British Journal of Guidance & Counselling

ISSN: (Print) (Online) Journal homepage: https://www.tandfonline.com/loi/cbjg20

Virtual reality as a psychotherapeutic tool: current

uses and limitations

Joaquín Asiain, Malena Braun & Andrés J. Roussos

To cite this article: Joaquín Asiain, Malena Braun & Andrés J. Roussos (2021): Virtual reality as
a psychotherapeutic tool: current uses and limitations, British Journal of Guidance & Counselling,
DOI: 10.1080/03069885.2021.1885008

To link to this article: https://doi.org/10.1080/03069885.2021.1885008

Published online: 28 Apr 2021.

Submit your article to this journal

View related articles

View Crossmark data

Full Terms & Conditions of access and use can be found at

https://www.tandfonline.com/action/journalInformation?journalCode=cbjg20
BRITISH JOURNAL OF GUIDANCE & COUNSELLING
https://doi.org/10.1080/03069885.2021.1885008

REVIEW ARTICLE

Virtual reality as a psychotherapeutic tool: current uses and

limitations
a
Joaquín Asiain , Malena Brauna and Andrés J. Roussosa,b
a
Laboratorio para la investigación en Psicología y tecnología de la información y comunicación, LIPSTIC, Universidad
de Belgrano, Buenos Aires, Argentina; bCONICET, LIPSTIC, Universidad de Buenos Aires, Buenos Aires, Argentina

ABSTRACT ARTICLE HISTORY

Virtual Reality (VR) has been defined as the use of technological interfaces Received 2 February 2019
to simulate the behaviour of 3D entities that interact in real time with a Revised 20 December 2020
user immersed via sensorimotor channels. The aim of this study is to Accepted 30 January 2021
explore the possibilities and limitations in the use of VR systems in
KEYWORDS
mental health treatment and research. We conducted a review of Virtual reality; mental health;
articles addressing the qualities of the current state of research review; possibilities;
regarding the efficacy and clinical applications of VR as a therapeutic limitations; psychotherapy
tool. Despite finding general consensus about anxiety disorders, there’s
a lack of published empirical evidence regarding other mental health
disorders. Nevertheless VR components are being steadily used more
often for the assessment, treatment and research for more pathologies.

Introduction
The concept of reality has always been fundamental for the development of psychotherapy, defining
and transforming it according to different contextualizations, whether from the internal or external
world. In 1897, Freud confesses through the famous epistolary exchange with his friend Fliess that
“his hysterics lie to him”. As a result of phenomenon such as these, Freud incorporates the
concept of psychic reality “that which, in the individual’s psyche presents a coherence and resistance
comparable to those of material reality” (Laplanche & Pontalis, 1996, p. 352). That is to say, the exter-
nal (material) and internal (psychic) reality are independent events although they constantly interact
with each other.
From there, many psychoanalytic theorists continue to develop the conditions and implications of
these different realities. Outside of psychoanalysis, Watzlawick, in the early 1970′ s, takes up the
concept of psychic reality, qualifying it as belonging to a second-order reality, as a subjective con-
struction. The psychic reality happens to be a co-construction between patient-therapist that is
given by means of techniques such as cognitive restructuring and behavioural exposure. In this
sense, it is no longer external or internal, but shared (with its limitations) and mutually invented.
In parallel, taking a concept of reality from the world of technological developments, the concept
of Virtual Reality (VR) is incorporated into the world of interventions aimed at healing. This incorpor-
ation, although has its focus on the electronic devices associated with VR, provides the excuse to gen-
erate new conceptualizations about the concept of reality, opening the scope to think about a reality
that involves new spaces not physical, but digital. Now, not only patient and therapist create a reality
together, but new generated spaces are added to contain the therapeutic space.
This new space broadens what can be done in psychotherapy and allows us to rethink dilemmas
that traditional psychotherapy had no way of solving. Although traditional psychotherapy, in various

CONTACT Joaquín Asiain asiainjoaquin@gmail.com

© 2021 Informa UK Limited, trading as Taylor & Francis Group
2 J. ASIAIN ET AL.

formats, has proven to be effective in the treatment of mental disorders, it has proven insufficient to
cover the need for care that exists globally (Kazdin & Blase, 2011). The growing demand for psycho-
logical services is unattainable either through individual, group or community actions of treatments.
Geographic distances and the lack of trained professionals (Senson, 2016) are some of the arising
obstacles that append to existing problems such as an alarming increase of the prevalence of dis-
orders of different types (eg. Anxiety disorders, Depression, PTSD) and the associated increasing
social costs. In this context, information and communication technologies, including VR, allow us
to think about the possibility of reaching a greater proportion of the population and increasing
social welfare. This implies that the world of mental health must open its doors to new professionals,
such as engineers and programmers, in order to build interdisciplinary mental health teams.
The effective use of VR in the field of mental health is another form of reality. After the first two
decades and since the beginning of its use, it already has various applications for different mental
disorders. The empirical evidence regarding use of VR to treat anxiety disorders such as specific
phobias, and PTSD, support the need to both continue research about this kind of technology,
and to continue developing its applications; as Morina, Ijntema, Meyerbröker, and Emmelkamp
(2016) indicate, the validity of the application of Virtual Reality Exposure Therapy (VRET) is supported
by different meta-analyses that reflect a symptomatic decrease similar to that obtained by conven-
tional behavioural techniques. To a lesser extent, applications aimed at the treatment of psychotic,
food or substance abuse disorders have already been systematically tested. Also, there are new devel-
opments being tested with depressive patients and sleep disorders.
In this article we adopted the definition of Fuchs and Guitton (2011), who conceptualises VR as the
use of computer and behavioural interfaces to simulate the behaviour of 3D entities that interact in
real time with each other and with a user immersed via sensorimotor channels. Some key concepts
should be addressed in order to understand what this experience feels like. According to Slater and
Sanchez-Vives (2016) Immersion describes a system’s technical capabilities, while Presence is its sub-
jective correlate, an illusion of “being there” in the environment displayed by the VR system, in spite
of already knowing that one is not actually there. The “being there” feeling has also been referred to
as “place illusion” to distinguish it from alternative meanings that have been attributed to the term
“presence” (Slater, 2009; Slater, Spanlang, & Corominas, 2010). For a detailed explication of the Pres-
ence concept and its diverse conceptualizations see the work of Lombard and Ditton (1997). Follow-
ing Sanchez-Vives and Slater (2005), presence has a behavioural correlate, users behave in VR as they
would do in analogous circumstances in the real world. For example, Spanlang, Fröhlich, Descalzo,
Antley, and Slater (2007) built a VR experiment in which about 10% of the participants actually
tried to escape when confronted by a virtual fire accident. Coelho, Tichon, Hine, Wallis, and Riva
(2006) state that there is great consensus on the variables which influence presence: multiple
sensory channels, immersion, egocentric location, and the possibility of action in the particular
Virtual Environment (VE). Specific details on measuring presence can be found in the Presence
Measurement Compendium (van Baren & Ijsselsteijn, 2004) and the work of Rosakranse and Oh
(2014).
A user immerses himself with the hardware interface, and suddenly feels present somewhere else,
optionally embodied into an avatar (digital 3-dimension model that represents the user’s body), and
surrounded by interactive digital graphics. A VR simulation in which our experiences can have an
effective impact on real life. But the presented digital content is relevant, Bailey, Bailenson, and Casa-
santo (2016) suggest that not visual feedback alone but multiple sensory experiences of media, such
as sensorimotor feedback, may be necessary to influence cognition.
VR allows total control over the stimuli presented so that greater precision is achieved when
implementing therapeutic strategies of different kinds. Its technology also offers the possibility of
simulating situations that are difficult to recreate in the real world, with the option of recording
real-time feedback of the user’s experience.
 BRITISH JOURNAL OF GUIDANCE & COUNSELLING 3

Furthermore, using a VR device in a safe context as the therapist’s work area offers a great advan-
tage: patients do not need to worry about the possibility that others will find out about their particu-
lar difficulties (Botella, Perpiñá, Baños, & García-Palacios, 1998).
More sophisticated and accessible devices are appearing every year. Nowadays, the basic
elements of a VR system are: a computer generating images, a display that presents the visual infor-
mation, and a tracker giving feedback to the user’s position and orientation with the updating of the
perceived images (Roussos, Braun, & Asiain, 2018).
This review explores what is known until now about VR associated with the approach of different
mental disorders. It is intended to cover the results provided by the scientific literature (without oper-
ating with primary results) that has focused on the use of VR both as treatment and research tool.

Method
The literature was searched up to February of 2020. To be included the article needed to be a review
(of empirical evidence-based articles) or a meta-analysis; with a specific focus on the assessment or
treatment of one or more mental health disorders; which used a VR system; was published in a peer-
reviewed journal in English or Spanish. The exclusion criteria were: of VR but no specific focus on a
mental health symptom or condition. We did not look at health psychology, cognitive disorders,
childhood-onset disorders, or at the effects of VR games that were not designed as interventions
or assessments.
In this review Google Scholar, ResearchGate and PubMed were used for the searches, which were
conducted separately by major disorder types. The general search terms were: [([Virtual reality OR
Immersive virtual reality] AND [Assessment OR treatment]) AND (disorder-specific terms inserted
here)] AND English OR Spanish (language). The exploration was done using the following keywords:

. In Spanish: realidades virtuales, realidad virtual, entorno virtual, entorno digital, inmersión, terapia
de realidad virtual, psicoterapia, ansiedad, fobia, depresión, salud mental.
. In English: virtual reality, virtual environment, immersion, virtual health, virtual reality exposure,
virtual reality therapy, mental health, emotional disorders, anxiety, depression, psychotherapy.

In a second instance a “snowball” search method was implemented; for example, through authors’
ResearchGate profile pages, and in the bibliography of each included article.

Description of reviews and meta-analyses

In the following section we describe the included articles chronologically, with several references to
important works amongst them (For a simplified view see Table 1). Furthermore, each included article
is presented in one of three groups: reviews, meta-analyses, and articles that claim to be both. Finally,
we present discussion and conclusions regarding the possibilities and limitations on the use of VR
systems in the field of mental health.

Description of included articles

The total number of articles included in this review is thirty-eight (n = 38). The first article included
was conducted in 2001. With the expanding interest in the subject and the passing of the years,
an increase in the number of reviews and meta-analyses can be noted, particularly from 2012 (See
Figure 1).
Altogether they were twenty-six (n = 27) reviews included; three on Psychosis/Schizophrenia, two
on Eating Disorders (ED), one on Autism Spectrum Disorder (ASD), twelve on Anxiety Disorders, one
focused on research that used Head-Mounted-Displays (HMD) as part of the interventions, and eight
about various mental health disorders.
 4

Table 1. Reviews and meta-analysis.

Year Authors Title n Method Clinical application Conclusions
2001 Gourlay, D., Lun, K.C. & Liya, Review of Virtual Reality Treatment 15 VR based interventions Cognitive rehabilitation (n = 6), Specific . VR offers great potential as a health care
G. for Mental Health Phobias (n = 6), Relaxation and Pain tool.
relief (n = 3) . There is a lack of standards in virtual
environments applied to mental health.
J. ASIAIN ET AL.

2004 Krijn, M., Emmelkamp, Virtual reality exposure therapy of
P.M.G., Olafsson, R.P., &
Biemond, R.
31(483) VRET Claustrophobia, Fear of driving, Fear of
anxiety disorders: A review flying (FoF), Acrophobia,
Arachnophobia, Fear of public speaking,
Panic disorder with Agoraphobia, Post-
traumatic stress disorder (PTSD)
. VRET is more effective than no-
treatment for acrophobia, FoF, and
spider phobia.
. The cost effectiveness in fear of flying is
a particular advantage of VRET.
. Firm conclusions on the effectiveness of
VRET in other anxiety are less clear.
. More controlled and randomised studies
are needed to investigate whether VRET
can be recommended for use in clinical
practice, and whether its effects
generalise to the outside world.

