Therapist perspectives on telehealth-based virtual reality exposure therapy

Virtual reality (VR) can enhance mental health care. In particular, the effectiveness of VR-based exposure therapy (VRET) has been well-demonstrated for treatment of anxiety disorders. However, most applications of VRET remain localized to clinic spaces. We aimed to explore mental health therapists’ perceptions of telehealth-based VRET (tele-VRET) by conducting semi-structured, qualitative interviews with 18 telemental health therapists between October and December 2022. Interview topics included telehealth experiences, exposure therapy over telehealth, perceptions of VR in therapy, and perspectives on tele-VRET. Therapists described how telehealth reduced barriers (88.9%, 16/18), enhanced therapy (61.1%, 11/18), and improved access to clients (38.9%, 7/18), but entailed problems with technology (61.1%, 11/18), uncontrolled settings (55.6%, 10/18), and communication di culties (50%, 9/18). Therapists adapted exposure therapy to telehealth by using online resources (66.7%, 12/18), preparing client expectations (55.6%, 10/18), and adjusting workflows (27.8%, 5/18). Most therapists had used VR before (72.2%, 13/18) and had positive impressions (55.6%, 10/18), but none had used VR clinically. In response to tele-VRET, therapists requested interactive session activities (77.8%, 14/18) and customizable interventions components (55.6%, 10/18). Concerns about tele-VRET included risks with certain clients (77.8%, 14/18), costs (50%, 9/18), side effects and privacy (22.2%, 4/18), and inappropriateness for specific forms of exposure therapy (16.7%, 3/18). These results show how designing for telehealth may extend VRET and can help inform collaborative development of health technologies.


Introduction
The World Health Organization reported a 25% global increase in anxiety and depressive symptoms during the COVID-19 pandemic (WHO, 2022). It is estimated that 1 in 3 people are at risk for serious mental health disorders related to anxiety, stress, and phobias (Panchal et al., 2023). Therapists face unprecedented burnout and turnover with rapidly accelerating demand for mental health services (Van Hoy & Rzeszutek, 2022). Technological solutions are needed to extend the clinical capabilities of mental health therapists and meet growing demands in the treatment of anxiety and related disorders.
Telehealth is one such solution that has been demonstrated to make therapy more accessible, less stigmatized, more convenient, and more cost-effective ( There remains a pressing need for innovative solutions to expand clinical options for anxiety and other mental health needs. Virtual reality (VR) is one of the most promising technologies in the treatment of anxiety and related disorders. In mental health contexts, VR combines interactive computer simulations and encompassing display systems to create immersive therapeutic experiences, and has been used most frequently in the treatment of anxiety disorders (Cieślik et al., 2020). Exposure therapy is the gold standard treatment for anxiety disorders such as speci c phobia, social anxiety, post-traumatic stress disorder (PTSD), and obsessive compulsive disorder (OCD) (Steinman et al., 2016). However, exposure therapy can be di cult in practice. It can be challenging to recreate anxiety-related situations in a clinic o ce or hazardous to handle anxiety-inducing stimuli in person. As a result, most therapists know exposure therapy would bene t their clients, but few use it in practice (Pittig et al., 2019). Research has consistently shown that VR-based exposure therapy (VRET) can achieve equivalent or better results than in-person exposure with greater ease, comfort, engagement, safety, and lower relapse (Carl et  There is growing clinical potential for VR to extend the ways people receive mental health therapy over telemedicine . In recent years, fostering relationships, meeting new people, and creative self-exploration have been primary uses of VR in the hands of everyday consumers (Barreda-Ángeles & Hartmann, 2022). Many VR enthusiasts have reported using a popular social VR platform called VRChat to reduce negative thoughts, alleviate isolation during the pandemic, increase opportunity and ease of socializing, and other forms of self-directed mental health care (Deighan et al., 2023;Kelley, 2021;Sykownik et al., 2021;Zamanifard & Robb, 2023). However, only 9% of people who bought VR during the pandemic did so for telehealth purposes (Ball et al., 2021). Despite the promise of VR for telemental health care, most VR remains designed for personal entertainment and not for formal therapy.
Integrating the convenience of telehealth and the exibility of VR (i.e., tele-VR) can empower therapists with innovative health IT solutions and improve client access to evidence-based treatments such as exposure therapy. To understand end-user perspectives and inform the design of highly usable and effective tele-VRET, it is critical that these solutions be co-designed in direct collaboration with mental health therapists and clients (Bevan Jones et al., 2020; Chung et al., 2022). Toward that end, we conducted semi-structured interviews with telemental health therapists to investigate their past experiences, current opinions, and future perspectives on tele-VR for anxiety and related disorders.

