Evidence-Based Virtual Reality for Mental Health and Rehabilitation

This section provides an overview and background information on virtual reality, VR-based therapy, and VR therapy research, as well as on current developments, aspects of tolerability, and the medical device and regulatory classification of VR therapy.

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What is Virtual Reality?

Virtual Reality (VR) is a computer-generated, simulated world that, through the use of VR technology, allows artificial situations to be perceived and experienced as realistic. VR users can look around, move, and interact with the virtual environment.

VR addresses visual, auditory, vestibular, and—depending on the application—other sensory channels, allowing intuitive interaction through user interfaces ranging from input devices and gesture recognition to neural interfaces.

VR technology can include a head-mounted display (HMD) with stereoscopic visualization or a multi-channel projection system (CAVE), supported by localized audio and, if needed, additional components such as motion platforms or systems for simulating heat, cold, or wind stimuli. Further essential VR modules include tracking systems, 3D computing hardware, and software for simulation, visualization, and control.

The configuration of a VR system determines the degree of immersion, and thus one of the key factors for the sense of presence in virtual reality.

VR can reliably evoke realistic emotional responses such as fear, craving, or stress. This is achieved through purpose-built virtual environments, selected stimuli, and interactive elements of varying intensity—matching or, in a controlled manner, exceeding the corresponding real-life situations.

As a result, VR opens up diverse fields of application in psychotherapy, neurorehabilitation, diagnostics, training, and education.

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Use of Virtual Reality in Therapy

Virtual reality enables innovative digital medical technologies to improve health outcomes—for example by enhancing therapeutic processes or supporting more efficient treatment courses. Below is a selection of already established and emerging therapeutic applications.

Exposure Therapy Using Virtual Reality (VRET) – Evidence

The German S3 Clinical Guideline “Treatment of Anxiety Disorders” ›› provides the following recommendation grades and levels of evidence:

Virtual Reality Exposure Therapy (VRET) should be offered to patients with spider, height, or flight phobias—when available—if in-vivo exposure is not feasible. This recommendation is based on evidence level Ib (Eccles & Mason, 2001), indicating support from at least one randomized controlled trial (RCT) or a meta-analysis of fewer than three RCTs.

For social phobia, Virtual Reality Exposure Therapy may be used in addition to standard psychotherapy, but not as a stand-alone treatment.

The guideline committee suggests that VRET can be integrated as a complementary measure to standard psychotherapy and notes that VR can reduce the number of patients who refuse exposure-based therapy.

The summary assessment concludes that there is no sufficient evidence suggesting that VRET is less effective than in-vivo exposure.

International Guidelines and Regulatory Framework

The United Kingdom’s National Institute for Health and Care Excellence (NICE) highlights the potential of VR-supported exposure therapy in its recent recommendations, particularly for anxiety disorders and agoraphobic symptoms in the context of psychotic conditions. As part of its Early Value Assessments, NICE recommended the automated VR therapy program gameChange for use within the NHS under defined conditions to treat severe agoraphobia in people with psychosis—subject to ongoing data collection and accompanying health-economic evaluation (NICE, 2023).

In the United States, VR-based therapies for selected indications have been prioritized by the Food and Drug Administration (FDA) under the Breakthrough Device Program. This includes applications for the treatment of chronic lower back pain as well as VR-supported interventions addressing agoraphobic anxiety in the context of psychotic disorders. The FDA does not issue therapeutic recommendations; rather, it evaluates medical devices based on safety, technical quality, and clinical effectiveness within the specific intended use. The Breakthrough Device designation does not constitute market authorization but provides an accelerated pathway with prioritized guidance and review for devices with significant potential clinical benefit.

Exposure and Behavioral Exercises in Psychotherapy

Exposure and behavioral training in virtual reality environments allow therapists full and detailed control over therapeutic scenarios. Exposure steps can be individually graded and repeated as often as needed. Exercises can be performed in adaptable contexts, independent of weather or physical environment.

Advantages of VR for behavioral exercises include:

• Complete and detailed control of the scenario by the therapist
• Individually adjustable and repeatable exposure levels
• Exercises in variable, customizable contexts
• Independence from real-world conditions such as weather or location
• Safe handling of situations that could be dangerous in reality

How VR therapy is applied in the treatment of specific phobias — illustrated here using the examples of public-speaking anxiety, fear of heights and arachnophobia — is demonstrated in the following video ›› from the Bad Sassendorf Children’s Clinic in an impressively clear, practice-oriented presentation.

VR Brille Bad Sassendorf

Durch Anklicken des obigen Videos erklären Sie sich mit der Anzeige durch Youtube und der dafür notwendigen Datenübertragung laut Google Datenschutzerklärung ›› einverstanden.

