Virtual Reality (VR) Treatments for Anxiety Disorders Are Unambiguously Successful, so Why Are so Few Therapists Using It? Barriers to Adoption and Potential Solutions

“These guidelines summarize the existing scientific evidence on available treatments for a given condition, make recommendations about which treatment approaches might provide the most benefit for patients, and provide guidance about the best ways to deliver them (Steinberg et al., 2011).”

“VR refers to a computer-generated experience that provides an extensive, immersive, and vivid illusion of reality to human users (Slater & Wilbur, 1997).”

“Exposure techniques call for individuals to gradually confront fear-provoking stimuli to acquire new safety learning that contradicts their anxious beliefs about the dangerousness and intolerability of feared situations (Abramowitz et al., 2019; Craske et al., 2014; Rauch et al., 2012).”

“…drift,” which involves a tendency for a treatment to show more limited benefits as therapists deliver it in the real world and deviate from its essential components, is also frequently a challenge to real-world delivery of standardized treatments (Chambers et al., 2013; Waller & Turner, 2016).”

“Again, negative attitudes about evidence-based practices in general could play an important role (Aarons, 2004).”

“The Anxiety Disorders Association of Canada’s (ADAC) clinical practice guidelines for management of anxiety disorders, published in 2014, provides similarly tepid recommendations, suggesting that VRET “can be effective” for specific phobias (Katzman et al., 2014).”

“, 2017), although other authors suggest training therapists in general principles over specific techniques or manuals (Abramowitz, 2006; Miller et al., 2004).”

“Given the strong evidence base for exposure as an essential element of evidence-based practices (EBPs) for anxiety disorders, there have long been calls to prioritize the dissemination of exposure-based techniques in typical practice (McHugh & Barlow, 2010).”

“Meta-analyses have shown that VR-assisted exposure therapy (VRET) is as effective as in vivo exposures for specific phobias and has large effects versus waitlist and placebo conditions (Carl et al., 2019).”

“Anxiety disorders are among the most common mental health disorders worldwide (Lépine, 2002; Michael et al., 2007) and are a significant source of health burden as the sixth leading cause of disability globally (Baxter et al., 2014).”

“A survey of doctoral-level psychologists found that only 17% had used exposure techniques to treat patients with PTSD, despite up to 27% having been trained in using these techniques (Becker et al., 2004).”

““Simulator sickness” or “cybersickness,” a condition similar to motion sickness in which patients experience dizziness, headache, blurred vision, and nausea/vomiting after using VR, is also a problem for some users (Saredakis et al., 2019).”

“Yet, less than a third of those suffering with anxiety disorders receive any treatment, and less than 10% receive treatment that could be considered of adequate quality (Alonso et al., 2018).”

“In turn, nearly all of the most effective approaches to psychotherapy across anxiety disorders involve some degree of exposure (Chorpita & Daleiden, 2009; Gunter & Whittal, 2010), and these exposures are likely responsible for much of the clinical benefit conferred by these treatments (Gould et…”

“…rigidity of the culture of the organization and specific departments (e.g. information technology), and the organization’s resistance to change have been shown to affect the adoption and sustainability of new psychotherapies and programs (Glisson, Schoenwald, et al., 2008; Patterson et al., 2013).”

“Despite clear evidence of the benefits of adopting evidence-based practices for patients (Cukrowicz et al., 2011; Weisz et al., 2006), many therapists instead opt to rely primarily on their clinical judgement (e.g. Stewart & Chambless, 2007; Von Ranson et al., 2013).”

“Psychotherapy is one of the most effective and durable treatment options available for almost all types of anxiety disorders (Bystritsky, 2006; Cuijpers et al., 2013).”

“Taken together, there is ample evidence that the effects of VR-delivered treatment generalize to improvement in symptoms across many anxiety disorders in real life (Deng et al., 2019; Morina et al., 2015) and that, for most, VRET use generally reduces symptoms about as much as in vivo exposure.”