2005 Riva, G. Virtual Reality in Psychotherapy: 14(399) VRET Acrophobia, Arachnophobia, FoF, Erectile . There is a lack of standardisation in VR
Review dysfunction disorder (n = 1), Eating devices, software and application
disorders (ED), Panic disorder with protocols.
Agoraphobia. . Introduction of patients and clinicians to
virtual environments raises particular
safety and ethical issues.

2007 Gregg, L. & Tarrier, N.
Virtual reality in mental health. A
review of the literature
17(731) VRET Acrophobia, Arachnophobia, FoF, Social . VR therapy appears to be superior to no
phobia, ED, Panic disorder with A treatment.
goraphobia. . VR has not yet been shown to be
superior to standard treatments as
comparisons, either of advantage or
equivalence, and have not been made in
trials of appropriate methodology, size
and statistical power.
. Well controlled robust randomised trials
with well described clinical protocols
and long term follow ups are required to
draw firm conclusions about the efficacy
of VR in psychotherapy.
2008 Powers, M. B. & Emmelkamp, Virtual reality exposure therapy for 13(397) VRET Anxiety disorders . VRET is highly effective for the treatment
P. M. G. anxiety disorders: A meta-analysis of phobias, being superior to inactive
control conditions (waiting list and
attention control) and active control
(relaxation and bibliotherapy).
. VRET is mild but significantly more
effective than in vivo exposure.
. There is a clear need for more detailed
analysis of the role of cognitive
techniques in VR exposure.

2008 Parsons, T. D. & Rizzo, A. A. Affective outcomes of virtual reality
exposure therapy for anxiety and
specific phobias: A meta-analysis
21(300) VRET Social phobia (n = 4), Aracnophobia (n =
4), Agoraphobia (n = 3), PTSD (n = 2),
Acrophobia (n = 4), FoF (n = 4)
. VRET can reduce anxiety and phobia
symptoms.
. Whether the affective enhancements are
directly related to VRET, or some other
factor, remains to be specified, as do the
clinical predictors for such
improvements.
. Well-designed and adequately powered
studies are needed that focus on the
affective outcomes of VRET.

2010 Meyerbröker, K. &
Emmelkamp, P.M.G.
Virtual reality exposure therapy in
anxiety disorders: A systematic
review of process-and-outcome
studies
20 + 2 VRET Acrophobia (n = 4), FoF (n = 8), Social . There is enough evidence to support
meta- phobia (n = 1), Fear of public speaking that the VRET is effective for FoF and
analysis (n = 1), Panic Disorder (n = 4), PTSD (n = acrophobia.
(760) 2) . In anxiety disorders such as Panic
Disorder and Social Phobia the first
results with VRET are promising, but
more and better controlled studies are
needed.
. Only two open studies support the
notion that patients suffering from PTSD
improve with VRET.
. There is a clear need of studies
investigating the cognitive and
physiological processes presumed to
underlie VRET.
. R esearch into the role of the therapeutic
alliance during VRET is scarce.
BRITISH JOURNAL OF GUIDANCE & COUNSELLING

(Continued )
5
Table 1. Continued.
6

Year Authors Title n Method Clinical application Conclusions

2012 Eichenberg, C. & Wolters, C. Virtual Realities in the Treatment of
Mental Disorders: A Review of the
Current State of Research
43(672) VRET / VRET + CBT Acrophobia (n = 5), FoF (n = 9),
Arachnophobia (n = 5), Cockroach
phobia (n = 1), Social phobia (n = 5),
Fear of public speaking (n = 2),
Obsessive-compulsive disorder (n = 1),
Panic disorder (n = 6), PTSD (n = 9)
. VR applications are highly effective in
the treatment of anxiety disorders.
. There were small sample sizes as well as
missing data about the point of time of
follow-up ratings and therefore
questionable lastingness of treatment
J. ASIAIN ET AL.

effects.
. Future research should include varied
levels of immersion and ensure
controlled study designs.

2012 Gonçalves, R. et al.
Efficacy of Virtual Reality Exposure
Therapy in the Treatment of PTSD:
A Systematic Review
10 VRET / VRET + CBT PTSD . Results suggest the potential efficacy of
VRET in the treatment of PTSD for
different types of trauma.
. VRET proved to be as efficacious as In
Vivo Exposure.
. VRET can be particularly useful in the
treatment of PTSD that is resistant to
traditional exposure.

2012 Opriş, D. et al.
Virtual reality exposure therapy in
anxiety disorders: A quantitative
meta-analysis.
23(608) VRET FoF (n = 7), Panic disorder/Agoraphobia
(n = 5), Social phobia (n = 5),
Arachnophobia (n = 3), Acrophobia (n =
2), PTSD (n = 1)
. VRET does far better than the waitlist
control for anxiety disorders.
. Post-treatment results show similar
efficacy between the behavioral and the
cognitive-behavioral interventions
incorporating a VR exposure component
and the classical evidence-based
interventions, with no VR exposure
component.
. VRET has a powerful real-life impact,
similar to that of the classical evidence-
based treatments.
. VRET has a good stability of results in
time, similar to that of the classical
evidence-based treatments.
. There is a dose–response relationship for
VRET.
. There is no difference in the dropout
rate between VRET and In Vivo Exposure.
2012 Ferrer-Garcia, M. & Gutiérrez- The use of virtual reality in the study,
Maldonado, J. assessment, and treatment of body
image in eating disorders and
nonclinical samples: A review of the
literature
20(309) VRET + CBT Body Image in Eating Disorders . VRET seems to be especially suitable for
improving body image both in patients
with eating disorders and in subclinical
samples.
. Improvements found are even greater in
the follow-up. Therefore, the treatment
based on VR seems to be superior to not
receiving treatment, and at least as
effective as traditional interventions.
. More controlled studies with larger
clinical samples and follow-up data are
needed.

2013 Ferrer-Garcia, M., Gutiérrez- Virtual reality based treatments in 17(541) VRET Eating Disorders and Obesity . All the reviewed studies report positive
Maldonado, J. & Riva, G eating disorders and obesity: A results regarding the effectiveness of VR-
review based treatments for ED and obesity.

2013 Bloch, F., Rigaud, A. &
Kemoun, G.
Virtual Reality Exposure Therapy in
posttraumatic stress disorder: A
brief review to open new
opportunities for post-fall
syndrome in elderly subjects
23 VRET PTSD . Results suggests potential efficacy of
VRET in the treatment PTSD for different
types of trauma (combat-related,
terrorism & motor vehicle accidents)

2014 Haniff, D., Chamberlain, A, Virtual environments for mental 48 VR based interventions PTSD (n = 6), Specific Phobias (n = 17),
Moody, L. & De Freitas, S. health issues: A review Addictions (n = 2), Autism Spectrum
Disorder (n = 2), Attention deficit
hyperactive disorder (n = 2), Pain
distraction (n = 3), Schizophrenia (n = 2),
Cognitive rehabilitation (n = 5), Body
image (n = 1), ED (n = 2), Stress (n = 2),
Serious games (n = 4)
. 3D environments’ sense of realism has
beneficial effects.
. People respond to 3D environment and
virtual people emotionally in a similar
manner to real environments and real
people.
. There is great potential and work being
carried out in the use of 3D
environments for the treatment of
mental health issues.

2014 Motraghi, T.E. et al.
Virtual Reality Exposure Therapy for
the Treatment of Posttraumatic
Stress Disorder: A Methodological
Review Using CONSORT Guidelines.
9(139) VRET PTSD . To date, there have been no randomised
controlled trials comparing VRET with
active treatment that was powerful
enough to detect differences between
groups in the general symptoms of
PTSD.
BRITISH JOURNAL OF GUIDANCE & COUNSELLING

. Additional research using well-specified

randomisation procedures, assessor

(Continued )
7
Table 1. Continued.
Year Authors
2014 McCann, R.A. et al.
2014 Turner, W. A. & Casey, L. M. Outcomes associated with virtual
2015 Botella, C. et al.
Title n Method
Virtual reality exposure therapy for 27(1080)
the treatment of anxiety disorders:
An evaluation of research quality.
30(762)
reality in psychological
interventions: where are we now?
Virtual reality exposure-based 12
therapy for the treatment of post-
traumatic stress disorder: A review
of its efficacy, the adequacy of the
treatment protocol, and its
acceptability
Clinical application
VRET / VR + CBT FoF (n = 7), Fear of public speaking (n = 4),
Acrophobia (n = 3), Arachnophobia (n =
3), Panic disorder with Agoraphobia (n
= 3), PTSD (n = 3), Generalised anxiety
disorder (n = 1), Mixed stress-related
disorders (n = 1), Panic disorder with or
without Agoraphobia (n = 1), School
phobia (n = 1)
VRET (n = 20), VR skills training Specific phobias: (n = 15), P ain
(e.g.: social skills training, n = 6), management (n = 3), D evelopmental
Cognitive-behavioral interventions and intellectual disabilities (n = 1), C
(n = 2), Occupational therapy (n = erebral palsy (n = 1), M ultiple sclerosis
2) (n = 1), P anic disorder (n = 1), S ocial
anxiety (n = 1), T raumatic brain injury
(n = 1), PTSD, A djustment disorder, P
athological guilt (n = 3), S chizophrenia
(n = 1), A ddictions (n = 1) and Dementia
(n = 1)
VRET PTSD
8
Conclusions
blinding, and monitoring of treatment
adherence is warranted.
. VRET may be an effective method of
treatment but caution should be
exercised in interpreting the existing
J. ASIAIN ET AL.
body of literature supporting VRET
relative to existing standards of care.
. The VRET body of literature would be
strengthened by additional high quality,
well-designed RCTs that compare this
intervention control conditions,
particularly other standards of care.
. VR interventions demonstrated large
effect sizes when compared to non-
intervention and moderate effect sizes
when compared to active intervention
controls.
. VR interventions were more effective in
ameliorating psychological disorders,
syndromes or behaviours than active
interventions, a finding that remained
unaffected via publication bias analysis.
. This review supports VR interventions as
efficacious forms of psychological
treatment and as a promising addition
to existing treatment options.
. Larger sample sizes, more control
intervention comparisons, replication
studies, and measures of potentially
important variables such as presence are
required to develop the field of VR based
interventions.
. Results showed that VRET was effective
in the treatment of PTSD.
. Patients reported high acceptability and
satisfaction with the inclusion of VR in
the treatment of PTSD.

