavior in both realistic and imaginative contexts, offering high ecological validity without sacrificing experimental control (Andreatta et al., 2023; Baker & Fairclough, 2022).

Clinically, VR has shown effectiveness across a range of psychiatric conditions, including anxiety disorders, post-traumatic stress disorders, eating disorders, and schizophrenia, by facilitating exposure, emotional regulation, and cognitive restructuring in controlled, replicable settings (Boeldt et al., 2019; Di Natale et al., 2024; Emmelkamp & Meyerbröker, 2021; Freeman et al., 2017; Gainsford et al., 2020; Kothgassner et al., 2019; Valmaggia et al., 2016).

Technological advancements such as head-mounted displays, motion tracking, and AI-integrated biosensors have enhanced the capacity of VR to respond in real time to user input, reinforcing a sense of embodiment and deepening emotional engagement (Mancuso et al., 2023; Riva, 2022). Innovative experimental projects such as ARCADIA VR exemplify this potential by integrating artificial intelligence and biosensing technologies to deliver personalized treatments tailored to individual clinical profiles, functioning as a VR protocol designed to support cognitive-behavioral therapy (CBT) (Riva et al., 2023).

While VR's clinical applications are well established within cognitive-behavioral approaches, its integration into psychodynamic and insight-oriented therapies remains relatively nascent (Li et al., 2017). Nonetheless, the broader digital transformation of mental health care, marked by teletherapy, virtual environments, and digitally mediated embodiment, calls for a reconsideration of how psychodynamic psychotherapy might engage with these evolving modalities (Oasi et al., 2023). VR challenges classical notions of therapeutic presence, authenticity, and relational immediacy, while simultaneously opening novel avenues for emotional exploration and symbolic interaction. For instance, digital avatars as customizable representations of the self may offer patients a way to explore identity, relational patterns, and unconscious material from a distanced and potentially safer perspective. The combination of perceived anonymity, symbolic displacement, and altered presence can reduce psychological defenses and foster emotional expression and insight (Frisone et al., 2024; Kahan, 2000).

Early evidence suggests that psychodynamic constructs can indeed be activated in VR contexts. Slater et al. (2019) found that users who embodied alternative avatars engaged in reflective self-dialogue enriched by embodied cues such as movement and voice tone, transforming introspection into a relational, experiential process. Similarly, techniques like perspective-taking can be operationalized in VR by allowing patients to embody avatars representing significant others. This facilitates empathy, enhances reflective functioning, and encourages insight into how one’s behavior might be perceived intersubjectively (Zhao et al., 2023).

The psychotherapeutic potential of VR may be conceptualized through its affinity with traditional projective psychological instruments, such as the Rorschach Inkblot Test or the Thematic Apperception Test (TAT), which elicit unconscious material through symbolically charged and emotionally evocative stimuli (Werbart, 2014). However, VR extends beyond these graphic projective tools by offering dynamic and interactive environments that simulate relational encounters and identity-relevant scenarios. These immersive simulations engage mechanisms of role enactment and experiential learning, both of which are associated with the development of reflective capacities. Supporting this, findings from simulation-based education in clinical psychology highlight the efficacy of experiential role-play in enhancing practitioners’ confidence and therapeutic competence (Sheen et al., 2021), suggesting translational relevance for psychotherapeutic applications. Moreover, narrative structures inspired by TableTop Role-Playing Games (TTRPGs) provide an additional theoretical framework for understanding VR’s psychodynamic dimensions. TTRPGs employ structured narrative and relational scaffolding, enabling participants to explore internal conflicts and interpersonal patterns through symbolic identification with fictional roles and scenarios. This ludic-narrative format supports the symbolic elaboration of psychodynamic material, facilitating key processes such as transference, projection, and transformation (Scalone, Schimmenti et al., 2024). In this respect, VR can be conceptualized as a hybrid medium that integrates projective, experiential, and narrative mechanisms, constituting a multimodal space conducive to symbolic elaboration and psychotherapeutic intervention.