“…approaches to psychotherapy across anxiety disorders involve some degree of exposure (Chorpita & Daleiden, 2009; Gunter & Whittal, 2010), and these exposures are likely responsible for much of the clinical benefit conferred by these treatments (Gould et al., 1997; Woody & Ollendick, 2006).”

“…in a 2014 study of Canadian psychologists, only 12% reported monitoring their patients’ progress while in psychotherapy (Ionita & Fitzpatrick, 2014), even though meta-analyses have clearly established the value of outcome measurement in improving care (de Jong et al., 2021; Lambert et al., 2018).”

“Although the gap between research and practice is well-known in many areas of healthcare, the divide between scientifically-established best practices and the care being delivered in community settings seems to be uniquely wide in psychotherapy (Marinelli-Casey et al., 2002; Miller et al., 2006).”

“Screening patients for a history of motion sickness prior to use (Girard et al., 2009; Gold et al., 2006) and periodically checking in with them during use may help clinicians manage patient discomfort.”

“…in a 2014 study of Canadian psychologists, only 12% reported monitoring their patients’ progress while in psychotherapy (Ionita & Fitzpatrick, 2014), even though meta-analyses have clearly established the value of outcome measurement in improving care (de Jong et al., 2021; Lambert et al., 2018).”

“…much more common with older systems that had dated technology and incorporated fewer ergonomic elements (e.g. inappropriate acceleration speeds, no independent visual background, poorer refresh rates, etc.) (Birckhead et al., 2019; Budhiraja et al., 2017; Gavgani et al., 2017; Yao et al., 2014).”

“These disorders are also very responsive to available treatments (Barlow & Lehman, 1996; Bystritsky, 2006).”

“Research has affirmed the importance of organizational factors in determining therapists’ use of specific treatment approaches and techniques (Aarons et al., 2012; Beidas et al., 2015; Glisson, Landsverk, et al., 2008).”

“Other approaches could potentially involve delivering all psychotherapy sessions in VR, rather than using videoconferencing, as some are exploring (Businesswire, 2021; Usmani et al., 2022).”

“…drift,” which involves a tendency for a treatment to show more limited benefits as therapists deliver it in the real world and deviate from its essential components, is also frequently a challenge to real-world delivery of standardized treatments (Chambers et al., 2013; Waller & Turner, 2016).”

“Exposure techniques call for individuals to gradually confront fear-provoking stimuli to acquire new safety learning that contradicts their anxious beliefs about the dangerousness and intolerability of feared situations (Abramowitz et al., 2019; Craske et al., 2014; Rauch et al., 2012).”

“Although others have discussed several key issues in this area (Boeldt et al., 2019), we believe a number of additional factors and potential solutions are relevant to the conversation.”

“…note, however, that the challenges to adjusting to tele-medicine are not unique to VRET; telemedicine also presents unique and shared challenges for the delivery of in vivo exposure techniques, as well, although there is a much larger body of literature available on this topic (Gros et al., 2013).”

“…nearly all of the most effective approaches to psychotherapy across anxiety disorders involve some degree of exposure (Chorpita & Daleiden, 2009; Gunter & Whittal, 2010), and these exposures are likely responsible for much of the clinical benefit conferred by these treatments (Gould et al.,…”

“…potential for improving care for several other mental health conditions, as well (e.g. eating disorders, substance use disorders; De Carvalho et al., 2017; Segawa et al., 2020), but that potential is unlikely to be realized so long as these shared barriers to adoption remain unaddressed.”

“Taken together, there is ample evidence that the effects of VR-delivered treatment generalize to improvement in symptoms across many anxiety disorders in real life (Deng et al., 2019; Morina et al., 2015) and that, for most, VRET use generally reduces symptoms about as much as in vivo exposure.”

“Dissemination research has also consistently shown that, even with effective training, it is difficult to encourage therapists to adopt new techniques in general (Carroll, 2012; Edmunds et al., 2013).”

“Despite clear evidence of the benefits of adopting evidence-based practices for patients (Cukrowicz et al., 2011; Weisz et al., 2006), many therapists instead opt to rely primarily on their clinical judgement (e.g. Stewart & Chambless, 2007; Von Ranson et al., 2013).”