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Established Applications of VR Therapy

Virtual reality is applied in psychotherapeutic practice particularly in situations where exposure and behavioral exercises in real-world environments are only feasible to a limited extent, require significant effort, or involve safety-related risks. VR-based exercises are designed to be interactive, enable body-oriented exercises, and are individually controlled and adapted by therapists.

Established VR therapy applications primarily include exposure-based interventions for specific phobias, social anxiety disorders, and addiction-related behavioral patterns, as well as the controlled confrontation with stressful or potentially trauma-related situations in support of therapeutically guided interventions. In addition, VR-supported mindfulness and relaxation exercises are applied, particularly to support the treatment of depressive symptoms and stress-related conditions. Established areas of application include, among others:

• Fear of Heights (Acrophobia)
  Exposure exercises in virtual height scenarios with individually adjustable intensity and gradual approach, aimed at fostering coping strategies and self-efficacy.
• Fear of Flying
  Virtual flight scenarios for confronting anxiety-provoking situations before and during a flight, including typical physical and cognitive anxiety symptoms.
• Specific Animal Phobias (e.g., spiders, birds)
  Virtual simulation of anxiety-inducing stimuli with controllable proximity, movement, and interaction to enable gradual exposure.
• Social Anxiety Disorders
  VR-based confrontation exercises in social situations such as public speaking, job interviews, or interactions with colleagues, with variable levels of difficulty and audience reactions.
• Claustrophobia
  Exposure in virtual confined spaces such as elevators or basement rooms with adaptable spatial dimensions and stimulus intensities.
• Addiction-Related Behavioral Exercises (e.g., nicotine dependence)
  Training the refusal of addictive substances in virtual social situations with realistic interactions and repeatable training sequences.

Note: The use of VR is embedded within an overall therapeutic concept and is not intended to replace guideline-based psychotherapeutic or psychiatric treatment.

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Side Effects and Tolerability

When using virtual reality, technology-related physiological as well as psychological effects may occur.

Possible physiological effects include symptoms such as nausea, dizziness, headaches, or eye strain, which are commonly referred to as cybersickness or simulator sickness. The occurrence of cybersickness is substantially influenced by the combination of tracking and navigation methods used.

VR systems with stable frame rates, absence of graphical artifacts, reliable 6DoF tracking, and physical movement are associated with the lowest incidence of side effects.
In contrast, controller-based artificial locomotion without corresponding vestibular input is considered one of the key triggers of cybersickness. However, its occurrence can be significantly reduced through modern navigation concepts such as incremental movement mechanisms (“narrow steps”) or teleportation.

In clinically developed VR therapy systems, cybersickness can largely be avoided through appropriate system architecture and configuration.

The scientific literature occasionally reports short-term emotional fatigue or tiredness following VR exposure sessions. There is no evidence indicating that these effects result in persistent symptom worsening or a generalization of negative effects.

In rare cases, dissociative perceptual effects have been described in vulnerable individuals, particularly in persons with high trait dissociation.

Acute anxiety and stress responses are not considered side effects but rather an intended and therapeutically relevant activation that is expected to occur during exposure.
There is no evidence of increased discontinuation or dropout rates compared to traditional in-vivo exposure therapy.

Medical Device Aspects of VR Therapy

Depending on their technical design and intended purpose, VR therapy systems may be subject to safety and regulatory requirements applicable to medical devices. In the European market, this includes compliance with the European Medical Device Regulation (MDR), as well as applicable national laws and regulations governing the operation and use of medical devices. For the United States, regulatory oversight may fall under the jurisdiction of the U.S. Food and Drug Administration (FDA), depending on the product classification and intended medical use, including applicable clearance or approval pathways, where required.

Medical VR complete systems designed for use in clinical and outpatient settings address, in addition to the therapeutic function, relevant medical device aspects such as system integration, electrical and functional safety, documentation, and use within the patient environment.

The chosen system architecture therefore constitutes a key foundation for the safe and compliant use of virtual reality in a medical and clinical context.

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VR Therapy Systems for Clinics and Practices

VR therapy is already established in many hospitals and outpatient facilities (see ››).
The highly integrated VT+ExpoCart2 and VT+ExpoCart3 systems from VTplus offer the following benefits:

VT+ VR Therapy Systems › provide individually controlled exposure and behavioral exercises for treating anxiety, addiction, and social competence training, as well as stress management through virtual reality.
The systems include interactive VR therapy modules addressing social anxieties (e.g. public speaking, job interviews, social interactions), specific phobias (heights, spiders, flying, claustrophobia), and addiction therapy, such as nicotine dependence, allowing users to practice rejecting an offered cigarette in virtual reality.