2016 Valmaggia, L.R. et al.
2016 Morina, N. et al.
2016 Valmaggia, L. R., Day, F., &
Rus-Calafell, M.
Virtual reality in the psychological
treatment for mental health
problems: An systematic review of
recent evidence
Can virtual reality exposure therapy
gains be generalised to real-life? A
meta-analysis of studies applying
behavioral assessments
Using virtual reality to investigate
psychological processes and
mechanisms associated with the
onset and maintenance of
psychosis: a systematic review
24(1328) VR in psychological treatment Panic disorder with Agoraphobia (n = 3),
Agoraphobia w/w Panic disorder (n = 2),
Fear of public speaking (n = 1), Social
anxiety disorder (n = 1), FoF (n = 3),
Arachnophobia (n = 2), Acrophobia (n =
1), Social phobia (n = 1), PTSD (n = 3),
Psychological stress (n = 1),
Schizophrenia (n = 4), Autism Spectrum
Disorder (n = 2)
14(265) VRET Arachnophobia (n = 5), Acrophobia (n = 9)
16(867) Evaluation in diverse VR Psychosis
environments
. There is a need for: more controlled
studies, VRET standardised treatment
protocols, inclusion of assessments of
acceptability and related variables.
. VRT has been shown to be more
effective than treatment as usual or
waiting list control, and has similar
results as conventional CBT and or in
vivo exposure.
. R esults confirm that multiple sessions
treatment protocols of VRT can be a
valuable treatment for Agoraphobia w/
w Panic disorder, FoF, Social anxiety and
Fear of public speaking, and
Arachnophobia.
. Single session VR exposure did not seem
effective for specific phobia.
. A substantial number of studies reported
relatively high drop-out rates, often had
small sample sizes and lacked statistical
power.
. VRET can produce significant behavior
change in real-life situations and support
its application in treating specific
phobias.
. VRET should be applied if it is justified by
potential advantages as compared to
evidence-based treatments.
. M ore methodologically strong
randomised controlled trials with
adequate power are needed.
. There is lack of research on assessing
potential mechanisms underlying
therapeutic change within VRET.
. VR can be used to investigate
psychological processes and
mechanisms associated with psychosis.
BRITISH JOURNAL OF GUIDANCE & COUNSELLING
. The ability to assess real-time, cognitive,
emotional, behavioral and physiological
(Continued )
9
Table 1. Continued.
Year Authors
2017 Rus-Calafell et al.
2017 Cardoş, R.A.I, David, O.A &
David, D.O.,
2017 Botella, C. et al.
2017 Freeman, D. et al.
Title
Virtual reality in the assessment and
treatment of psychosis: a
systematic review of its utility,
acceptability and effectiveness
Virtual reality exposure therapy in
flight anxiety: A quantitative meta-
analysis
Recent Progress in Virtual Reality
Exposure Therapy for Phobias: A
Systematic Review
Virtual reality in the assessment,
understanding, and treatment of
mental health disorders
10
n Method Clinical application Conclusions
responses in a controlled but
ecologically valid environment has
enormous potential for future research
in the mechanisms involved in the onset
and maintenance of psychosis.
J. ASIAIN ET AL.
50(1872) VR Safety and acceptability (n = 3), Psychosis . VR is a well-tolerated and safe tool to
VR Neurocognitive evaluation (n = explore neurocognitive deficits, to study
11), VR Real-time operation (n = 9), relevant clinical symptoms, and to
VR Symptom evaluation (n = 19), investigate correlations of symptoms
VR Treatment (n = 8) and causal factors in people suffering
from psychosis disorders.
. VR enables the clinician to help people
to observe and modify their emotions,
cognitions and behaviours directly and
as they occur, and in carefully controlled
environments.
. The participants did not show any
exacerbation of psychotic symptoms
after exposure to VR environments, nor
did they report any distress related to
the experimental situations.
11 VRET, VRET+CBT, VRET+Group CBT, Flight anxiety . This meta-analysis indicates the
VRET+Relaxation efficiency of VRET in flight anxiety and
encourages the use of this type of
exposure both in clinical practice and
research fields.
11(721) VRET Social Anxiety Disorder, Small Animal . VRET applications have become an
Phobia, FoF, Flying Phobia, effective alternative that can equal the
Agoraphobia, Panic Disorder with results of traditional treatments for
Agoraphobia, Acrophobia phobias from an efficacy point of view.
. New research lines should find the best
strategies to enhance exposure therapy,
re duce the recurrence of fear, and
increase the acceptability of exposure-
based treatments.
213 VRET Anxiety disorders (n = 127), Psychosis (n = . VR has the potential to transform the
44), Depression (n = 2), Substance use assessment, understanding and
treatment of mental health problems.

2017 Mishkind, M.C. et al. Review of Virtual Reality Treatment in
Psychiatry: Evidence Versus Current
Diffusion and Use
2018 Jerdan S. W., Boulos M. N. K. Head-Mounted Virtual Reality and
& Woerden H. C. V. Mental Health: Critical Review of
Current Research
2018 Brito, H. & Vicente, B. Realidad virtual y sus aplicaciones en
trastornos mentales: una revisión
2018 The effectiveness of virtual reality
based interventions for symptoms
disorders (n = 22), Eating disorders (n =
18)
49 VRET PTSD (n = 9), Anxiety Disorders (n = 3),
Addictions (n = 10), Binge Eating
Disorders (n = 2), Social and Vocational
skills training (n = 13), Cognitive
Rehabilitation (n = 3), Pain Management
(n = 9)
81 VR based interventions Anxiety Disorders (n = 42), Depression (n
= 1), Stress (n = 2), Pain Management (n
= 22), Addiction (n = 9), Eating
Disorders/Body image (n = 5)
29 VR based interventions Anxiety Disorders (n = 3), Depression (n =
3), Psychosis (n = 5), Eating Disorders (n
= 5), OCD (n = 2), + Empiric trials (n =
11)
39(1991) VR based interventions Anxiety Disorders (n = 29), Depression (n
= 10)
. The capability of VR to simulate reality
could greatly increase access to
psychological therapies, while treatment
outcomes could be enhanced by the
technology’s ability to create new
realities.
. VRET is effective but haven’t consistently
demonstrated superiority over other
validated treatments for PTSD.
. VRET is similarly effective as traditional
treatment approaches for anxiety
disorders.
. VR has been shown to be an effective
tool for social and vocational skills
training.
. VR for chronic pain, rehabilitation, and
addictions shows clinical promise but
needs further well-designed research.
. Significant evidence indicates VR
reduces pain by providing distractions
during medical procedures.
. The state of research suggests that VR
cannot be a clinical tool itself and,
instead, its success relies on the content
it provides a platform for.
. This review points to VR as a useful
method of modifying the behavior in an
effort to enhance mental health.
. There is a lack of studies surrounding
depression and stress.
. The ability of VR to simulate reality could
greatly increase access to therapies in
mental disorders, while results could be
improved by the ability of technology to
create new realities.
BRITISH JOURNAL OF GUIDANCE & COUNSELLING
. Virtual reality enhanced interventions
had moderate to large effects compared
(Continued )
11
Table 1. Continued.
12

Year Authors Title n Method Clinical application Conclusions

Fodor L. A., Cotet C. A.,
Cuijpers P., Szamoskozi S.,
David D. & Cristea I. A.
of anxiety and depression: A meta- to control conditions, though these
analysis effects were likely inflated by several
factors in the design and
implementation of the trials. Many
existent trials are poorly reported and
exposed to bias.
. VR interventions outperformed control
J. ASIAIN ET AL.

conditions for anxiety and depression

but did not improve treatment drop-out.

2019 Carl E., Stein A. T., Levihn- Virtual reality exposure therapy for 30(1057) VRET Specific phobias (n = 12), Social anxiety . VRET has a large effect size compared to
Coon A., Pogue J. R., anxiety and related disorders: A disorder and performance anxiety (n = control conditions and an equal effect
Rothbaum B., Emmelkamp meta-analysis of randomised 7), PTSD (n = 5), Panic disorder (n = 2) size to that of in vivo exposure.
P., Asmundson G. J. G., controlled trials . These results were consistent for
Carlbring P. & Powers M. B. different disorders, with a medium or
large effect size for VRET compared to
controls for specific phobias, SAD and
performance anxiety, PTSD, and PD.
. VRET can be considered an acceptable
and efficacious alternative to IVE for the
treatment of anxiety-related disorders.

2018 Chesham, R. K., Malouff, Meta-Analysis of the Efficacy of Virtual 9(573) VRET Social Anxiety . The results of both meta-analyses
J. M. & Schutte, N. S. Reality Exposure Therapy for Social support the use of virtual reality in the
Anxiety treatment of social anxiety.

2018 Riva, G., Wiederhold, B. K. & Neuroscience of Virtual Reality: From 25 VR based interventions Anxiety disorders, E ating and W eight . The reviewed articles have
Mantovani, F. Virtual Exposure to Embodied disorders, P sychosis, A utism Spectrum demonstrated the clinical potential of
Medicine Disorder, P rocedural pain, P ediatrics this technology in both the diagnosis
and the treatment of mental health
disorders.
. VR compares favourably to existing
treatments in anxiety disorders, eating
and weight disorders, and pain
management.
. VR based intervention show long-term
effects that generalise to the real world.

2018 Mesa-Gresa, P. et al. Effectiveness of virtual reality for 31(602) VR based interventions Autism Spectrum Disorder
children and adolescents with
 autism spectrum disorder: An
evidence-based systematic review
2019 Deng, W. et al. The efficacy of virtual reality exposure
therapy for PTSD symptoms: A
systematic review and meta-
analysis
2019 Kothgassner, O. D. et al. Virtual reality exposure therapy for
posttraumatic stress disorder
(PTSD): a meta-analysis
2018 Singh, S. & Nathan-Roberts, Virtual Reality Exposure Therapy and
D. Military Personnel with Post-
Traumatic Stress Disorder: A
Systematic Review
. There is moderate evidence that VR-
based treatments can help children with
Autism Spectrum Disorder.
. There is still no definitive findings that
VR-based treatments can improve the
results of traditional treatments.
18(759) VRET PTSD . VRET is effective in treating PTSD.
. Theres is a dose-response relationship:
more VRET sessions showed larger
effects.
. VRET has a sustainable therapeutic
effect.
. VRET doesn’t have dependance or
withdrawal response.
9(296) VRET PTSD . VRET had a medium sized effect over
waitlist controls and at least no
significant difference between VRET and
active interventions in terms of reducing
PTSD symptom severity and depressive
symptoms in adults.
. VRET constitutes an ecologically valid,
safe and controlled environment for the
induction of emotional, cognitive and
behavioural as well as physiological
reactions which are equivalent to those
found in comparable in vivo
environments.
. VRET has the potential for treatment
standardisation.
14 VRET PTSD . VRET is efficacious in reducing the
symptoms of PTSD in war veterans and
active service members.
. VRET isn’t statistically or clinically better
than exposure therapy that relied on the
patient’s imagination.
(Continued )
BRITISH JOURNAL OF GUIDANCE & COUNSELLING
13
Table 1. Continued.
Year Authors Title
2019 Park, L. et al. A Literature Overview of Virtual
Reality (VR) in Treatment of
Psychiatric Disorders: Recent
Advances and Limitations
2019 Dellazizzo, L. et al. Comprehensive review on virtual
reality for the treatment of
violence: implications for youth
with schizophrenia
14
n Method Clinical application Conclusions
36(1959) VRET, VR-DBT, VR-CBT, VR-based PTSD, Anxiety Disorders, Schizophrenia, . VR environments show the possibility of
interventions Autism Spectrum Disorder, Dementia treating anxiety, depression, cognition,
and Mild Cognitive Impairment, Stress and social functions by effectively
and Pain Alleviation exposing patients to sources of fear,
presenting interactive virtual
environments of cognitive-behavioral
J. ASIAIN ET AL.
approaches, and contributing to other
rehabilitation applications.
. VR systems can deliver an ideal place
where one can confront the problem
which needs to be overcome through
virtual environments with well-
controlled sensory stimuli.
16(1215) VRET, Avatar Therapy, VR+CBT, VR- Schizophrenia (n = 4), Anger management . Studies in populations other than
based interventions & Social skills (n = 12) schizophrenia show reductions in anger
and impulsivity, improvements in
conflict-resolution skills as well as in
empathy levels, and decreases in
aggression.
. VR interventions for schizophrenia show
reductions in delusions and auditory
hallucinations, but they were not related
to violence since this outcome wasn’t
measured.
 BRITISH JOURNAL OF GUIDANCE & COUNSELLING 15

Figure 1. Amount of VR mental health publication per year.

Nine (n = 9) meta-analyses were included in this systematic review. Eight on Anxiety Disorders, one
about anxiety disorders and depression, and one about various applications; the work of Turner and
Casey (2014) also includes articles on: pain management, developmental and intellectual disabilities,
cerebral paralysis, multiple sclerosis, panic disorder, social anxiety, traumatic brain injury, post-trau-
matic stress disorder (PTSD), adjustment disorder, pathological guilt, schizophrenia, addictions and
dementia.
Finally, two (n = 2) articles included present a review and a meta-analysis, particularly focused on
anxiety disorders.