“Another study of doctoral and masters-level clinicians who provided outpatient psychotherapy for children with anxiety disorders showed that fewer than 5% of therapists had used exposure techniques to treat specific phobia (Whiteside et al., 2016).”

“One study reported that therapists were hesitant to adopt innovations like empirically supported treatments (ESTs) because they believed they lacked warmth and humanity, they did not have sufficient training, and because of the cost of materials (e.g. manuals, assessments; Pagoto et al., 2007).”

“Research has affirmed the importance of organizational factors in determining therapists’ use of specific treatment approaches and techniques (Aarons et al., 2012; Beidas et al., 2015; Glisson, Landsverk, et al., 2008).”

“…approaches when a significant mentor championed it with them (Cook et al., 2009), suggesting that training influential practitioners in VR-assisted therapies who, in turn, provide training to their colleagues could be one strategy to improve adoption (Moore et al., 2004; Yarber et al., 2015).”

“Past studies show that lack of training (Becker et al., 2004) and negative attitudes and beliefs about exposure-based therapies likely contribute to low use (e.g. that exposure therapies are dangerous or intolerable for patients, or that it is unethical; Pittig et al., 2019).”

“Further, one meta-analysis showed that VRET is as effective as in vivo exposures for social anxiety at follow-ups collected soon after intervention, and that VRET again had very large effects versus waitlist controls (Horigome et al., 2020; Morina et al., 2023).”

“In addition, Kourtesis et al. (2019) found that, among those who experience simulator sickness, symptoms usually peak after 11–20 minutes of use, and dissipate quickly after discontinuation.”

“…other therapist barriers are likely unique to VR. Hesitation about their capacity to effectively and smoothly use new technologies in general (Feijt et al., 2018; Muir et al., 2020) and VR systems specifically (Glegg et al., 2013) may contribute to low adoption of VR. Skepticism about its…”

“However, the cost of purchasing VR hardware, licensing a software platform, and accessing ongoing training, maintenance, and support continues to be a key barrier to wider adoption (Chung et al., 2022; Lindner et al., 2019; Wray & Emery, 2022).”

“…almost half of therapists in this study reported being more likely to use a new treatment if they had been trained on it while in graduate school (Cook et al., 2009), so incorporating VR-assisted therapies into both core curriculum and experiential learning experiences (e.g. departmental…”

“…their capacity to effectively and smoothly use new technologies in general (Feijt et al., 2018; Muir et al., 2020) and VR systems specifically (Glegg et al., 2013) may contribute to low adoption of VR. Skepticism about its realism and efficacy is likely to play an important role, as well…”

“Screening patients for a history of motion sickness prior to use (Girard et al., 2009; Gold et al., 2006) and periodically checking in with them during use may help clinicians manage patient discomfort.”

“Although the gap between research and practice is well-known in many areas of healthcare, the divide between scientifically-established best practices and the care being delivered in community settings seems to be uniquely wide in psychotherapy (Marinelli-Casey et al., 2002; Miller et al., 2006).”

“…has considerable potential for improving care for several other mental health conditions, as well (e.g. eating disorders, substance use disorders; De Carvalho et al., 2017; Segawa et al., 2020), but that potential is unlikely to be realized so long as these shared barriers to adoption remain…”

“Exposures presented in VR generally involve gradually introducing the feared situation, place, or object to the user in the digital environment in a manner consistent with real-life, in-vivo exposures (Bush, 2008).”

“However, practical barriers are also a common reason for not using exposure techniques (Deacon & Farrell, 2013).”

“Interactive trainings that involve demonstrations and two-way communication, whether delivered face-to-face or remotely, should presumably increase therapists’ confidence with VR, especially relative to manuals and other passive training materials (Gallo & Barlow, 2012).”

“The COVID-19 pandemic accelerated the use of telemedicine to deliver psychotherapy for many therapist and patients (Betancourt et al., 2020), and although many therapists have now returned to providing at least some care face-to-face, use of telemedicine remains high (Palma, 2021; Shklarski et al.,…”

“Despite clear evidence of the benefits of adopting evidence-based practices for patients (Cukrowicz et al., 2011; Weisz et al., 2006), many therapists instead opt to rely primarily on their clinical judgement (e.g. Stewart & Chambless, 2007; Von Ranson et al., 2013).”