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VR Therapy Research

Further promising VR applications are found in medical therapy, neurorehabilitation (e.g. post-stroke recovery), and chronic pain treatment.

VTplus develops scientifically grounded medical device applications, demonstrated by the active participation of its staff in numerous academic publications. (see: Publications)

The following applications are developed and clinically evaluated in cooperation with leading scientific, clinical, and industrial partners.

Neurorehabilitation After Stroke

Every year, approximately 270,000 people in Germany suffer a stroke and must undergo a lengthy neurorehabilitation process to regain physical and cognitive function and reintegrate socially and professionally. Despite substantial investment in rehabilitation resources, the time available for individualized therapy by physiotherapists, occupational therapists, and speech therapists is limited.

Within the research consortium “Rehality” ›, VTplus collaborates with the Neurological University Clinic of Tübingen and the Stuttgart Media University to enhance neurorehabilitation after stroke using an EEG/EMG brain-state–driven virtual reality therapy paradigm.

Treatment of Chronic Pain

Chronic pain often causes long-term suffering and significant limitations in daily life. Purely pharmacological treatment is typically insufficient and associated with side effects.

In the “VirtualNoPain” research consortium ››, VTplus and partners from the health and medtech sectors are exploring the use of virtual reality combined with neurofeedback to provide side-effect-free treatment of chronic pain and improve patients’ quality of life.

VR-assisted neurofeedback enables individuals to learn to self-regulate specific brain activities, receiving real-time feedback on brain signals that are otherwise not consciously perceived or controlled.

Read more… ›

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VR in Empirical Research

VR is used as a method in both basic and applied empirical research, offering advantages such as:

• Highly standardized and repeatable virtual environments and simulations
• Controlled manipulation of stimuli and situations
• Greater ecological validity than paper-based, image, or video-stimulus studies
• Measurement of implicit behavioral data such as approach behavior, head and body movement, and gaze – offering objective metrics
• Modifiable and reusable simulation setups

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References

• Bandelow, B.; Aden, I.; Alpers, G. W.; Benecke, A.; Benecke, C.; Beutel, M. E., Deckert, J.; Domschke, K.; Eckhardt-Henn, A.; Geiser, F.; Gerlach, A. L.; Harfst, T; Hau, S.; Hoffmann, S.; Hoyer, J.; Hunger-Schoppe, C.; Kellner, M.; Köllner, V.; Kopp, I.; B.; Langs, G.; Liebeck, H.; Matzat, J.; Ohly, M.; Rüddel, H. P.; Rudolf, S.; Scheufele, E.; Simon, R.; Staats, H.; Ströhle, A.; Waldherr, B.; Wedekind, D.; Werner, A. M., Wiltink, J.; Wolters, J. P., Beutel M. E. Deutsche S3-Leitlinie Behandlung von Angststörungen, Version 2 (2021). https://www.awmf.org/leitlinien/detail/ll/051-028.html
• Eccles M, Mason J. How to develop cost-conscious guidelines. Health Technology Assessment. 2001; 5(16): 1–69. doi:10.3310/hta5160
• NICE – National Institute for Health and Care Excellence (2023): Virtual reality technologies for treating agoraphobia or agoraphobic avoidance: early value assessment [HTE15]. Published: 15 November 2023. https://www.nice.org.uk/guidance/hte15

Selected Practice-Oriented Literature

• Wechsler, T., & Mühlberger, A. (2025). Virtuelle Realität in der Psychotherapie. Hogrefe Verlag, Reihe „Fortschritte der Psychotherapie“, Band 97.
• Felnhofer A, Pfannerstill F, Gänsler L, Kothgassner OD, Humer E, Büttner J and Probst T (2025) Barriers to adopting therapeutic virtual reality: the perspective of clinical psychologists and psychotherapists. Front. Psychiatry 16:1549090. doi: 10.3389/fpsyt.2025.1549090
• Quinque, E.M., Blume, M., Gaebler, M. (2024). Einsatz und Perspektive der immersiven Virtuellen Realität bei der Neurorehabilitation. In: Frommelt, P., Thöne-Otto, A., Grötzbach, H. (eds) NeuroRehabilitation. Springer, Berlin, Heidelberg. doi: 10.1007/978-3-662-66957-0_39

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Further Information

Press reports from users of VTplus VR Therapy and VR Research systems are available in the Press Review ›.

Additional resources can be found on CyberSession.Info ››, including:

• Brief overview of treatment facilities using VT+ VR Therapy Systems ››
• Publications on the scientific evidence ›› for Virtual Reality Exposure Therapy (VRET), including RCTs, meta-analyses, and reviews
• Publications from empirical research ›› in the fields of anxiety, therapy, safety, neurophysiology, and experimental psychology using VT+ VR research systems and CyberSession simulation software