Reviews
The first review on VR research applied to mental health was accomplished by Gourlay, Lun, and Liya
(2001), who included, very broadly, articles about cognitive and psychological problems, presented in
the following sections; phobias, relaxation, pain relief, motivation, imagination, immersion, and sense
of presence. They also present important considerations regarding the development of VR appli-
cation, focusing primarily on side effects: exposure to VEs could cause symptoms such as coordi-
nation difficulties, motion sickness, and visual disturbances. This was due to latency with the
position tracking and display systems of VR hardware, which at this point was still a very limited
kind of technology. Nowadays, these side effects can be mitigated and controlled to a far extent.
This was the first review article on this topic asserting VR technology offers great potential as a
next generation health care tool.
Krijn, Emmelkamp, Olafsson, and Biemond (2004) review focused on anxiety disorders and they
indicate that the VRET for acrophobia, fear of flying (FoF) and arachnophobia is more effective
than no treatment, and as effective as In Vivo Exposure (IVE) for FoF and fear of heights (FoH). In
addition, they highlight the advantage of the VRET for the treatment FoF, due to the possibility of
reducing implementation stage costs. However, they warn that the reviewed research had used
very small samples and had presented high dropout rates very often.
A year later Riva (2005) states in his review that there are still missing standards for the hardware of
devices to be instrumented and for the software to be applied in the treatment sessions. The lack of
standardisation of application protocols is also remarked by Gregg and Tarrier (2007), Parsons and
Rizzo (2008), and Botella, Serrano, Baños, and Garcia-Palacios (2015). Riva also highlights the lack
of ethical regulations regarding the use of VR systems, which should be taken into account in relation
to the existence of cybersickness (see Gallagher & Ferrè, 2018), both to prevent it and to develop ways
16 J. ASIAIN ET AL.

to avoid it. According to Riva (2005), the most important factor to consider is the therapist’s expertise,
since the therapist will have total control over the VR system and thus the VEs in the clinical context.
Gregg and Tarrier (2007) assessed the methodological quality of the studies they included (n = 17)
in their review using the Clinical Trials Assessment Measures (CTAM) scale: they concluded that there
is a wide variability in methodologies, with the majority of studies with small, underpowered samples.
These authors also refer to the work of Lewis and Griffin (1997) in which they recommend that
exposure management protocols for patients and VR should include: (a) screening procedures to
detect people who may present particular risks, (b) procedures for managing patient exposure to
VR applications and (c) procedures monitoring unexpected side effects. In addition, both Gregg
and Tarrier (2007) and Parsons and Rizzo (2008) indicate that data about presence factors is often
not presented in studies.
Although there is still a lack of methodological rigour in research designs, and more research on
mediator and moderator factors is needed, it can be said that the VRET is effective for FoF and Acro-
phobia in comparison with IVE (Meyerbröker & Emmelkamp, 2010). The results of the systematic
review by Gonçalves, Pedrozo, Coutinho, Figueira, and Ventura (2012) suggest the potential
efficacy of VRET in the treatment of PTSD for different types of trauma, and that it may be particularly
useful to patients resistant to traditional treatment. Also regarding PTSD, Motraghi, Seim, Meyer, and
Morissette (2014) indicate that, until then, there had been no controlled and randomised controlled
trials comparing VRET with an active treatment that was powerful enough to detect differences
between groups in the general symptoms of PTSD. Eichenberg and Wolters (2012) indicate that
future research on VR in the treatment of mental health problems should include varying levels of
immersion and controlled designs. They recommend psychotherapists to act in accordance with
certain guidelines to abet positive results and minimise negative treatment effects. Moreover, they
highlight the lack of knowledge about the therapeutic alliance when using VR systems, as others
have also noted (Botella, Fernández-Álvarez, Guillén, García-Palacios, & Baños, 2017; Meyerbröker &
Emmelkamp, 2010).
We found two reviews focused on ED. The first by Ferrer-García and Gutiérrez-Maldonado (2012),
who had reviewed published research on the use of VR in the study, assessment, and treatment of
body image disorders. Their results suggest that therapies based on VR seem to be especially suitable
to improve body image in the population with ED and subclinical samples. In addition, the improve-
ments found are even greater at follow-up. Therefore, they concluded that treatments based on VR
are superior to no treatment, and at least as effective as most used interventions for ED. However,
they warn of several methodological limitations: very few controlled studies have been done (only
four with clinical samples), and almost all studies used small samples that lacked statistical power;
therefore, the stated conclusions should be taken as tentative.
Ferrer-Garcia, Gutiérrez-Maldonado, and Riva (2013) extended the previous review (Ferrer-García &
Gutiérrez-Maldonado, 2012) adding binge eating disorders and obesity focusing exclusively on clini-
cal populations. Their main objective was to examine the evidence on the efficacy of VR-based treat-
ments as a component of therapeutic interventions for ED, binge eating disorders, and obesity. They
affirm all the studies they had reviewed showed positive results regarding the effectiveness of adding
VR to standard cognitive–behavioural interventions. These authors also state that the VR component
seems to be adequate for the treatment of body image disorders and related behaviours (such as
avoidance), self-esteem and self-efficacy, and distorted emotions such as depression; however, the
mechanisms underlying this effectiveness have not been elucidated yet.
Bloch, Rigaud, and Kemoun (2013) reviewed articles about VRET in PTSD, with a particular interest
in highlighting new opportunities for post-fall syndrome in elderly subjects. They claim the psycho-
logical symptoms of post-fall syndrome presented by some elderly subjects after a fall can be related
to PTSD, and conclude that it would appear worthwhile to carry out studies in VEs in order to evaluate
the usefulness of VRET for the development of novel treatments for this condition. For this purpose,
they indicate there is some evidence that VRET can be effective for the treatment of patients with
PTSD, and propose the following VE: an avatar has to walk down a long corridor which each wall
 BRITISH JOURNAL OF GUIDANCE & COUNSELLING 17

will tend to move away gradually and where the end of the course cannot be seen; the main objective
will be to look forward to significant improvements in functional and motor independence in com-
parison to control conditions.
The work of Haniff, Chamberlain, Mood, and De Freitas (2014) reviews VR applications for the
assessment and treatment of a variety of mental health problems; PTSD, Specific Phobias, Addictions,
ASD, Attention deficit hyperactive disorder (ADHD), Pain distraction, Schizophrenia, Cognitive reha-
bilitation, Body image, ED, Stress, and Serious games. They indicate there is a huge potential and
work being developed in the use of VEs for the treatment of mental health problems, but some
issues need to be addressed in order to provide effective VR systems, such as what level of narrative
is needed to help someone undergoing VRET overcome their fear, and when and in what form thera-
pist interventions would be needed.
McCann et al. (2014) worked on the first systematic evaluation of the quality of VRET randomised
controlled trials (RCT) for the treatment of anxiety disorders. They suggest that the body of literature
on VRET would be reinforced by additional high quality, well-designed RCTs that compare this inter-
vention control conditions. McCann et al. (2014) observe an issue in their review Riva (2005) had
already highlighted before: the lack of standards in terms of hardware and software for research
designs in this field of work.
The review of Botella et al. (2015) aims to evaluate the efficacy of VR exposure-based therapy (VR-
EBT) for the treatment of PTSD, evaluate the adequacy of psychological treatment protocols used,
and analyse its acceptability as a form of therapy. Their results showed that VR-EBT was effective
in the treatment of PTSD. In relation to adequacy, their findings showed that not all studies reported
having followed the clinical. Concerning acceptability, patients reported high acceptability and sat-
isfaction with the inclusion of the VR component in the treatment of PTSD.
Valmaggia, Latif, Kempton, and Rus-Calafell (2016) found 24 controlled studies published since
2012; VRET has proven to be more effective than treatment as usual or waitlist (WL) control and
has similar results as conventional cognitive–behavioural therapy (CBT) and or IVE. The evidence
varied depending on the mental health disorder reviewed. The results of the review of Valmaggia,
Latif, et al. (2016) confirm that treatment protocols of multiple VRET sessions can be a valuable treat-
ment for agoraphobia with or without panic disorder, FoF, social anxiety, fear of public speaking and
arachnophobia. Although evidence is little yet, they also consider VRET as a promising alternative for
the treatment of PTSD and the management of psychological stress. They also indicate that a single
session of VRET is not effective for specific phobias. In addition, they remark that little research has
been published focused on ED, ASD and that, in the case of schizophrenia, VR was used to deliver
vocational or social skills training, but there were no studies using VR to target the distress associated
with hallucinations or delusion. This statement seems to elude the existence of an article published
by Leff, Williams, Huckvale, Arbuthnot, and Leff (2014) in which they claim to have developed a virtual
novel therapy, which enables the patient to create an avatar of the entity, human or non-human,
which they believe is persecuting them, but then the therapist encourages the patient to enter
into a dialogue with their avatar, and is able to use the programme to change the avatar so that it
comes under the patient’s control over the course of six 30-min sessions and alters from being
abusive to becoming friendly and supportive. Valmaggia, Latif, et al. (2016) caution that there are
several limitations that should be taken into account: studies reporting high dropout rates due to
cybersickness or subjects finding the treatment too confronting, using small samples that lacked stat-
istical power (Eichenberg & Wolters, 2012); studies were conducted with young or middle-aged adults
and no evidence was found with younger children or older adults. In addition, the authors highlight
that VR systems can enable the assessment of cognitions, emotions, and behaviour in an ecologically
valid environment (Valmaggia, Latif, et al., 2016). This is the first review that, at least explicitly,
excluded studies that hadn’t have used immersive VR systems, such as those using internet platforms
from a computer.
Two reviews focused on psychosis were found. Valmaggia, Day, and Rus-Calafell (2016) reviewed
experimental studies using VR to investigate mechanisms and underlying psychological processes
18 J. ASIAIN ET AL.