By simulating relational encounters, emotional narratives, and identity-related experiences, VR creates a symbolic and experiential space for engaging with internal conflicts and defenses. Thus, VR represents both a challenge and an opportunity for psychodynamic clinicians and theorists seeking to expand the boundaries of therapeutic practice in the digital age. It invites a rethinking of how unconscious processes, such as projection, transference, and reality testing, may unfold in immersive environments that blur the line between inner and outer worlds.

This paper aims to critically evaluate the relevance and applicability of VR within a psychodynamic framework, examining how it might enhance therapeutic work through three core dimensions: (1) the dynamic between fantasy and reality, (2) the symbolic function of VR environments, and (3) the evolving relationship between the self, the body, and the avatar.

Between Fantasy and Virtual Reality

In psychoanalytic theory, the distinction between internal representations and external reality, referred to by Freud as reality testing, constitutes a foundational construct, denoting the individual’s capacity to differentiate between intrapsychic phenomena and objective external events (Freud, 1911, 1923). Classical metapsychology further posits that unconscious processes, primarily originating in the id, exert a significant influence on perception, affect regulation, and behavior, often bypassing conscious control (Freud, 1900). However, contemporary psychodynamic perspectives have expanded the notion of the unconscious to encompass not only repressed content but also implicit relational patterns, procedural memory, and embodied affective responses that shape experience in a non-reflective, prerepresentational manner (Fodor, 1998; Kepner, 2008).

Within this broader theoretical framework, VR environments may be conceptualized as immersive experiential spaces capable of activating unconscious processes through symbolic, sensory, and relational affordances. These environments afford a shift from the classical stimulus-response paradigm to one in which affectively and relationally charged material emerges during the immersive interaction itself. For instance, avatar-mediated exchanges, emotionally salient narratives, and spatial configurations may operate as transferential triggers or projective surfaces, prompting the emergence of internal object relations and unconscious affect. Such responses may manifest through embodied reactions, shifts in posture or voice, or pre-reflective intuitive responses, phenomena interpretable as indicators of implicit emotional knowledge (Fodor, 1998).

From a clinical standpoint, the therapeutic

significance of these processes lies in their potential to be accessed and worked through either during or after the VR session. The virtual environment, in this view, may function as a "transitional space" in the Winnicottian sense (Winnicott, 1951), enabling symbolic elaboration of dissociated self-states or internal conflicts. This conceptualization aligns with recent findings in microprocess analysis and meaning co-construction, which emphasize the dynamic and relational unfolding of therapeutic insight in real time (Nabzo et al., 2023).

In addition to post-session elaboration, the immersive immediacy of VR warrants specific attention. Contemporary research highlights the role of flow, a psychological state marked by focused attention, perceived control, intrinsic motivation, and altered temporal perception, as a key therapeutic mechanism in VR settings (Bocci et al., 2023). When narrative immersion is combined with emotional and cognitive challenge, users may enter a flow state that facilitates a heightened sense of presence, defined as the subjective experience of being physically and emotionally situated in the virtual environment. This experiential configuration enables affective activation and symbolic interaction in real time, potentially catalyzing the emergence of unconscious material without requiring explicit instruction or interpretation.

These phenomena position VR as a therapeutic space that can vary across different modalities: (1) post-session dialogic reconstruction of the VR encounter, (2) synchronous observation via screen casting, or (3) full co-immersion, where the therapist and patient participate jointly within the VR environment. Each modality entails a distinct level of shared experience and therapeutic attunement. These differences may influence the timing, depth, and relational context of interpretive interventions and merit empirical investigation.

A conceptual precedent for VR-based psychodynamic interventions may be found in Melanie Klein’s (1958) theory of unconscious fantasy, in which symbolic play serves as a vehicle for elaborating internal drives, defenses, and object relations. Klein’s clinical work with children utilized imaginative scenarios to access unconscious dynamics. While VR constitutes a more technologically mediated form of engagement, its symbolic and experiential function is analogous: both media facilitate symbolic enactment within a relationally meaningful and affectively charged space. This perspective also builds on Lingiardi’s (2008) notion of cyberspace as an emotionally meaningful extension of the analytic setting. While Lingiardi’s discussion centers on digital communications such as emails and messaging, the underlying concept can be extended to VR environments, provided they are embedded in a co-constructed therapeutic context and employed reflectively by the therapist as part of the ongoing analytic frame.