“For example, one study showed that, after one clinic adopted an electronic health record system (EHR), nearly two-thirds of its clinicians were unwilling to record confidential information in it because of these concerns (Salomon et al., 2010).”

“Similarly, in a 2014 study of Canadian psychologists, only 12% reported monitoring their patients’ progress while in psychotherapy (Ionita & Fitzpatrick, 2014), even though meta-analyses have clearly established the value of outcome measurement in improving care (de Jong et al., 2021; Lambert et…”

“…may have more positive views about evidence-based practices that clearly specify what content should be delivered in each session and in what order (Barnett et al., 2017), although other authors suggest training therapists in general principles over specific techniques or manuals (Abramowitz,…”

“Further, one meta-analysis showed that VRET is as effective as in vivo exposures for social anxiety at follow-ups collected soon after intervention, and that VRET again had very large effects versus waitlist controls (Horigome et al., 2020; Morina et al., 2023).”

“Research has begun to explore optimal ways of providing training and changing therapist attitudes about both exposure therapy and VR (Farrell et al., 2016; Frank et al., 2020), but conducting demonstrations to give therapists first-COGNITIVE hand experience with VR and countering specific negative…”

“There is some evidence that therapist’s general attitudes toward VR may improve somewhat after trying VRET (Rimer et al., 2021).”

“…rigidity of the culture of the organization and specific departments (e.g. information technology), and the organization’s resistance to change have been shown to affect the adoption and sustainability of new psychotherapies and programs (Glisson, Schoenwald, et al., 2008; Patterson et al., 2013).”

“Clinical practice guidelines have limitations (Courtois & Brown, 2019; Silver & Levant, 2019), but they are undoubtedly important in shaping the practices of therapists and conferring legitimacy to promising new treatments.”

“…approaches when a significant mentor championed it with them (Cook et al., 2009), suggesting that training influential practitioners in VR-assisted therapies who, in turn, provide training to their colleagues could be one strategy to improve adoption (Moore et al., 2004; Yarber et al., 2015).”

“Other potential strategies could involve pursuing one or more of the alternative payment and delivery models that are increasingly building momentum, such as value-based care or pay-for-performance models (Carlo et al., 2020).”

“Similarly, 90% of psychologists expressed concerns about confidentiality when considering whether to use telehealth (Perle et al., 2014).”

“Although a few basic usability studies of the therapist interfaces of some platforms have been published (Brander et al., 2021; Brinkman et al., 2010; Gunawan et al., 2004; Helle et al., 2022), very little information is available about how well these platforms fare on important clinician…”

“Dissemination research has also consistently shown that, even with effective training, it is difficult to encourage therapists to adopt new techniques in general (Carroll, 2012; Edmunds et al., 2013).”

“We believe is likely that care will increasingly be delivered via a mixture of telemedicine-based and face-to-face sessions (a “hybrid” approach), rather than exclusively one or the other (Uscher-Pines et al., 2020).”

“…barriers are likely unique to VR. Hesitation about their capacity to effectively and smoothly use new technologies in general (Feijt et al., 2018; Muir et al., 2020) and VR systems specifically (Glegg et al., 2013) may contribute to low adoption of VR. Skepticism about its realism and efficacy…”

“departmental clinics) in graduate clinical training programs could translate into more widespread use of VR once these clinicians begin practicing independently (Chung et al., 2022).”

“…has begun to explore optimal ways of providing training and changing therapist attitudes about both exposure therapy and VR (Farrell et al., 2016; Frank et al., 2020), but conducting demonstrations to give therapists first-COGNITIVE hand experience with VR and countering specific negative…”

“Despite clear evidence of the benefits of adopting evidence-based practices for patients (Cukrowicz et al., 2011; Weisz et al., 2006), many therapists instead opt to rely primarily on their clinical judgement (e.g. Stewart & Chambless, 2007; Von Ranson et al., 2013).”