associated with the initiation and maintenance of psychosis. Their results indicate that methodology
including VR can be used to investigate psychological processes and mechanisms associated with
psychosis: to improve the understanding of psychosis and to evaluate psychotic symptoms (such
as interpersonal sensitivity).
Rus-Calafell, Garety, Sason, Craig, and Valmaggia (2017) carried out a detailed review on the main
applications of VR as an assessment tool and as an adjunctive technique for treatment in psychosis,
with a secondary aim to review and critically evaluate the quality of the selected studies. They con-
clude that VR is a safe and well-tolerated tool to explore neurocognitive deficits, to study relevant
clinical symptoms, and to investigate symptom correlations and causal factors in people who
suffer from psychotic disorders. The most important additional benefits would be, in the long
term, for treatment. VR allows the clinician to help people observe and modify their emotions, cogni-
tions, and behaviours, directly and as they occur, and in carefully controlled environments. In
addition, the participants of the reviewed studies did not show any exacerbation of psychotic symp-
toms after exposure to VR environments and did not report any distress related to the experimental
situations. Even so, Rus-Calafell et al. (2017) indicate that these conclusions should be taken carefully,
since the samples have been generally small, and the processes involved in therapy with VR com-
ponents remain relatively unexplored; assessment and treatment studies haven’t generally demon-
strated how the findings in their results would translate to the real-world environment.
In the systematic review done by Freeman et al. (2017) a much greater number of articles were
identified in contrast with all previous reviews (n = 285): 86 on evaluation, 45 on theory development,
and 154 on treatment. The mainly investigated disorders were anxiety (n = 192), then schizophrenia
(n = 44), then substance-related disorders (n = 22), and finally ED (n = 18). His most concrete finding is
that treatments based on VR exposure can reduce anxiety disorders. Accordingly, the same year
Botella, Fernández-Álvarez, et al. (2017) state that VRET is effective to treat specific phobias, and a
very useful tool to improve exposure treatment. Freeman et al. (2017) highlight that the term
Virtual Reality has been frequently misused, often applied to non-interactive or non-immersive tech-
nologies. They conclude that VR environments have the potential to transform the assessment,
understanding, and treatment of mental health problems.
Mishkind, Norr, Katz, and Reger (2017) review provide an overview of the evidence base for clinical
applications of the use of VR for PTSD, anxiety, specific phobias, chronic pain, addictions, and reha-
bilitation. They indicate studies demonstrate the effectiveness of using VRET for PTSD but have not
consistently demonstrated superiority over other validated treatments. Regarding anxiety and
specific phobias studies demonstrate similar effectiveness between VRET and traditional treatment
approaches. About addictions, early findings show the promise of VR cue-exposure therapy, but
findings are mixed as to the additional benefit compared to traditional CBT. Related to pain manage-
ment, significant evidence exists showing that VR reduces pain by providing distractions during tra-
ditional medical procedures. Furthermore, VR has been shown to be an effective tool for social and
vocational skills training, and to improve rehabilitation in working memory, attention, and executive
and global functioning. Mishkind et al. (2017) conclude that the use of VR in mental health has shown
a lot of promise as a potential alternative to traditional therapeutic approaches, but also remark that
providers adopting VR systems should consider preparations to be basic clinician technologists, as
technical challenges using any computer system are expected.
Jerdan, Grindle, van Woerden, and Boulos (2018) published a review assessing the current state of
head-mounted VR research in relation to mental health; they looked to determine which conditions
are more susceptible to VR interventions, in what form these are most effective, and which conditions
need a special focus. Their work, as they state, demonstrated that VR is effective in provoking realistic
reactions to feared stimuli, particularly for anxiety; furthermore, it proved that the immersive nature
of VR is an ideal fit for the management of pain. They also remark that there is still a lack of research
about VR in relation to depression and stress. Jerdan et al. (2018) conclude that VR is a useful method
for modifying human behaviour and that the current state of research does not illustrate VR’s ability
 BRITISH JOURNAL OF GUIDANCE & COUNSELLING 19

to improve mental health on its own; instead, it highlights the importance of the condition-oriented
content within VR interventions.
Brito and Benjamín (2018) made a systematic review on the use of VR in relation to various mental
health problems. They selected 29 studies corresponding to different disorders: anxiety, depression,
psychosis, schizophrenia, ED, and obsessive compulsive disorder. The authors focus on technology’s
ability to create new realities and therefore conclude that VR’s simulation ability could greatly
increase the accessibility of psychotherapy.
The work of Riva, Wiederhold, and Mantovani (2018) is a meta-review that selected twenty-five
articles which had “demonstrated” the clinical potential of VR in both the diagnosis and treatment
of mental health disorders. These authors affirm that these articles specifically indicate VR compares
favourably to existing treatments in anxiety disorders, eating and weight disorders, and pain manage-
ment, with long-term effects that also generalise to the real world. In this meta-review they also
suggest VR is effective because it shares a basic mechanism called “embodied simulation” with the
human brain; it creates an embodied simulation of the body in the world used to represent and
predict actions, concepts, and emotions (Riva et al., 2018)
We found one systematic review focused on ASD. Mesa-Gresa, Gil-Gómez, Lozano-Quilis, and Gil-
Gómez (2018) work is the first contribution that has carried out an evidence-based systematic review
including both clinical and technical databases about the effectiveness of VR-based intervention in
ASD. They discuss that since autism is diagnosed in children and many of the interventions are per-
formed during their youth, the use of VR systems as part of the treatment can increase the motivation
and adherence of patients to the therapeutic programme. Mesa-Gresa et al. (2018) conclude there is
only moderate evidence that VR-based treatments can help children with ASD, and the lack of defini-
tive findings does not allow them to state that VR-based treatments can improve the results of tra-
ditional treatments; future studies must be validated through well-designed evaluation processes.
Singh and Nathan-Roberts (2018) have published a systematic review focused on the use of VRET
for military personnel (both veterans and active duty members) with PTSD. They found that VR in con-
junction with varying forms of exposure therapy was efficacious in reducing the symptoms of PTSD
for these samples, but the results did not demonstrate that using VRET was statistically or clinically
better than imagination exposure. Furthermore, exposure to trauma, whether imagined or virtual,
did not worsen the PTSD or any host of comorbid symptoms. They found some major limitations
of the studies: the high attrition rates of patients, samples were composed almost entirely of men,
and no studies employed surveys to verify that the VR systems were creating presence or that
patients felt immersed.
Park, Kim, Lee, Na, and Jeon (2019) reviewed VR applications in the treatment of various psychiatric
disorders: PTSD, Anxiety disorders, Schizophrenia, ASD, Dementia and Mild Cognitive Impairment,
Stress, and Pain Alleviation. The authors indicate VEs show the possibility of effectively exposing
patients to sources of fear, presenting interactive elements of cognitive–behavioural approaches,
and contributing to rehabilitation applications. Moreover, they conclude modern VR systems can
deliver an ideal place where one can confront the problem which needs to be overcome, not only
through talking with clinicians in real time, but also through VEs with well-controlled sensory
stimuli. Park et al. (2019) also state VR needs to overcome technical hurdles such as motion sickness
and dry eyes.
The last review included is the one of Dellazizzo, Potvin, Bahig, and Dumais (2019), which focuses
on studies using VR to manage violence across several at-risk populations, with a particular emphasis
on youth with schizophrenia. They included 16 articles in their review: 2 measuring impulsivity in
juvenile offenders, 2 assessing conflict-resolution skills in adolescents and prisoners, 2 assessing
empathy in violent offenders and middle school students, 2 measuring aggression in veterans and
forensic patients, 1 treating persecutory delusions, and 3 treating auditory hallucinations. The
former twelve articles focused on populations other than schizophrenia have shown reductions in
anger and impulsivity, improvements in conflict-resolution skills as well as in empathy levels and
decreases in aggression. The latter four articles regarding VR interventions for schizophrenia
20 J. ASIAIN ET AL.

showed reductions in delusions and auditory hallucinations, but they were not related to violence
since this outcome was not assessed. The authors state that if reducing psychotic symptoms will
result in a reduction of violence is still not elucidated, and that the reviewed studies show numerous
methodological defects: small sample sizes, lack of results follow-up, and lack of consideration of
cofounding factors. Lastly, Dellazizzo et al. (2019) indicate that these results should be taken carefully
as all reviewed studies had evaluated a different type of intervention with a VR component.

Meta-analyses
Powers and Emmelkamp (2008) worked on the first meta-analysis on the efficacy of VRET for anxiety
disorders compared to IVE and control conditions (WL, relaxation, bibliotherapy, and attention
control). They included 13 studies in total: nine on specific phobias, two on social phobia, one on
panic disorder, and one on PTSD. Their meta-analysis revealed that VRET is slightly but significantly
more effective than IVE, and more effective than inactive control conditions (WL and attention
control). The authors indicate VRET showed a large overall effect size on fear-specific measures com-
pared to control conditions, Cohen’s d = 1.11 (S.E. = 0.15, 95% CI: 0.82–1.39). In addition, results were
consistent among secondary outcome variables (general subjective distress, cognition, behaviour,
and psychophysiology), and IVE was not significantly more effective than VRET; VRET outperformed
IVE (for this comparison the authors established alpha at 0.25 or greater), Cohen’s d = 0.35 (S.E. = 0.15,
95% CI: 0.05–0.65). Contrary to Powers and Emmelkamp (2008) prediction, the dose–response
relationship (number of exposure sessions – effect sizes) did not reach significance. However,
there was a trend: more sessions produced larger effect sizes (p = 0.06). Sample size and publication
year didn’t show association with the overall effect sizes. In sum, Powers & Emmelkamp conclude that
VRET is highly effective in treating phobias, even more so than inactive (WL and attention control)
and active (relaxation and bibliotherapy) control conditions. They add that VRET has many advan-
tages over traditional exposure therapy: safe and predictable therapy context, more gradual assign-
ments (sequence and intensity of treatment), and idiosyncratically designed exposure.
Parsons and Rizzo (2008) worked on a meta-analysis with clinical and non-clinical samples from 21
studies: 12 on specific phobias, 4 on social phobia, 3 on agoraphobia, and 2 on PTSD. Although they
did not include information about the instruments they had used to evaluate these studies, they
affirm that, from a psychotherapeutic point of view, VRET seems to be relatively effective reducing
anxiety symptoms and phobias in carefully selected patients. This refers to their meta-analysis reveal-
ing large size effects on all affective domains they had included, but also meaning this conclusion
may not generalise to unselected patients. However, they also indicate that there is a clear need
for: additional well-designed and adequately powered studies researching the affective outcomes
of VRET, more extensive and uniform reporting of data, and for meta-analysis of the VRET effects
on depression, cognition, and quality of life.
Opriş et al. (2012) worked on a meta-analysis which main novelty is the comparative analysis
between interventions with VRET and interventions based on classical evidence (either CBT
without exposure to VR and behavioural therapy without exposure to VR) for anxiety disorders. In
addition, it’s the first meta-analysis to report data on the impact of VRET in real life and its long-
term effects. These authors conclude that VRET has a powerful real-life impact and good stability
of results over time, similar to other classical evidence-based treatments. Furthermore, post-treat-
ment results showed similar efficacy between the behavioural and the cognitive–behavioural inter-
ventions incorporating a VR exposure component and the classical evidence-based interventions,
with no VR exposure component, and also that VRET does far better than the WL control. Opriş
et al. (2012) asset there is a dose–response relationship for VRET (number of exposure sessions –
effect sizes); in relation to what was concluded by Powers and Emmelkamp (2008), this affirmative
conclusion may be due to a greater number of controlled and randomised studies analysed.
Turner and Casey (2014) remark the results and conclusions of the three previous meta-analyses
but indicate that if these findings can be generalised to all interventions with VR is yet unknown. For
this reason, they started a meta-analysis of the results associated with psychological treatments in VR
 BRITISH JOURNAL OF GUIDANCE & COUNSELLING 21