Recent studies support VR’s potential to enhance empathy, perspective-taking, and mentalizing capacities central to both insight-oriented therapy and psychological growth (Gerry et al., 2022; Kizhevska et al., 2023; Ventura et al., 2020). In VR, patients may interact with lifelike avatars displaying realistic behaviors and emotions, facilitating reflection on their own reactions and those of others. This can deepen awareness of internal states, motivations, and relational patterns. Such perspective-shifting experiences echo the therapeutic aim of broadening reflective functioning and reducing egocentricity.

Contemporary psychotherapy techniques, particularly those highlighted by the Boston Group perspective (Beebe, 2020), stress the significance of integrating new experiences gained by the patient during therapy. Indeed, the capacity to fully immerse oneself in virtual environments can result in increased emotional investment and comprehension of other people's experiences, both of which are essential for the growth of empathy and empathic responses. In this context, emotions and sense of presence elicited by immersive videos are comparable with those evoked by real-life scenarios (Chirico & Gaggioli, 2019). A compelling example of VR’s reflective potential is provided by Osimo et al. (2015), who developed a paradigm in which participants engage in a dialogue with a virtual representation of Freud. After stating their concerns, participants switch avatars and respond from Freud’s perspective, thus hearing their own narrative from an altered standpoint. While the structure resembles the Gestalt "empty chair" technique, the process also supports psychodynamic mechanisms of identification, symbolic role reversal, and integration of self-states. When integrated within a broader therapeutic framework, such interventions may facilitate affective transformation and insight.

A (Virtual) Symbolic Space

Although VR is a technologically mediated tool, it generates a deeply personal experience of presence, allowing users to feel as though they are truly “inside” the environment. This immersive quality arises through the convergence of visual and auditory cues, interactivity, and emotional engagement, while minimizing external distractions (Riva, 2022). As such, VR becomes more than a digital interface; it becomes a symbolic field in which internal states are projected, represented, and reworked.

Winnicott’s (1951) concept of the transitional object offers a valuable lens for understanding VR’s therapeutic potential. In early development, a child uses transitional objects, such as a blanket or stuffed toy, to mediate the shift from dependence to autonomy. These objects exist in an intermediate space, neither fully internal nor external, and support the child’s emerging sense of self. Analogously, VR can function as a kind of third transitional object in therapy: a shared experiential space in which the patient’s internal world is externalized and engaged with symbolically, often through avatars, environments, or narratives. This symbolic function is not merely cognitive, it is emotional and relational. The VR setting, like the child’s imaginative play, becomes a medium through which unconscious content can emerge, be symbolized, and eventually integrated.

Certain VR applications or narratives may take on the qualities of subjective objects, allowing patients to project aspects of the self onto digital characters or symbolic elements. The externalization of projections within a virtual environment may render unconscious material more accessible for therapeutic interpretation and reflective processing. In this sense, immersive VR can facilitate processes analogous to symbol formation, which psychodynamic theory defines as the transformation of raw affect into structured, representational forms that can be thought about and communicated (Ogden, 2007, 2018). Although Ogden does not explicitly refer to VR, his conceptualization provides a valuable theoretical framework for understanding how immersive technologies might support the emergence of symbolically mediated affective experiences. Moreover, VR may play a role in the creation of what Ogden (2007) terms the analytic third, a co-constructed intersubjective space between therapist and patient. Within a VR context, this third is technologically mediated yet symbolically meaningful, offering a dynamic setting in which unconscious content can emerge and be elaborated. Interpretation, in this setting, may extend beyond verbal exchange to include the patient's embodied interaction with symbolic elements embedded in the virtual environment. Affective reactions such as discomfort, resonance, avoidance, or emotional intensification during the VR experience can thus serve as clinically relevant markers, guiding deeper psychodynamic exploration.