Study Design
This study used a qualitative design that included semi-structured, qualitative, individual interviews with therapists.

Participants and Recruitment
We recruited therapists from TelehealthEngage, a research registry of more than 5,000 independent healthcare professionals registered with Doxy.me, a commercial telemedicine software provider. Therapists were invited to participate in the study if they met the following inclusion criteria: (1) were an actively practicing telemental health therapist at the time of the study (October-December 2022), (2) spoke English uently, and (3) had previously used telehealth to conduct exposure therapy. Therapists were noti ed they would be compensated with a $75 USD eGift card upon completion of their interview.

Procedures
Study sessions consisted of a single, one-on-one, recorded, one hour long, online interview using a secure version of Google Meet. One research team member (TO) conducted the interviews using a semistructured guide (Appendix 1). Interviews proceeded in ve sections. The rst section consisted of a discussion of informed consent and ve basic demographic questions (i.e., specialty, age, sex, ethnicity, race). The second section included questions about therapists' general experiences with telehealth, while the third section focused speci cally on telehealth for exposure therapy. The fourth section involved discussion of therapists' prior experiences with VR and perceptions of VR for mental health therapy. At the end of the fourth section and before the fth, the researcher played a 1 min and 35 second video describing tele-VRET ( Figure 1). Finally, the fth section was a discussion of therapists' impressions, concerns, needs, and wants regarding tele-VRET. Study procedures were reviewed and approved as exempt by the Institutional Review Board of the University of South Florida (IRB003548).

Data Analysis
Interview recordings were transcribed using Dovetail and analyzed using MAXQDA 2022 to identify emergent themes related to the four main sections of the interview (i.e., telehealth, exposure therapy over telehealth, prior experience with VR, and perspectives on tele-VRET). One researcher (TO) led thematic analysis (Braun & Clarke, 2012;Nowell et al., 2017). Themes and operational de nitions were honed across three iterations, upon which a second researcher (JI) reviewed codes. Discrepancies were resolved through discussion until consensus. Interview transcripts were analyzed descriptively to report the percentage of therapists whose statements were included within respective codes.

Reduced barriers for clients
Nearly all participants (88.9%, 16/18) reported ways in which telehealth made it easier, more convenient, and more comfortable for clients to engage in therapy. Reduced travel burden was the most commonly reported way that telehealth reduced barriers (61.1%, 11/18). Since clients could access telemental health services from personal and mobile devices, they experienced less need to alter their daily schedules for travel time and avoided the stress of navigating tra c before and after a session. Some therapists (16.7%, 3/18) reported how some clients seemed concerned about stigma (e.g., being recognized in an inperson waiting room) and that telehealth helped provide a more private care experience. Some therapists (16.7%, 3/18) also cited continuity of care throughout the COVID-19 pandemic as a bene t of telemental health services.
"They can sneak out to their car on their lunch break. It just makes it so the people that might have had more barriers to therapy can more easily access it now." (Therapist 14)

Telehealth enhanced aspects of mental health practice
Most therapists (61.1%, 11/18) reported that telehealth made it easier to conduct some in-session mental health practices. Therapists described how the remote format of telehealth allowed them to feel more con dent when helping clients confront sensitive issues and challenging beliefs. Therapies that required detailed scheduling and coordination when done in-person, such as support groups, were reported to be more accessible for clients over telehealth as they could join from home without the need for childcare.
"I can be a little more pushy or assertive because there isn't as much tension over the computer as you might feel in the room. Sometimes I'll notice that I'll get a little ushed or I'm uncomfortable or it feels really intense [in-person] and I think that gets diluted over the computer. You can go a little further with certain lines of questioning or confrontation." (Therapist 10) Therapists also enjoyed how telemental health services allowed them to simplify clinical work ows. While in-person therapy could involve handling a variety of devices within a session, some therapists (16.7%, 3/18) used telehealth platforms with all-in-one interfaces and features such as in-session exercises and assessments, screen sharing, chat boxes, and video. Some therapists (16.7%, 3/18) also reported that providing telehealth from home allowed them to better enjoy the ow of their work with more restful breaks and comfortable spaces.
"I like that I'm wearing my slippers right now. I like how I have more time to do other things instead of the commute and it's just easier than having to pack a lunch." (Therapist 14) Some therapists (16.7%, 3/18) reported that offering telemental health services improved business aspects of their practice. Telehealth allowed therapists to increase their caseloads with larger client pools from greater distances, expand their operational hours into different time zones, reduce or eliminate rented clinic o ces, reduce expenses enough to justify taking on additional staff or supervisees, and more exibility to prevent late or canceled sessions.
"I'm able to practice with so many other clients that would normally have to travel out to meet with me. Now I'm able to get them in a couple of time zones. I'm able to push back the time in my o ce a little bit at night also. There's a lot of exibility there. None of this would've been possible without telehealth." (Therapist 11)