throughout the range of mental health problems. Their analysis focused on both WL and active treat-
ment controls and, furthermore, as the results can be influenced by the methodological rigour in the
research designs, they used the CONSORT and CONSORT-EHEALTH guidelines to establish a standard
and thus evaluate potential methodological biases. Turner and Casey (2014) indicate that interven-
tions with VR components demonstrated large effect sizes compared with no intervention and mod-
erate effect sizes when compared to control groups with active intervention. Furthermore,
interventions with VR showed to be more effective in ameliorating psychological disorders, syn-
dromes or behaviours than the active interventions; this finding was not affected by publication
bias, as analysed by the authors. Their work supports VR interventions as efficacious forms of psycho-
logical treatment and as a promising additive component to existing treatment options (Turner &
Casey, 2014).
Cardoş, David, and David (2017) presented the first meta-analysis examining VRET effectiveness
for flight anxiety compared to various control conditions, at post-test and follow-up. Their results
revealed similar efficacy between VRET and exposure based interventions at post-test, and showed
better treatment gains over time when using VRET vs. exposure based interventions. They also ana-
lysed moderation factors, revealing that low quality trials, with smaller and younger samples led to a
larger effect size of VRET for flight anxiety, other significant moderator of the efficacy of VRET for this
disorder are the number of exposure sessions and follow-up. Cardoş et al. (2017) conclude that the
present meta-analysis supports the efficiency of VRET in flight anxiety and encourages the use of this
type of application both in clinical practice and research fields.
Chesham, Malouff, and Schutte (2018) made two meta-analyses with the purpose of examining
the efficacy of VRET for social anxiety. Consisting of 6 studies and 233 participants the results of
the first meta-analysis showed a significant overall effect size, indicating that VRET was effective in
reducing social anxiety compared to WL, with g = 0.82, p < .001, 95% CI [0.49, 1.15]. The second
meta-analysis, consisting of 7 studies and 340 participants, showed essentially no difference in
effect sizes between VRET and IVE or imaginal exposure, with g = −0.01, p = .955, 95% CI [−0.30,
0.28]. Chesham et al. (2018) conclude both meta-analyses support the use of VR in the treatment
of social anxiety.
Fodor et al. (2018) meta-analysis focused on anxiety and depression symptoms; they found that
interventions enhanced by a VR component had moderate to large effects compared to control con-
ditions, but they highlight that these effects were likely inflated by several design and implemen-
tation factors in the analysed trials; these authors also indicate that few difference has been found
when comparing VR enhanced interventions with other active interventions.
Following the scope of the previous article (Fodor et al., 2018), Carl et al. (2019) found that VRET
has a medium to large effect size compared to control conditions and an equal effect size to that of
IVE for Specific phobias, Social anxiety disorder, Performance anxiety, PTSD, and Panic Disorder; they
also state that in cases where VRET is preferable or more accessible, it can be considered an effica-
cious alternative to IVE for the treatment of anxiety-related disorders.
Kothgassner et al. (2019) have recently published a meta-analysis focused on VRET for PTSD. Their
results indicate that VRET showed a significantly better outcome for PTSD symptoms compared to WL
controls (g = 0.62, p = .017) and depressive symptoms (g = 0.50, p = .008). There was no significant
difference between VRET and active controls regarding PTSD symptoms (g = 0.25, p = .356) and
depressive symptoms (g = 0.24, p = .340) post-treatment; No significant effects emerged for anxiety
symptoms. Kothgassner et al. (2019) conclude that the evidence from their meta-analysis was insuffi-
cient to assume efficacy of VRET for particular trauma types. A considerable amount of research sup-
ports the efficacy of VRET for the treatment of specific phobias (Powers & Emmelkamp, 2008; Opriş
et al., 2012; Cardoş et al., 2017; Fodor et al., 2018; Carl et al. 2019), but only a small number of con-
trolled studies have investigated the efficacy of VRET in patients with PTSD. Therefore, they state that
despite the moderately positive results of their meta-analysis, more research is required to determine
whether VRET constitutes a valuable tool for PTSD treatment (Kothgassner et al., 2019).
22 J. ASIAIN ET AL.

Review & meta-analysis

We found two articles claiming to present both a systematic review and a meta-analysis. Morina et al.
(2016) state that all previous meta-analyses on the efficacy of VRET for anxiety disorders have mainly
focused on self-reports of intrapersonal states, instead of behavioural laboratory tests or behavioural
activities in real life. The objective of their work was to provide a comprehensive and up-to-date sys-
tematic review and meta-analysis of the extent to which the gains in VRET can be transferred to real
life. Morina et al. (2016) concluded that the results of their research indicate that patients undergoing
VRET score significantly better on behavioural assessments at post-treatment and at follow-up com-
pared to pre-treatment. Patients treated by VRET reported significantly better scores in behavioural
assessments than patients in inactive conditions. In addition, the results indicate a non-significant
difference in behavioural evaluations between VRET and behavioural therapy. Also, effect sizes result-
ing from the behavioural assessment scores were similar to those calculated from the self-reported
measures. In summary, Morina et al. (2016) state that the presented findings support the efficacy of
VRET for specific phobias, that the results obtained in VRET can effectively enable behaviour change
in real-life situations, and that more research is needed to make reliable statements about other dis-
orders and to address the mechanisms underlying behaviour change in VRET.
The last included work is the one of Deng et al. (2019) focused on the efficacy of VRET for PTSD
symptoms. Their main effects analysis showed a moderate effect size (g = 0.327, 95% CI: 0.105–0.550,
p < 0.01) for VRET compared to control conditions on PTSD symptoms. Their subgroup analysis
revealed that the effects of VRET were larger when compared to inactive groups (g = 0.567) than
active control groups (g = 0.017). Deng et al. (2019) also found a dose–response relationship
existed with more VRET sessions showing larger effects, in agreement with previous meta-analyses
(Powers & Emmelkamp, 2008; Opriş et al., 2012). Deng et al. (2019) also found a long-range effect
of VRET on PTSD symptoms indicating a sustained decrease in PTSD symptoms at 3-month follow-
up (g = 0.697) and 6-month follow-up (g = 0.848). According to Deng et al. (2019) this novel treatment
is effective, it can be improved more, and patients’ attrition rates are high, but these findings indicate
VRET is effective in treating PTSD, as it reduces PTSD and depressive symptoms. However, they state it
is still a kind of treatment that isn’t absolutely better than traditional therapies, but has a sustainable
therapeutic effect.

Discussion & conclusions

There has been a steadily growing amount of research regarding the use of VR for mental health. This
increase goes in hand with the design and the massive release of equipments with a significant
reduction of costs. Not only the reduction of the cost is an important asset but also the versatility
of these hardware pieces have permitted many researchers to test their uses in innovative and
diverse ways. VR software applications have shown to be a flexible and useful tool in the mental
health field. This technology not only enables researchers to explore new and more complex ways
to study psychotherapeutic issues, but also enables the personalisation and broader accessibility
of treatments. With this technology we may have begun to change the eyes that see reality (Wieder-
hold, 2016).
VR applications as psychotherapeutic tools have been mostly used to treat anxiety disorders. It’s
been used specifically as an additive, and sometimes an alternative, to exposure therapy, called
virtual reality exposure therapy. VRET is safe and effective to treat PTSD, binge and eating disorders,
and specific phobias (acrophobia, spider phobia, agoraphobia w/w panic disorder, FoF, social anxiety,
fear of public speaking). There’s still not enough evidence to support VR based interventions for ASD,
psychosis, or depression. However, it is a safe and useful tool to explore these pathologies, specifically
the ones where neurocognitive deficits are involved.
As Cipresso and his colleagues mentioned, “the first 30 years of VR and AR consisted of a continu-
ous research on better resolution and improved perception”. Now the proposal for the future of the
 BRITISH JOURNAL OF GUIDANCE & COUNSELLING 23

VR is not to focus on the resolution of the images but in the transformation of the experience in a
more vivid and natural interaction, maybe abandoning the reality as a goal and looking for attractive
representations (Cipresso, Giglioli, Raya, & Riva, 2018, p. 15). According to Botella, Baños, García-Pala-
cios, and Quero (2017) the available evidence indicates that it is worthwhile to continue research in
order to define which VR systems can be more useful to whom, and how and when should they be
applied.
Different generations and actions from Cognitive–behavioural therapy are the most present theor-
etical background in the studies reviewed. This might be explained partially because CBT has been
adapted to manuals and it might be easier to translate its mechanisms to virtual reality environments.
A great challenge lies ahead when considering the incorporation of VR tools into other theoretical
frameworks. Researchers, clients and clinicians will need to work together in creative ways to
include VR in their treatments.
Most reviews and meta-analysis agree on the serious lack of methodological rigour of most of the
studies: small samples composed of mostly male adults, no randomisation, no solid active control
conditions, no explicit application protocols, very few follow-ups, and high drop-out rates. This is
only one side of the methodological challenge, since the validation of this type of technological inter-
ventions also requires the incorporation and evaluation of criteria related to the care of user data,
such as use permits, the detail of the exact information that is collected from users, the availability
of information generated for patients, among other aspects.
There’s still a lack of knowledge regarding the relationship between the use of VR applications and
the therapeutic alliance. Works focusing on this topic have been few but relevant, especially those of
Meyerbröker and Emmelkamp (2010) and Ngai, Tully, and Anderson (2015).
Professionals looking forward to using this kind of technology must take several precautions: there
are no software and hardware standards for its use in mental health. Whoever attempts to use this
kind of technology in psychotherapy must get training in computational sciences first in order to
understand which the implications are. Also, there is a lack of administration protocols, although
some have been published (Bouchard, Robillard, Larouche, & Loranger, 2012; Rothbaum, Hodges,
& Smith, 1999; Spira, Wiederhold, Pyne, & Wiederhold, 2006). In addition, Nichols and Patel (2002)
made a number of recommendations regarding the future direction of research into health and
safety implications of VR, emphasising on the need to take into account the way in which VR is
being used when conducting empirical research. Furthermore, the work of Birckhead et al.(2018)
aimed to develop a methodological framework in order to guide the design, implementation, analy-
sis, interpretation and communication of trials that develop and test VR treatments. Professionals
seeking to understand more about this line of research would be interested in Cyberpsychology,
the study of the human mind and behaviour and how the culture of technology, specifically,
virtual reality, and social media affect them (Blascovich & Bailenson, 2011).
Focusing on ethical issues related to VR, Madary and Metzinger (2016) published an article which
goal is to present a first list of ethical concerns that may arise from research and personal user of VR
and related technology. In their work a set of ethical recommendations is presented as a platform for
future discussions; a set of normative starting points that can be continuously refined and expanded
as this research field grows.
VR technology is not an answer in and of itself: the content delivered will matter for outcomes
(Freeman et al., 2017; Jerdan et al., 2018; Reger et al., 2016). The content delivered must be pre-pro-
grammed; its characteristics represent a digital world potentially therapeutic for the user. As Bailey
et al. (2016) explain, cognition is rooted in the human body and learning occurs at an unconscious
level; thus memories and mental representations may be extended out onto technology, blurring
the physical and the mediated. The idea of incorporating a VR component to new or traditional
forms of treatment must be carefully taken into account. This parallels Kazdin (2009) perspective
about therapeutic treatment; there is no simple and single path to many mental health problems,
and there may be akin complexity in mechanisms for a given treatment technique or therapeutic
outcome.
24 J. ASIAIN ET AL.

We want to highlight that studies including a relevant role for Avatars are scarce. A VR simulation
can exist and work without avatars, but representations of other human beings, or even the user as
one, are often used to raise ecological validity, giving the VE a sense of actual reality, in order to elicit a
higher sense of presence. Several authors have shown the importance and complexity about avatars
(Ahn, Fox, & Bailenson, 2012; Bailenson, Blascovich, & Guadagno, 2008; Guadagno, Swinth, & Blasco-
vich, 2011; Ratan & Dawson, 2015; Rehm, Foenander, Wallace, Abbott, & Kyrios, 2016; Yee & Bailenson,
2007) and, accordingly, we believe research in this field must take them into account when designing
studies and drawing conclusions. A special mention can be done about the work of van Rijn, Cooper,
Jackson, and Wild (2015), who presented an avatar-based virtual reality therapy called ProReal, as an
addition to a therapeutic programme within a therapeutic community prison in the UK, with the aim
of investigating whether this approach would improve mental health outcomes for the prisoners,
interpersonal relationships within the prison and facilitate the achievement of personal goals for
the prisoners. van Rijn et al. (2015) concluded ProReal intensified emotional experiences and also
seemed to increase empathy and develop relationships between participants.
Nowadays people can acquire a VR system and a computer for an accessible price, and start build-
ing digital worlds easily. Internet brings the possibility of connecting these new digital worlds to the
world wide web, potentially inviting almost anyone on Earth to meet in VEs, where phenomena has
the potential to make effects in each case’s actual reality. This means we can foster and enhance
human wellbeing in brand new ways, or even modified traditional ways. But we still do need inter-
disciplinary ethical regulations, safety and health parameters and guidelines, and help services
focused on users of VR.
VR brings the possibility of creating and moulding environments able to assess, explore, treat, play
and even train; training of social skills is an already real example. Professional training in augmented
and/or virtual reality is today a fact in the field of Medicine. VEs can be used to safely train anything
implying any sort of risks in the actual reality. In Mental Health this means having the possibility of
training psychology clinicians more integrally and accurately.

Disclosure statement
No potential conflict of interest was reported by the author(s).

