Defining and addressing research-level and therapist-level barriers to virtual reality therapy implementation in mental health settings

Given the global impact of mental health disorders, enhancing clinical treatment access and choice is essential. One area for improvement concerns therapies that incorporate off-clinic environmental, situational and/or sensory-orientated stimuli. A primary example is in vivo exposure therapy, an efficacious treatment for anxiety disorders. Because exposure needs vary (e.g., acrophobia, social phobia) and feared stimuli can be uncommon (e.g., snakes), and/or situational (e.g., flying), off-clinic exposure is often needed. This affects treatment availability. Additionally, since in vivo stimuli are difficult to control, some therapists avoid exposure to minimise harm. Imaginal exposure is also problematic because not all clients can develop sufficient mental imagery. In comparison, virtual reality (VR) delivers in-clinic sensory-orientated therapies, such as exposure, on-demand. However, despite support for a range of VR interventions, clinical uptake is low and challenges concerning VR therapy implementation remain uncharted. This project aimed to identify and address research-level and therapists-level barriers that impede clinical VR therapy implementation. Research-level investigations related to anxiety disorders and were informed through three critical reviews and a meta-analysis. Therapist-level research employed a survey-based methodology. Review 1 evaluated the clinical relevance of VR literature. A key finding was that presence, the sense of being there, dominated emotion-orientated VR therapy research. Presence was determined to be a facile concept that overlooked more complex cognition. Overall, inadequate psychological theory within VR literature limited its clinical relevance. In response, a cognitive model for VR-based emotional regulation was developed. Review 2 examined the impact of non-VR hardware within VR research—a compromise to validity. Because a standardised VR definition was not evident, a hardware-based VR qualification model was developed. A review was conducted to assess misclassification prevalence. From 115 studies, 35.7% utilised VR (6-degrees of freedom), 31.3% utilised non-VR hardware, 18.3% were considered quasi-VR (3-degrees of freedom), and 14.8% lacked hardware specifications. VR misclassification was also evident within meta-analytic research. Review 3 determined that meta-analytic guidelines lacked appropriate study selection protocols. To address this, experimental variable homogeneity criteria were developed. Study 1, a meta-analysis examining VR exposure efficacy for anxiety disorders, was restricted to studies with validated VR hardware. From 1219 studies, 140 underwent VR assessment: 43.6% did not utilise VR, 27.1% failed to declare hardware, and 11.4% had inadequate details for hardware validation. Six randomised control trial studies were pooled. VR had a large effect on reducing anxiety relative to controls, while quasi-VR (3-DoF) did not have a statistically significant effect. Study 2, a survey of mental health professionals (n = 123), examined therapist-level barriers. Only 8.3% of therapists reported using VR therapy. Most indicated considering VR in the next five years. However, VR therapy familiarity and confidence were low; both factors having a negative correlation with VR therapy delivery hesitations. Lack of training, general and VR, was a key theme. Most therapists supported accredited VR training, but indicated that their professional body was not doing enough to support VR interventions.   This project identified and addressed five core barriers to clinical VR implementation: (1) inadequate clinical-relevance within VR research; (2) literature validity issues arising from VR misclassification; (3) therapists’ low VR therapy familiarity; (4) therapists’ low VR confidence; and (5) lack of VR-related training. Recommendations were made to improve clinical VR uptake include establishing more clinically-relevant research, addressing VR misclassification, discipline-level support and endorsement of VR therapies, and VR therapy education for practitioners and postgraduate students.