The Body and the Avatar

If VR can serve as a symbolic space in which unconscious material is projected and elaborated, it also offers a unique medium through which the body itself (real, virtual, and imagined) enters the therapeutic dialogue. One of VR’s most powerful affordances is its ability to create a sense of embodiment: the feeling of occupying a virtual body that moves in synchrony with the user’s own physical movements. This experience goes beyond visual or auditory stimulation, engaging deeper processes of identification, projection, and bodily awareness (Slater, 2018). Within a psychodynamic framework, this dynamic opens new territory for exploring the often-fragmented relationship between the self and the body. Drawing on Lacan’s (2014) theory of the mirror stage, the avatar in VR can be seen as a technologically mediated mirror image that both enables recognition and evokes alienation. In Lacan’s model, the mirror stage involves identification with an external body image, producing an illusion of unity while introducing a split between internal experience and external representation. Similarly, avatars in VR may serve as surfaces for identification, expressing dissociated or idealized aspects of the self. This view aligns with González-Campo et al. (2013), who argue that avatars reflect unconscious desires and function as projections of the ideal ego. While Lacan did not address digital technologies, his framework remains useful for examining self-representation in immersive environments. These dynamics may support therapeutic exploration of body image, identity, and symbolic elaboration in VR-based psychotherapy.

Object relations theory provides a valuable framework for understanding psychological processes activated during immersive VR experiences. According to Klein (1958) and Winnicott (1951), the psyche develops through the internalization of early relational experiences, forming enduring representations of self and other. In VR, avatars and virtual agents may act as projective surfaces for these internal objects, enabling users to symbolically engage with internalized relational patterns, a conceptualization supported by clinical literature on transference-like dynamics in VR (González-Campo et al., 2013).

The embodied features of VR may further intensify these processes. Research on body ownership illusions shows that synchrony between real and virtual bodies fosters a strong sense of agency and self-location (Kilteni et al., 2015; Slater et al., 2010), and discrepancies in this congruence can evoke affective responses linked to self-perception. Recent studies indicate that embodied VR experiences can modulate emotional processing (Gall et al., 2021) and support therapeutic mechanisms such as self-reflection and emotional regulation (Matamala-Gomez et al., 2021). While further empirical validation is needed, these findings suggest VR's potential as a tool to promote self-integration within psychodynamic frameworks.

Moreover, the unique modulation of sensory input in VR environments creates a liminal space between reality and imagination, one that can amplify internal experiences while unsettling familiar perceptual cues. This can evoke what Freud (1919) termed the uncanny (unheimlich), a phenomenon in which something simultaneously feels familiar and foreign, often surfacing repressed material or unresolved conflicts. Similarly, Schimmenti and Caretti’s (2017) concept of “video-terminal dissociative trance” captures technology-induced states marked by absorption and detachment. Empirical studies show that VR exposure may transiently induce dissociative symptoms such as depersonalization and derealization, typically without lasting adverse effects (Aardema et al., 2010). Additionally, VR is known to elicit flow states involving focused attention, reduced self-awareness, and altered time perception (Weibel et al., 2022).

The artificial absence or simulation of senses like smell or touch may contribute to perceptual disorientation. Although mostly studied in relation to cybersickness and sensory incongruence (Baus & Bouchard, 2017), such disruptions could hypothetically heighten access to internal states. This altered experiential frame may support symbolic processing and psychodynamic insight, warranting further empirical exploration in therapeutic VR contexts.

The sense of uncanniness in VR is not merely disorienting; it can serve as a therapeutic signal, pointing to unconscious material that is becoming accessible. As users encounter emotionally charged or symbolically significant scenarios, they may begin to recognize and articulate previously inaccessible thoughts or feelings. This process of symbolic confrontation and elaboration parallels the goals of psychodynamic therapy, which seeks to bring unconscious conflicts into conscious awareness, enabling greater self-understanding and integration. In this way, VR becomes more than a technological tool, it functions as a psychologically active space that invites users to navigate and reconfigure the landscapes of their inner world.

Possible Advantages and Disadvantages

Following the exploration of symbolic and embodied experiences in VR, it becomes essential to critically evaluate its practical advantages and limitations.

One of VR’s most compelling strengths is its ability to immerse patients in emotionally charged, yet controlled environments. This experience is particularly useful in the treatment of anxiety disorders, trauma, and phobias, allowing patients to explore and cope with such emotions in a controlled setting (Freeman et al., 2017). Additionally, the therapist is always aware of the conditions, the challenges the patient is facing, and the factors that can be distressing (Riva, 2005) and can provide immediate feedback, allowing patients to assess and refine their social or coping skills.

