We conducted a qualitative study of U.S. mental health clients’ perspectives on using tele-VR for immersive therapy, using semi-structured interviews and thematic analysis. We specifically examined the perspectives of mental health clients who had previously received exposure therapy via telehealth, in order to compare participants lived experiences with the emerging potential for tele-VR. The Institutional Review Board of the University of South Florida approved the study procedures as exempt human subjects research (IRB003548).

Between February and April 2023, we invited participants via therapist referral, flyers, and Research Match if they (NIMH, 2023) were adults (18 years or older), (Arias et al., 2022) spoke English fluently, (Vigo et al., 2022) had previously received exposure therapy over telehealth, and (Piao et al., 2022) resided in the U.S. We compensated participants with a $75 eGift card upon completion of the interview. Participant recruitment continued until thematic saturation was achieved and additional interviews yielded no newer findings (Weller et al., 2018).

Each participant joined the first author in a 1-h online video call using a secure version of Google Meet. The researcher used a five-part semi-structured interview guide from a previous study of therapists, (Ong et al., 2024a) modified to emphasize the client’s perspective. The guide included sections for (NIMH, 2023) informed consent and demographics; (Arias et al., 2022) TMH for exposure therapy; (Vigo et al., 2022) experiences with VR; (Piao et al., 2022) a 1 min and 35 s video depicting tele-VRET (i.e., therapist and client meeting in a video call, transitioning to tele-VR, then conducting exposure therapy over tele-VR; Figure 1); and (Dubreucq et al., 2021) impressions, concerns, and wants for tele-VRET specifically and tele-VR generally (Supplementary Material). We emphasized that compensation was for completion of the interview only and their genuine opinions were important for this research.

The first author led the thematic analysis using an approach from our previous study with therapists, (Ong et al., 2024a) modified for the client perspective. Clients’ perceptions of tele-VR features, overall benefits, and implementation concerns were emphasized particularly in analysis to compare with those of therapists from our previous studies. (30,35) Analysis of transcripts was conducted in MAXQDA 2022 to identify emergent themes related to exposure therapy over TMH, experiences with VR, and perspectives on tele-VRET. The researcher used meaningful phrases as the coding unit to explore repetitions, similarities and differences, cutting and sorting, and metacoding to identify and organize themes (Nowell et al., 2017; Bernard et al., 2016; Braun et al., 2012; Braun and Clarke, 2019). Emergent themes were organized by code frequency. Codes were consolidated into recurring higher-level themes and operationalized definitions across two iterations, upon which the second author reviewed the codebook. Discrepancies between the first and second authors’ interpretations of the codebook were resolved through discussion until consensus to ensure consistency and accuracy in the qualitative method (Campbell et al., 2013; Raskind et al., 2019).

The 17 clients were generally younger adults (M = 29.7 years, SD = 9.5, range 20–59), mostly females (52.9%, 9/17), mostly non-Hispanic White (88.2%, 15/17), and with varied annual incomes (M = $35,671; SD = $30,074; range unemployed to $100,000) (Table 1).

Clients described ways telehealth facilitated exposure therapy, and some ways telehealth could make therapy feel incomplete. All clients (100%, 17/17) reported experiencing TMH in the form of video calls.

Most clients (64.7%, 11/17) stated TMH made exposure therapy easier to access, especially clients with few local specialists and clients who preferred to speak with their therapist while doing exposures in their daily life. Some clients (29.4%, 5/17) felt TMH made exposure therapy less stressful as they could engage with their feared situations from home, and their therapist seemed more efficient with telehealth.

A few clients (17.6%, 3/17) felt less engaged with exposure therapy over TMH due to a weaker sense of accountability. A few clients (17.6%, 3/17) encountered exposure-specific technical concerns such as unintuitive interfaces and perceptions of weak internet security. A few clients (11.8%, 2/17) also felt exposure therapy over TMH made it harder to build rapport with their remote therapist due to difficulty perceiving body language and nonverbal communication.

All clients (100%, 17/17) defined VR as feeling immersed in another world through head-mounted displays. Most clients (9/17) had tried VR video games like Rec Room (https://recroom.com) and Beat Saber (https://beatsaber.com). Some clients (29.4%, 5/17) experienced VR at their friends’ houses. Some clients (29.4%, 5/17) tried VR at a university library or computer lab. Two clients (11.8%, 2/17) personally owned VR for gaming. Four clients (23.5%, 4/17) had never tried VR. No clients used VR for mental healthcare, but some (35.3%, 6/17) heard about VR for exposure therapy on TV or news articles.