Seeing naturalistic settings
Some therapists (38.9%, 7/18) reported appreciating how telehealth let them see clients outside the clinic. Clients' presentations during telehealth sessions provided valuable insights and opportunities to advocate for client wellbeing, self-care, and living situations which may have gone undetected during an in-person session.
"It gives you a view into people's world that you might not otherwise get. I had someone connect to a session from their closet under a blanket and I was like, 'what's going on?' We ended up calling the police and the abuser was removed from the home, which probably wouldn't have happened had they not [joined via telehealth], right?" (Therapist 4) One therapist reported how telehealth allowed them to share their own settings to make a stronger interpersonal connection with a client.
"One time my dog walked up and was sitting in the frame. Typically I closed the door so that the dog can't get into this room. But for some reason I left the door open that day, and it was just happenstance that it helped me make a connection with my seven year old client because the client had a dog. So at that point, I guess I became more human to the client. So what I thought was gonna be a disruption was actually helpful." (Therapist 13)

Limitations of telemental health care
While therapists were positive about telehealth overall, they reported experiencing disruptive technical issues, feeling they had less control over remote session settings, and that communication over telehealth was not as rich as the in-person experience (Table 3). "When I was in person, I always had spaces that were speci cally structured to be welcoming.
[Telehealth] is different, right? There's a lot more effort on my end." (Therapist 9)

Communication di culties
Video calls limited therapists' abilities to express and assess nonverbals (e.g., body language, posture). 9 (50%) "Getting a sense of distress is a little harder.
There are times when people are like, 'I'm at a 10,' and I'm like, 'really?' I don't feel that, but maybe I would if I was sitting with you." (Therapist 10)

Technology problems
Most therapists (61.1%, 11/18) reported encountering technical problems with telehealth. Internet issues were the primary concern due to weak signal, low bandwidth, or inconsistent connectivity. These internet problems could disrupt audio and video signals and impact the progress of therapy sessions.
"I hate when I'm in the middle of a processing session and it glitches and I need them to repeat something they said. When we're processing, it feels like the internet is messing with my ability to be as present and attuned as I'd like to be. If it actually freezes, I'm horri ed." (Therapist 14) A few therapists (11.1%, 2/18) also described restrictive organizational policies or security programs that limited their access to online content. These technical restrictions prevented therapists from using websites, search engines, or Youtube videos as part of their telehealth exposure practices.

Less formal session environments
Most therapists (55.6%, 10/18) reported feeling they had less control over telehealth session arrangements. When meeting in-person, therapists dedicated substantial efforts to create safe and comforting physical spaces. Over telehealth, however, therapists reported fewer options to personalize session settings and expressed concern over their inability to intervene physically if necessary.
"You just never fully know. Even if someone looks really high functioning and well resourced, every once in a while something severe can happen. I can't intervene [over telehealth] in the same physical ways as I can in person. I am way more cautious and I ask a lot of different questions about what's going on in their environment." (Therapist 14) Some therapists (11.1%, 2/18) described new distractions in their telehealth practices. To their dismay, therapists noticed how telehealth made it easy to stealthily direct attention away from a client to check noti cations or engage in unrelated administrative tasks during a session. Telehealth also introduced the need to set expectations as some therapists (16.7%, 3/18) had clients join sessions inappropriately such as while in line at a grocery store, at another therapists' o ce, driving in tra c, or while undressed in bed.
"We probably could improve our orientation to people about what's acceptable. I'm on a text thread with a lot of my colleagues and we've all had that one moment where we're like, 'how could someone think this is okay?' It's just probably about reestablishing protocol in etiquette for a really new thing that none of us were doing a couple years ago." (Therapist 10)