The meticulous control exerted over the VR environment in therapeutic applications presents a dual-edged scenario. While such control offers advantages in ensuring a structured and targeted approach, it concurrently introduces potential disadvantages reminiscent of the constraints associated with limiting patients' topics in traditional psychoanalytic analyses. Excessive control may curtail the spontaneity crucial for fostering genuine therapeutic exploration, akin to the hindrance posed by restricting patients' free association in psychoanalysis. Furthermore, an overly controlled VR environment might compromise individualization, as patients' unique experiences may not find adequate expression within predetermined parameters. Achieving an optimal balance between providing a supportive, controlled setting and allowing for spontaneity and individual expression is imperative for maximizing the therapeutic efficacy of VR interventions, necessitating careful consideration of the nuanced dynamics at play.

The adaptability of VR, particularly when augmented by artificial intelligence, facilitates the creation of customized environments by either the patient or therapist. This capability enables the simulation of complex scenarios and social situations, providing therapists with an effective means to explore interpersonal dynamics and develop coping strategies. Moreover, the novelty and interactivity inherent in VR may enhance patient motivation and adherence, especially among individuals who find traditional talk-based therapy less engaging. Empirical studies have demonstrated that gamified and immersive VR interventions can significantly improve user engagement and treatment adherence in mental health settings (Jingli et al., 2023; Kahlon et al., 2023; Lindner et al., 2020)

Undoubtedly, these benefits are accompanied by significant challenges. Firstly, the creation and implementation of virtual environments require significant financial resources. VR devices are expensive and require regular maintenance, which may increase the cost of treatment for patients. This can limit access for many patients and therapists. Secondly, the effective integration of VR into psychotherapeutic practice necessitates the development of specific technical competencies by clinicians. This requirement should not be interpreted as indicative of generalized resistance among mental health professionals, but rather as reflective of a broader structural challenge: many clinicians may face difficulties engaging with unfamiliar technologies, especially those not covered in their formal education. Addressing this gap through targeted training and institutional support, such as integrating content on gamification techniques and technological tools into university programs, could facilitate the adoption of VR in clinical practice.

Lastly, while VR therapy often creates an environment where patients might feel less guarded, thereby facilitating deeper therapeutic exploration, responses to VR can significantly differ among individuals. Some may experience discomfort, disorientation, or cybersickness (Rebenitsch & Owen, 2016), while others may feel emotionally overwhelmed or respond defensively to the immersive intensity of the experience (Freeman et al., 2018).

In this light, VR should be understood not as an autonomous therapeutic modality, but as an adjunctive tool, one whose efficacy depends entirely on its integration into a thoughtful, individualized, and ethically attuned psychodynamic process. Without this clinical scaffolding, the depth and complexity of therapeutic work risk being flattened by the very medium meant to enhance it.

Conclusion

As immersive technologies continue to shape the landscape of contemporary life, VR emerges not only as a clinical innovation but as a conceptual provocation for psychodynamic psychotherapy. Far from being a neutral tool, VR introduces new symbolic spaces, novel relational dynamics, and embodied experiences that challenge and expand traditional notions of presence, identity, and unconscious expression.

Throughout this paper, we have argued that VR holds meaningful potential as an adjunctive modality within psychodynamic frameworks. Its immersive nature allows for the externalization of internal conflicts, the reenactment of relational patterns, and the projection of unconscious material onto symbolic virtual forms. In these ways, VR can function analogously to transitional objects, projective tests, or even the analytic frame itself, offering patients new routes into reflection, insight, and transformation.

Yet, this potential must be held with clinical discernment. The therapeutic use of VR cannot and should not be divorced from the interpretive, relational, and ethical scaffolding that defines psychodynamic work. Without this frame, VR risks becoming a spectacle rather than a space for symbolic elaboration. It is only when embedded in a meaningful therapeutic alliance and guided by the principles of depth psychology that VR can become a generative medium for psychic growth.

As psychotherapists face an increasingly digitized world and a generation of patients whose emotional lives are already intertwined with virtual spaces, the question is no longer whether to engage with immersive technologies, but how to do so without losing the specificity and richness of our clinical traditions. If we, as clinicians, do not take up this task, who will?

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