Most clients (76.5%, 13/17) had positive perceptions of VR as useful, fun, and improving over time. Some clients (35.3%, 6/17) had neutral perceptions of VR as helpful under certain conditions. Some clients (35.3%, 6/17) had negative perceptions of VR, believing it was clunky, nauseating, or potentially harmful.

We asked clients about their reactions to the tele-VRET video, relevance to their TMH experience, and tele-VR for mental healthcare (Table 2).

All but one client (94.1%, 16/17) expressed positive perceptions of tele-VRET. Many clients (82.3%, 14/17) perceived tele-VRET as useful to share media, review clinical progress, travel to different environments, and interact with phobias safely. About half of clients (47.1%, 8/17) thought tele-VRET would be more comfortable than conventional TMH as VR could allow therapy to be more personalized and approachable. Some clients (35.3%, 6/17) believed tele-VRET would have been easier than conventional TMH or in-person, as tele-VRET may lessen pre-session stress.

Some clients (35.3%, 6/17) had neutral perceptions of tele-VRET. A few clients (17.6%, 3/17) were uncertain if tele-VRET would feel realistic. A few clients (11.8%, 2/17) were unclear about how tele-VRET functions. One client (5.9%, 1/17) was unsure if tele-VRET would add utility to imaginal exposure therapy.

More than half of clients (58.8%, 10/17) also described negative perceptions of tele-VRET, mostly due to unrealistic aesthetics or avatars. More than half (55.9%, 9/17) also stated tele-VRET avatars felt cartoonish and may not capture facial expressions and body language. One client (5.9%, 1/17) expressed that tele-VRET felt inappropriate for mental health and may be an existential threat to society.

When asked to discuss how tele-VRET could enhance care, clients described specific phobic stimuli and scenario simulations, data collection and assessment from within the VR experience, and VR experiences to complete on their own.

Many clients (55.9%, 9/17) requested social situations related to bullying, family, work, or tasks outside the home such as grocery shopping. Some clients (23.5%, 4/17) requested sensory experiences to smell flowers bloom or feel the rain on your skin. Some clients (23.5%, 4/17) requested different environments such as parks, stores, specific streets, or locations generated from photos. A few clients (17.6%, 3/17) requested highly specific narrative experiences to simulate past or future events with the ability to conclude peacefully.

A few clients (17.6%, 3/17) requested assessments within tele-VRET to complete data forms, track clinical progress, and view immersive recordings of previous sessions.

Two clients (11.8%, 2/17) requested to engage in VRET alone on their own time (e.g., homework).

Clients requested a variety of tele-VR uses other than exposure therapy, information on how tele-VR would work, and opportunities to customize client experiences (Table 3).

We explored client perspectives by interviewing 17 adults about their exposure therapy over TMH, VR experience, reactions to a video depicting tele-VRET, and wants from tele-VR generally. Clients said exposure therapy over TMH was accessible, but could feel less engaging. Clients had mostly positive reactions to tele-VRET, believing its immersion and interactivity could make exposure therapy easier, more comfortable, and more personalized. They proposed other helpful tele-VR practices like art therapy, empty chair therapy, and immersive games to build rapport with therapists. While exciting, clients felt tele-VR should serve specific needs and were concerned whether VR would be affordable and covered by their insurance. Overall, clients described ways VR may enhance engagement and personalization of TMH, if cost and complexity are minimized. These findings can expand the understanding of immersive telehealth in several ways.

Client perspectives broadly agreed with prior studies of therapists’ perceptions of tele-VR (Ong et al., 2024a; Ong et al., 2024b). Therapists and clients were excited about how VR could enhance presence and interactivity in TMH, as well as customizable client experiences, tele-VRET for social and specific phobia, and for clients to engage asynchronously (i.e., homework). Clients’ and therapists’ largest concerns were costs and clinical evidence, and also believed unrealistic avatars could limit communication and immersion. Collectively, it seems therapists and clients may be likely to try tele-VR if it is affordable and relevant for a client’s specific needs. Both parties want to know tele-VR is clinically validated and will add to the healing experience with minimal, predictable risks.