Notes on contributors
Joaquín Asiain is a licensed psychologist from the Universidad de Belgrano, Buenos Aires, Argentina. He is a researcher in
Clinical Psychology, with a focus on technology and mental health, and how technological adjuncts can enhance human
quality of life. Actual member of the Latin American Chapter of the Society for Psychotherapy Research (SPR), and
member of LIPSTIC, (Lab for research in psychology and technology). He is an assistant professor in two departments:
Social psychology, and Research methods and epistemology, both part of the psychology degree career at the University
of Belgrano. He is an active psychotherapist with an integrative orientation working in private practice. He specializes in
the treatment of people with anxiety disorders, stress, and/or depression.
Malena Braun is a licensed psychologist from the Universidad de Belgrano, Buenos Aires, Argentina. She is a researcher in
Clinical Psychology, President of the Latin American Chapter of the Society for Psychotherapy Research, SPR, and a
founding member LIPSTIC. She is a coordinator at the research team in Clinical Psychology of the Universidad de Bel-
grano. She has published papers in Latin American and international scientific journals, a book and online publications,
received various research awards and made presentations in international scientific meetings. She is a professor in
Research Methods and Epistemology in the Psychology degree career, at the Universidad de Belgrano and professor
of Introduction to Psychology at the Universidad de San Andres. An active psychotherapist with an integrative orien-
tation working in private practice, she specializes in the treatment of people with anxiety disorders, stress, and/or
depression and psychotherapy for personal growth or coping with vital crises.
Andrés J. Roussos is a Doctor in Psychology from the University of Belgrano. He studied specialization in the Department
of Psychotherapy at the University of Ulm, (Germany) and postdoctoral studies at the Glass Institute of the Adelphi Uni-
versity (United States) and CONICET, based at the University of Buenos Aires (Argentina). He has worked as a professor at
universities in Argentina, Chile, Uruguay and the United States. He is currently Director of the Clinical Psychology research
team (EIPSI) of the University of Belgrano (Argentina) and principal researcher of the CONICET (Argentina). He is a
 BRITISH JOURNAL OF GUIDANCE & COUNSELLING 25

member of the Research Chapter of the Argentine Society of Psychoanalysis, of the International Society for Mental
Health Online (ISMHO) and of the Society for Psychotherapy Research (SPR) of which he has been president of its
Latin American chapter (2010-2013). He is a tenured professor in the subject Methodology of research in Psychology,
Faculty of Humanities, Universidad de Belgrano, Argentina, and Regular Associate Professor in the subject Psychology
Research Methodology, Faculty of Psychology, University of Buenos Aires, Argentina. Dr. Roussos has published more
than 80 articles in national and international scientific journals, 2 books and 5 book chapters, in Spanish, Portuguese
and English.

ORCID
Joaquín Asiain http://orcid.org/0000-0002-2885-5444

References
Ahn, S. J., Fox, J., & Bailenson, J. N. (2012). Avatars. In W. S. Bainbridge (Ed.), Leadership in science and technology: A refer-
ence handbook (pp. 1–20). Chicago: SAGE publications. doi:10.4135/9781412994231
Bailenson, J., Blascovich, J., & Guadagno, R. E. (2008). Self-Representations in immersive virtual environments. Journal of
Applied Social Psychology, 38, 2673–2690. Retrieved from http://onlinelibrary.wiley.com/doi/10.1111/j.1559-1816.2008.
00409.x/full.
Bailey, J. N., Bailenson, J. N., & Casasanto, D. (2016). When does virtual embodiment change Our minds? Presence:
Teleoperators and Virtual Environments, 25(3), 222–233. doi:10.1162/PRES_a_00263
Birckhead, B., Khalil, C., Liu, X., Conovitz, S., Rizzo, A., Danovitch, I., … Spiegel, B. (2018). Methodology for clinical trials of
virtual reality in healthcare: Recommendations from an international working group. JMIR Mental Health. doi:10.2196/
11973
Blascovich, J., & Bailenson, J. (2011). Infinite reality: Avatars, eternal life, new worlds, and the dawn of the virtual revolution.
New York: HarperCollins Publishers.
Bloch, F., Rigaud, A. S., & Kemoun, G. (2013). Virtual reality exposure therapy in posttraumatic stress disorder: A brief
review to open new opportunities for post-fall syndrome in elderly subjects. European Geriatric Medicine, 4, 427–
430. doi:10.1016/j.eurger.2013.10.005
Botella, C., Baños, R. M., García-Palacios, A., & Quero, S. (2017). Virtual reality and other realities. In S. G. Hofmann & G. J. G.
Asmundson (Eds.), The science of cognitive behavioral therapy (pp. 551–590). Amsterdam: Elsevier: Academic Press.
Botella, C., Fernández-Álvarez, J., Guillén, V., García-Palacios, A., & Baños, R. (2017). Recent progress in virtual reality
exposure therapy for phobias: A systematic review. Current Psychiatry Reports, 19, 7. doi:10.1007/s11920-017-0788-4
Botella, C., Perpiñá, C., Baños, R. M., & García-Palacios, A. (1998). Virtual reality: A new clinical setting lab. Studies in Health
Technology and Informatics, 58, 73–81. doi:10.3233/978-1-60750-902-8-73
Botella, C., Serrano, B., Baños, R. M., & Garcia-Palacios, A. (2015). Virtual reality exposure-based therapy for the treatment
of post-traumatic stress disorder: A review of its efficacy, the adequacy of the treatment protocol, and its acceptability.
Neuropsychiatric Disease and Treatment, 11(October), 2533–2545. doi:10.2147/NDT.S89542
Bouchard, S., Robillard, G., Larouche, S., & Loranger, C. (2012). Description of a treatment manual for in virtuo exposure
with specific phobia. In Virtual reality in psychological, medical and pedagogical applications (pp. 81–108). INTECH.
doi:10.5772/46417
Brito, H. C., & Benjamín, V. P. (2018). Realidad virtual y sus aplicaciones en trastornos mentales: Una revisión. Revista
Chilena de Neuro-Psiquiatría, 56(2), 127–135.
Cardoş, R. A. I., David, O. A., & David, D. O. (2017). Virtual reality exposure therapy in flight anxiety: A quantitative meta-
analysis. Computers in Human Behavior, 72. doi:10.1016/j.chb.2017.03.007
Carl, E., Stein, A. T., Levihn-Coon, A., Pogue, J. R., Rothbaum, B., Emmelkamp, P., Asmundson, G., Carlbring, P., & Powers, M.
B. (2019). Virtual reality exposure therapy for anxiety and related disorders: A meta-analysis of randomized controlled
trials. Journal of Anxiety Disorders, 61, 27–36. doi:10.1016/j.janxdis.2018.08.003
Chesham, R. K., Malouff, J. M., & Schutte, N. S. (2018). Meta-Analysis of the efficacy of virtual reality exposure therapy for
social anxiety. Behaviour Change, 35(3), 152–166. doi:10.1017/bec.2018.15
Cipresso, P., Giglioli, I. A. C., Raya, M. A., & Riva, G. (2018). The past, present, and future of virtual and augmented reality
research: A network and cluster analysis of the literature. Frontiers in Psychology, 9(November), doi:10.3389/fpsyg.2018.
02086
Coelho, C., Tichon, J., Hine, T. J., Wallis, G., & Riva, G. (2006). Media presence and inner presence: The sense of presence in
virtual reality technologies. In G. Riva, M. T. Anguera, B. K. Wiederhold, & F. Mantovani (Eds.), Communication to pres-
ence: Cognition, emotions and culture towards the ultimate communicative experience (pp. 25–45). Amsterdam: IOS
Press.
26 J. ASIAIN ET AL.

Dellazizzo, L., Potvin, S., Bahig, S., & Dumais, A. (2019). Comprehensive review on virtual reality for the treatment of vio-
lence: Implications for youth with schizophrenia. Nature Partner Journals: Schizophrenia, 5, 1–12. doi:10.1038/s41537-
019-0079-7
Deng, W., Hu, D., Xu, S., Liu, X., Zhao, J., Chen, Q., … Li, X. (2019). The efficacy of virtual reality exposure therapy for PTSD
symptoms: A systematic review and meta-analysis. Journal of Affective Disorders, 257, 698–709. doi:10.1016/j.jad.2019.
07.086
Eichenberg, C., & Wolters, C. (2012). Virtual realities in the treatment of mental disorders: A review of the current state of
research. In Virtual reality in psychological, medical and pedagogical applications (pp. 35–64). InTech. doi:10.5772/50094
Ferrer-García, M., & Gutiérrez-Maldonado, J. (2012). The use of virtual reality in the study, assessment, and treatment of
body image in eating disorders and nonclinical samples: A review of the literature. Body Image, 9(1), 1–11. doi:10.1016/
j.bodyim.2011.10.001
Ferrer-Garcia, M., Gutiérrez-Maldonado, J., & Riva, G. (2013). Virtual reality based treatments in eating disorders and
obesity: A review. Journal of Contemporary Psychotherapy, 43(4), 207–221. doi:10.1007/s10879-013-9240-1
Fodor, L. A., Coteţ, C. D., Cuijpers, P., Szamoskozi, Ş, David, D., & Cristea, I. A. (2018). The effectiveness of virtual reality
based interventions for symptoms of anxiety and depression: A meta-analysis. Scientific Reports, 8(1), 1–13. doi:10.
1038/s41598-018-28113-6
Freeman, D., Reeve, S., Robinson, A., Ehlers, A., Clark, D., Spanlang, B., & Slater, M. (2017). Virtual reality in the assessment,
understanding, and treatment of mental health disorders. Psychological Medicine, 47(14), 2393–2400. doi:10.1017/
S003329171700040X
Fuchs, P., & Guitton, P. (2011). Introduction to virtual reality. In P. F. Fuchs, G. Moreau, & P. Guitton (Eds.), Virtual reality:
Concepts and technologies (pp. 3–45). Boca Raton: CRC Press.
Gallagher, M., & Ferrè, E. R. (2018). Cybersickness: A multisensory integration perspective. Multisensory Research, 31(7),
645–674. doi:10.1163/22134808-20181293
Gonçalves, R., Pedrozo, A. L., Coutinho, E. S. F., Figueira, I., & Ventura, P. (2012). Efficacy of virtual reality exposure therapy
in the treatment of PTSD: A systematic review. PLoS ONE, 7(12), e48469. doi:10.1371/journal.pone.0048469
Gourlay, G., Lun, K., Liya, G., (2001). Review of virtual reality treatment for mental health. In V. Patel (Ed.), Studies in health
technology and informatics (pp. 820–824). Amsterdam: IOS Press.
Gregg, L., & Tarrier, N. (2007). Virtual reality in mental health. A review of the literature. Social Psychiatry and Psychiatric
Epidemiology, 42(5), 343–354. doi:10.1007/s00127-007-0173-4
Guadagno, R. E., Swinth, K. R., & Blascovich, J. (2011). Social evaluations of embodied agents and avatars. Computers in
Human Behavior, 27(6), 2380–2385. doi:10.1016/j.chb.2011.07.017
Haniff, D., Chamberlain, A., Mood, L., & De Freitas, S. (2014). Virtual environments for mental health issues: A review.
Journal of Metabolomics and Systems Biology, 3(1), 1–10. doi:10.5897/JMSB11.003
Jerdan, S. W., Grindle, M., van Woerden, H. C., & Boulos, M. N. K. (2018). Head-Mounted virtual reality and mental health :
Critical review of current research. JMIR Serious Games, 6(3), e14. doi:10.2196/games.9226
Kazdin, A. E. (2009). Understanding how and why psychotherapy leads to change. Psychotherapy Research, 19(4–5), 418–
428. doi:10.1080/10503300802448899
Kazdin, A. E., & Blase, S. L. (2011). Rebooting psychotherapy research and practice to reduce the burden of mental illness.
Perspectives on Psychological Science, 6(1), 21–37. doi:10.1177/1745691610393527
Kothgassner, O. D., Goreis, A., Kafka, J. X., Van Eickels, R. L., Plener, P. L., & Felnhofer, A. (2019). Virtual reality exposure
therapy for posttraumatic stress disorder (PTSD): A meta-analysis. European Journal of Psychotraumatology, 10(1),
1654782. doi:10.1080/20008198.2019.1654782
Krijn, M., Emmelkamp, P. M. G., Olafsson, R. P., & Biemond, R. (2004). Virtual reality exposure therapy of anxiety disorders: A
review. Clinical Psychology Review, 24(3), 259–281. doi:10.1016/j.cpr.2004.04.001
Laplanche, J., & Pontalis, J. (1996). Diccionario de psicoanálisis. paidós. doi:10.1007/s11904-015-0280-x
Leff, J., Williams, G., Huckvale, M., Arbuthnot, M., & Leff, A. P. (2014). Avatar therapy for persecutory auditory hallucina-
tions: What is it and how does it work? Psychosis, 6(2), 166–176. doi:10.1080/17522439.2013.773457
Lewis, C. H., & Griffin, M. J. (1997). Human factors consideration in clinical applications of virtual reality. Studies in Health
Technology and Informatics, 44, 35–56. Retrieved from citeulike-article-id:953237%5Cnpapers3://publication/uuid/
72F6F453-A472-4636-B294-FE1DAEA9540D.
Lombard, M., & Ditton, T. (1997). At the heart of it all: The concept of presence. Journal of Computer-Mediated
Communication, 3(2), Retrieved from https://academic.oup.com/jcmc/article/3/2/JCMC321/4080403.
Madary, M., & Metzinger, T. K. (2016). Real virtuality: A code of ethical conduct. recommendations for good scientific prac-
tice and the consumers of VR-technology. Frontiers in Robotics and AI, 3(3), 1–23. doi:10.3389/frobt.2016.00003
McCann, R. A., Armstrong, C. M., Skopp, N. A., Edwards-Stewart, A., Smolenski, D. J., June, J. D., … Reger, G. M. (2014).
Virtual reality exposure therapy for the treatment of anxiety disorders: An evaluation of research quality. Journal of
Anxiety Disorders, 28(6), 625–631. doi:10.1016/j.janxdis.2014.05.010
Mesa-Gresa, P., Gil-Gómez, H., Lozano-Quilis, J., & Gil-Gómez, J. (2018). Effectiveness of virtual reality for children and ado-
lescents with autism spectrum disorder: An evidence-based systematic review. Sensors, 18(2486), 1–18. doi:10.3390/
s18082486
 BRITISH JOURNAL OF GUIDANCE & COUNSELLING 27