Communication di culties
Half of the therapists (50%, 9/18) reported that telehealth limited their access to some forms of nonverbal communication. Reduced visibility of body language meant that some therapists felt they could not fully assess client affect. Subtle signs of distress, such as tapping feet or dgeting hands, were easily detectable during in-person sessions. However, webcam and smartphone setups did not display such events over telehealth. Therapists' own nonverbal communication was also limited over telehealth, as some clients were sensitive to changes in gaze or posture which led to miscommunications.
"The only thing that's missing from telehealth is the interpersonal thing. I think that telehealth only gives you maybe 70% of a person. You miss a lot of nonverbals. You can't see the person's whole body. Are they ddling with their ngers? Are they wiggling their feet? You only get from [shoulders] up and it would be very weird for you to ask the person, 'can you pan your camera all the way back so I can see your whole body?' So you kind of just take the face and not the rest. But that's just the nature of what it is to be on camera. You just miss that richness of the full in person experience." (Therapist 1) Half the therapists (50%, 9/18) also described how some client symptoms could be misaligned with remote care. Anxiety therapy often overlapped with client concerns about online privacy, unauthorized recording, or surveillance by intelligence agencies. Telehealth was described as risky for clients with covert symptoms. Clients with eating disorders, for example, could hide rapid weight change by framing or obscuring their body on a video call. Some therapists also reported the convenience and comfort of telehealth could be countertherapeutic for clients who would bene t from positive side effects of inperson care like preparatory routines and interactions outside the home.
"I think sometimes [telehealth] can keep people isolated a little bit. I think people have a lot of fears since the pandemic and now, to go to therapy, they don't have to go out and do other things. So sometimes [I need to] challenge people to get outside of their comfort zone and not just stay home just because it feels safer." (Therapist 17)

Adaptations of exposure therapy over telehealth
After discussing telemental health in general, therapists were asked about how they used telehealth to provide exposure therapy. Therapists spoke frequently about the di culty of providing exposure therapy in-person and how telehealth could involve new challenges and opportunities related to useful telehealth features and tools, the need to prepare clients in advance, and necessary adjustments to their work ows ( Table 4). In addition to preparing client expectations, half the therapists (50%, 9/18) described dedicating time to building rapport and client competence as prerequisites to exposure therapy over telehealth.
"Some of these clients come to me without even the capacity to tell their story because they're so anxious about what they experienced, or they're so afraid that I'm going to judge them.

Previous experience and perceptions of VR
We asked therapists to discuss how they conceptualized VR, prior experiences using VR, overall impressions of VR, and what they had heard about VR for mental health care (Table 5). "I think it can be a cool form of entertainment for some people. I think it can also be really valuable therapeutically in terms of treatment, especially for something like exposure. The more complicated or less common ones that are harder for people to actually do, like getting on a plane for fear of ying.
They're not going to get on a plane every day just to do exposures, right? So for something like that I could see VR being really helpful and just creating the same environment for them to actually do the exposures in, but not in real life." (Therapist 16) Neutral impressions of VR (33.3%, 6/18) included skepticism about its utility or general unfamiliarity.
"I think there's some really good stuff with virtual reality, but I still don't think that it replaces the real thing. I can put a VR on and go for a walk in the woods, but I'm not going to get the health bene ts of the fresh air and the UV, right?" (Therapist 13) Negative impressions of VR (33.3%, 6/18) consisted of previous VR experiences that resulted in nausea, low perceived realism, and anticipation that VR would introduce barriers to communication.
"First thing that comes to mind is the equipment, which I don't know why, but it turns me off. Having that kind of equipment attached to your face, I don't know. It feels like it's a barrier." (Therapist 12) Therapists Negative therapist reactions to tele-VRET (33.3%, 6/18) noted that stylized or non-photorealistic avatars could break immersion or inhibit therapists' ability to detect changes in affect during exposure sessions or therapy in general (e.g., facial expressions).
"You kind of lost me on the avatar. I feel like the avatar takes it away from me as therapist, you as client, and makes it character. I don't want to necessarily be looking at an avatar of them. The avatar isn't giving me a real indication of how they're [feeling], what they're looking [at], are they checked out? And you can't get that with an avatar. I'll hear them potentially talking, but I want to be able to see them. I want to be really connected with them at these points." (Therapist 11)