In these studies, client and therapist perspectives diverged on several topics. Therapists rated customizable avatars as one of their least important tele-VR features (Ong et al., 2024b). Yet, in this study, clients strongly favored customizable avatars for themselves, therapists, and simulated assistants. This signals the need for research exploring how therapists and clients can utilize VR avatars for therapy, including avatars in the likeness of others (van Minnen et al., 2022; Thompson et al., 2023). Therapists and clients agreed on factors for implementing tele-VR: affordability, insurance coverage, and accessibility. However, therapists rated enhanced presence as low priority while clients described it as a major appeal of tele-VR. Therapists may overestimate clients’ trust and comfort, which can negatively impact clinical outcomes (Bar-Kalifa et al., 2016; Moshe-Cohen et al., 2024). Hands-on user studies will be important to understand how therapists and their clients utilize tele-VR in practice.

VR may make therapy more approachable for those who avoid mental health because of stigma and poor expectations of individualized care (Dubreucq et al., 2021; SAMHSA, 2020). Here, clients reported tele-VR may provide a comforting sense of anonymity with avatars instead of their real self, while letting them feel immersed in a clinical space from home. Studies should evaluate how VR adds to conventional TMH experiences and outcomes, with emphasis on signals of success such as likelihood to seek care, therapeutic alliance, and satisfaction (Humbert et al., 2023; Benbow and Anderson, 2019). It will also be valuable to study predictors of clinical outcomes and how they may interrelate with features of tele-VR: therapeutic alliance, (Baier et al., 2020) presence and immersion in VR, (Slater et al., 2022) and therapeutic presence (Aafjes-Van Doorn et al., 2024). These results also provide qualitative ways therapists might use VR to personalize TMH: avatars that look like others relevant to a client’s treatment, (van Minnen et al., 2022; Chen et al., 2024; van Gelder et al., 2022) spontaneous but anonymous interactions in public spaces, (Dilgul et al., 2021; Fajnerova et al., 2024) using VR to visit real-world places, (Kostakos et al., 2019) and narrative VR in which a client could simulate outcomes different than those of prior experiences (Georgieva and Georgiev, 2019; Mao et al., 2023). These options should be explored to understand the economic and clinical feasibility of personalized tele-VR and its effect on client outcomes.

Clients were skeptical about tele-VR reliability, security, and privacy. One client expressed bleak expectations for tele-VR to disrupt face-to-face relations. Addressing these concerns will require transparency across academia, clinical care, and industry. While research suggests side effects of VR are minor, temporary, and preventable, (Simón-Vicente et al., 2024) these risks must be addressed nonetheless. Some clients reported dissociation after using VR, (Mondellini et al., 2021; Taveira et al., 2022) therapists have expressed concern about potential VR addiction, (Ong et al., 2024a; Kaimara et al., 2022) and leading VR companies have questionable reputations for user privacy (Cross, 2024; Tukur et al., 2023). Delphi studies and consensus statements by representative organizations may facilitate commitment to healthcare operations and privacy standards (Abbas et al., 2024).

These results should be interpreted with several limitations. First, these findings were the result of qualitative analysis, which may be subject to bias. However, themes and definitions identified in the current study align with those in similar studies with clients and therapists (Dilgul et al., 2021; Bruno et al., 2022; Vincent et al., 2021). Future research should validate these findings quantitatively. Second, we recruited mental health clients who had received exposure therapy over telehealth. While this strategy may have resulted in biased client perceptions (i.e., positive opinions having undergone therapy before), their discussions of tele-VR aligned with those in similar research. In a survey of 184 clients with a range of anxiety-related conditions, only 60% had received exposure therapy but 90% were willing to try VRET because it seemed safe, effective, private, and customizable (Levy et al., 2023). To maximize generality, future research should examine the perspectives of clients who had received other therapies over telehealth and in-person. Third, clients in this study sample had never used VR for therapy. While clients discussed tele-VR speculatively, their pros, cons, and uses of tele-VR matched those described by expert VR clinicians, educators, and developers (Abbas et al., 2024; Cushnan et al., 2024). It will be important to understand the perspectives of clients who have completed tele-VR as part of formal treatment to evaluate first-hand insights. Lastly, while we achieved thematic saturation, the sampling approach does not support generalization to all mental health clients. Qualitative input should be sought from participants in future studies of telehealth-based VR therapy.