“…pandemic accelerated the use of telemedicine to deliver psychotherapy for many therapist and patients (Betancourt et al., 2020), and although many therapists have now returned to providing at least some care face-to-face, use of telemedicine remains high (Palma, 2021; Shklarski et al., 2021).”

“, 2017), although other authors suggest training therapists in general principles over specific techniques or manuals (Abramowitz, 2006; Miller et al., 2004).”

“…approaches to psychotherapy across anxiety disorders involve some degree of exposure (Chorpita & Daleiden, 2009; Gunter & Whittal, 2010), and these exposures are likely responsible for much of the clinical benefit conferred by these treatments (Gould et al., 1997; Woody & Ollendick, 2006).”

“However, the cost of purchasing VR hardware, licensing a software platform, and accessing ongoing training, maintenance, and support continues to be a key barrier to wider adoption (Chung et al., 2022; Lindner et al., 2019; Wray & Emery, 2022).”

“…an environment as naturally as they would in the real world, and by providing realistic feedback across as many senses as possible as they do so (e.g. stereoscopic vision, adjusting the visual display in response to natural head movements, stereo sound, haptic feedback; Penn & Hout, 2018).”

“Although a few basic usability studies of the therapist interfaces of some platforms have been published (Brander et al., 2021; Brinkman et al., 2010; Gunawan et al., 2004; Helle et al., 2022), very little information is available about how well these platforms fare on important clinician…”

“Clinical practice guidelines have limitations (Courtois & Brown, 2019; Silver & Levant, 2019), but they are undoubtedly important in shaping the practices of therapists and conferring legitimacy to promising new treatments.”

“In our view, one of the most promising attributes of VRET is its potential to easily access certain feared stimuli and scenarios that are too difficult, costly, dangerous, or even impossible to re-create through in vivo exposures (e.g. combat, terrorism, flying; Mozgai et al., 2021).”

“…studies of the therapist interfaces of some platforms have been published (Brander et al., 2021; Brinkman et al., 2010; Gunawan et al., 2004; Helle et al., 2022), very little information is available about how well these platforms fare on important clinician implementation outcomes, like…”

“Several excellent books and manuals are available that describe how therapists might use VR with their patients, including detailed case examples, session descriptions, and checklists (Leaman et al., 2013; McMahon & Boeldt, 2021; Rothbaum et al., 1999).”

“…programs (e.g., in ‐ person and online), development of clinical guidelines, professional mentorship, institutional and financial support, and further software developments to ensure successful and easy implementation in clinical practice (Jeon et al. 2025; Felnhofer et al. 2025; Wray et al. 2023).”

“Wray et al. (2023) explored the anxiety teachers felt when faced with the task of incorporating VR and AR into their educational practices, particularly for assessments.”

“…freely available dedicated VRET applications for acrophobia or claustrophobia treatment are either not scientifically validated or developed for clinical use [37,44], or share a technological bias of being delivered through a smartphone-powered interface, such as the Easy Heights application [45].”

“Another limitation may present the need for further research to optimize the treatment, such as conducting studies on VRET's real-world effectiveness and treatment optimization trials (Wray et al. 2023).”

“Moreover, factors such as presence, i.e. the perceived feeling of being inside the simulation, and cybersickness may influence treatment effectiveness, as well as user adherence and user experience [45, 47].”

“Relative to both in vivo and imaginal exposure, VRET promises increased therapeutic control, making exposure conduct less demanding especially for inexperienced therapists (Wray et al., 2023).”

“At the technological level, hardware discomfort and content monotony directly impaired the ease of use [25,39].”

“Common limitations include low motivational appeal, limited interaction depth, and insufficient mechanisms for emotional safety and graded task complexity (Wray et al., 2023).”

“Therapists’ main concerns included doubts about the real-world transfer of therapeutic gains, worries about the quality of the virtual environment, and practical issues such as the potential impact of VR goggles on the therapeutic relationship and eye contact [20, 30].”

“In mental health treatment, concerns around security and patient privacy have arisen as barriers to implementing telehealth or VR therapy [49].”