Meyerbröker, K., & Emmelkamp, P. M. G. (2010). Virtual reality exposure therapy in anxiety disorders: A systematic review
of process-and-outcome studies. Depression and Anxiety, 27(10), 933–944. doi:10.1002/da.20734
Mishkind, M. C., Norr, A. M., Katz, A. C., & Reger, G. M. (2017). Review of virtual reality treatment in psychiatry: Evidence
versus current diffusion and use. Current Psychiatry Reports, 19(80), 1–8. doi:10.1007/s11920-017-0836-0
Morina, N., Ijntema, H., Meyerbröker, K., & Emmelkamp, P. M. G. (2016). Can virtual reality exposure therapy gains be gen-
eralized to real-life ? A meta-analysis of studies applying behavioral assessments. Behaviour Research and Therapy, 74
(2015), 18–24, doi:10.1016/j.brat.2015.08.010
Motraghi, T. E., Seim, R. W., Meyer, E. C., & Morissette, S. B. (2014). Virtual reality exposure therapy for the treatment of
posttraumatic stress disorder: A methodological review using CONSORT guidelines. Journal of Clinical Psychology,
70(3), 197–208. doi:10.1002/jclp.22051
Ngai, I., Tully, E. C., & Anderson, P. L. (2015). The course of the working alliance during virtual reality and exposure group
therapy for social anxiety disorder. Behavioural and Cognitive Psychotherapy, 43(October 2013), 167–181. doi:10.1017/
S135246581300088X
Nichols, S., & Patel, H. (2002). Health and safety implications of virtual reality: A review of empirical evidence. Applied
Ergonomics, 33(3), 251–271. doi:10.1016/S0003-6870(02)00020-0
Opriş, D., Pintea, S., García-Palacios, A., Botella, C., Szamosközi, Ş, & David, D. (2012). Virtual reality exposure therapy in
anxiety disorders: A quantitative meta-analysis. Depression and Anxiety, 29(2), 85–93. doi:10.1002/da.20910
Park, M. J., Kim, D. J., Lee, U., Na, E. J., & Jeon, H. J. (2019). A literature overview of virtual reality (VR) in treatment of psy-
chiatric disorders: Recent advances and limitations. Frontiers in Psychiatry, 10(505), 1–9. doi:10.3389/fpsyt.2019.00505
Parsons, T. D., & Rizzo, A. A. (2008). Affective outcomes of virtual reality exposure therapy for anxiety and specific phobias:
A meta-analysis. Journal of Behavior Therapy and Experimental Psychiatry, 39(3), 250–261. doi:10.1016/j.jbtep.2007.07.
007
Powers, M. B., & Emmelkamp, P. M. G. (2008). Virtual reality exposure therapy for anxiety disorders: A meta-analysis.
Journal of Anxiety Disorders, 22(3), 561–569. doi:10.1016/j.janxdis.2007.04.006
Ratan, R. A., & Dawson, M. (2015). When mii is me : A psychophysiological examination of avatar. doi:10.1177/
0093650215570652
Reger, G. M., Koenen-woods, P., Zetocha, K., Smolenski, D. J., Kevin, M., Rothbaum, B. O., … Gahm, G. A. (2016).
Randomized controlled trial of prolonged exposure using imaginal exposure vs. virtual reality exposure in active
duty soldiers With deployment-related posttraumatic stress disorder ( PTSD ). Journal of Consulting and Clinical
Psychology. doi:10.1037/ccp0000134
Rehm, I. C., Foenander, E., Wallace, K., Abbott, J. M., & Kyrios, M. (2016). What role Can avatars play in e-mental health
interventions? Exploring New Models of Client–Therapist Interaction, 7(November), 1–6. doi:10.3389/fpsyt.2016.00186
Riva, G. (2005). Virtual reality in psychotherapy: Review. CyberPsychology & Behavior, 8(3), 220–230. doi:10.1089/cpb.2005.
8.220
Riva, G., Wiederhold, B. K., & Mantovani, F. (2018). Neuroscience of virtual reality: From virtual exposure to embodied
medicine. Cyberpsychology, Behavior, and Social Networking, (September), 1–15. doi:0.1089/cyber.2017.29099.gri
Rosakranse, C., & Oh, S. Y. (2014, March 17–19). Measuring presence: The use trends of five canonical presence questionaires
from 1998–2012. ISPR 2014: 15th International Workshop on Presence (PRESENCE 2014), Vienna, Austria (pp. 17–21).
ISPR.
Rothbaum, B. O., Hodges, L., & Smith, S. (1999). Virtual reality exposure therapy abbreviated treatment manual: Fear of
flying application. Cognitive and Behavioral Practice, 6(3), 234–244. doi:10.1016/S1077-7229(99)80081-9
Roussos, A. J., Braun, M., & Asiain, J. (2018). Realidades virtuales en salud mental. In VERTEX Revista Argentina de psiquiatría,
137(XXIX), enero-febrero (pp. 41–50). Argentina: Editorial POLEMOS.
Rus-Calafell, M., Garety, P., Sason, E., Craig, T. J. K., & Valmaggia, L. R. (2017). Virtual reality in the assessment and treatment
of psychosis: A systematic review of its utility, acceptability and effectiveness. Psychological Medicine, 48(3), 362–391.
doi:10.1017/S0033291717001945
Sanchez-Vives, M. V., & Slater, M. (2005). Opinion: From presence to consciousness through virtual reality. Nature Reviews
Neuroscience, 6(4), 332–339. doi:10.1038/nrn1651
Senson, A. (2016, January 6). Virtual reality therapy: Treating the global mental health Crisis. Retrieved from https://
techcrunch.com/2016/01/06/virtual-reality-therapy-treating-the-global-mental-health-crisis/
Singh, S., & Nathan-Roberts, D. (2018). Virtual reality exposure therapy and military personnel with post-traumatic stress dis-
order: A systematic review. Presented at the Proceedings of the human factors and Ergonomics Society 2019 Annual
Meeting, doi:10.1177/1071181319631178
Slater, M. (2009). Place illusion and plausibility can lead to realistic behaviour in immersive virtual environments.
Philosophical Transactions of the Royal Society B: Biological Sciences, 364(1535), 3549–3557. doi:10.1098/rstb.2009.0138
Slater, M., & Sanchez-Vives, M. V. (2016). Enhancing Our lives with immersive virtual reality. Frontiers in Robotics and AI, 3
(December), 1–47. doi:10.3389/frobt.2016.00074
Slater, M., Spanlang, B., & Corominas, D. (2010). Simulating virtual environments within virtual environments as the basis
for a psychophysics of presence. ACM SIGGRAPH 2010 Papers on - SIGGRAPH ’10, 29(4), 1. doi:10.1145/1833351.1778829
28 J. ASIAIN ET AL.

Spanlang, B., Fröhlich, T., Descalzo, V. F., Antley, A., & Slater, M. (2007, October 25–27). The making of a presence exper-
iment: Responses to virtual fire. 10th Annual International Workshop on Presence. (PRESENCE 2007), Barcelona,
Spain (pp. 303–307). ISPR.
Spira, J. L., Wiederhold, B. K., Pyne, J. M., & Wiederhold, M. D. (2006). Virtual reality treatment manual: In virtuo physiologi-
cally-facilitated graded exposure therapy in the treatment of recently developed combat-related PTSD (training skill-based
resiliency). San Diego: The Virtual Reality Medical Center. Retrieved from http://atwarwithptsd.com/VRMC_PTSD_
TxManual.pdf
Turner, W. A., & Casey, L. M. (2014). Outcomes associated with virtual reality in psychological interventions: Where are we
now? Clinical Psychology Review, 34(6), 634–644. doi:10.1016/j.cpr.2014.10.003
Valmaggia, L. R., Day, F., & Rus-Calafell, M. (2016). Using virtual reality to investigate psychological processes and mech-
anisms associated with the onset and maintenance of psychosis: A systematic review. Social Psychiatry and Psychiatric
Epidemiology, 51(7), 921–936. doi:10.1007/s00127-016-1245-0
Valmaggia, L. R., Latif, L., Kempton, M. J., & Rus-Calafell, M. (2016). Virtual reality in the psychological treatment for mental
health problems: An systematic review of recent evidence. Psychiatry Research, 236, 189–195. doi:10.1016/j.psychres.
2016.01.015
van Baren, J., & Ijsselsteijn, W. (2004). Deliverable 5 - measuring presence : A guide to current measurement approaches (1.0).
Eindhoven: OmniPres.
van Rijn, B., Cooper, M., Jackson, A., & Wild, C. (2015). Avatar- based therapy within prison settings: Pilot evaluation. British
Journal of Guidance & Counselling, 45(3), 268–283. doi:10.1080/03069885.2015.1068273
Wiederhold, B. K. (2016). Lessons learned as We begin the third decade of virtual reality. Cyberpsychology, Behavior, and
Social Networking, 19(10), 577–578. doi:10.1089/cyber.2016.29052.bkw
Yee, N., & Bailenson, J. (2007). The proteus effect: The effect of transformed self-representation on behavior. Human
Communication Research, 33(3), 271–290. doi:10.1111/j.1468-2958.2007.00299.x