Requested qualities and features of telehealth-based VRET
All therapists provided ideas about features and functions that could make tele-VRET helpful for clients and appealing for their practice (Table 6). and allowing therapists to complete administrative tasks e ciently in VR.
Therapists described a wide range of VR features to facilitate their in-session activities for telehealthbased exposure therapy. These in-session VR features included interactive demonstrations of therapeutic exercises and 3D interfaces to co-create exposure hierarchies.
"The option to demonstrate certain coping skills in the sessions might be something cool to have so a client can actually see how you do that. One that I'll usually do is deep breathing. If you had a full body avatar, they could actually see the hand on the therapist's stomach and chest rather than just if we're doing a video session." (Therapist 6) "What I'd love to be able to do is drag in this level, this activity, and then all the variations. It's a lot of stuff. We're going to go to a familiar restaurant with a loved one at a booth. Therapists also described how tele-VRET could allow for automated data collection to enhance the engagement and monitoring of between-session exercises.
"I also wonder if there's a record feature on it, so that while they're doing it during homework, we could review it in our next session. Sometimes little things come up. They cough or they move [sideways]. Because the VR is so reactionary, that could affect the whole simulation that they're in. Even just the audio that we could hear what's going on, and potentially going back to the biofeedback loop to be able to see the heart rates when that's happening." (Therapist 11) Therapists described complex exposure work ows and how it would be important for VR to reduce or add minimally to that complexity. Some therapists speculated that VR could function as a platform to unify tools and tasks.
"I like the way that it looked integrated, that you could pull different things up. One of the things that comes up a lot for me [in exposure therapy over telehealth] is a lot of moving back and forth. We pull up whiteboards for a while, and then we pull up a video, and then…from the [VR video] it appears to be very smooth and very straightforward. Rather than me being like, 'ok, wait, hold on, I just have to nd which of these 37 things I have open in my doc goes next.' So to me it feels like it might be more streamlined." (Therapist 9) However, therapists emphasized these features should be easy to use so as to not interfere with their work ows or their clients' efforts.
"The ease of use, user friendliness would be important. You don't want to make things more complicated or more di cult for clients when they're doing this kind of work because it's already really di cult work. Anything that will keep that barrier to entry low is important. Whether it's the actual headset, and ease of use, or us using it together, the actual experience…If it's complicated and they're distracted by those things, that's actually going to interfere with the exposure." (Therapist 16)

VR content and customization
Most therapists (55.6%, 10/18) requested an expansive menu of precon gured VR stimuli with options to customize stimuli creatively. Driving was the most commonly requested exposure stimulus but therapists also requested heights, ying, social situations, public places, injury or contamination, violence such as war or domestic abuse, and small animals such as snakes and spiders ( "When people have anxiety related to trauma, where they feel safe and secure is really small. So exposure through VR could be really helpful. This is a coffee shop, this is a farmer's market, this is a crowded grocery store, this is a graduation, concerts, ball games." (Therapist 15)

Injury or contamination
The sight of another person or oneself bleeding, being bitten, or touching something unsanitary.

(22.2%)
"Another client is [phobic of] rabies. She also has a fear of blood, so seeing a bandaid on the side of the road or seeing blood or having somebody bleeding, worried about contamination." (Therapist 5)

Violence
Depictions of warzones or physical, sexual, or psychological abuse.

(22.2%)
"I've got folks that have rape trauma. When you were talking about doing VR, I'm like, 'I can't in vivo that.' So yeah." (Therapist 7) Small animals The sight of and interaction with animals such as dogs, insects, snakes, or rats.

(22.2%)
"The phobia of spiders or snakes or whatnot. I think that you could probably create pretty quickly." (Therapist 17)

Enclosed spaces
Being in small and inescapable spaces such as elevators, car trunks, or trains. These concerns included client preferences and clinical contraindications, costs of VR in practice, VR safety and side effects, and the appropriateness of VR in imaginal exposure (Table 8).  Most therapists (77.8%, 14/18) speculated that certain clients would be more receptive to tele-VR than others. Clients who are younger, more experienced with technology, interested in video games, experience symptoms of OCD, or struggle with imaginal exposure were identi ed as leading candidates for tele-VRET.
Therapists also described clients who they considered ineligible for tele-VRET such as those who exhibit symptoms of psychosis, traumatic brain injury, migraines, or anxiety severe enough to be at risk for crisis or physical harm.
"I think my younger adults are more con dent with technology. They know what virtual reality is. I have a handful of young adults that loved a video game so it's just an appealing thing to them. If you can nd a way to already nd something that they have excitement or passion about and incorporate it into their treatment, that's always a good thing." (Therapist 17)

Costs
Half of the therapists (50%, 9/18) mentioned cost concerns; speci cally, the costs to patients. Insurance coverage of VR equipment and services could be a dealbreaker as many clients relied on public healthcare or paid out of pocket for telemental health services.
"Wanting it to be cost effective because then each client has to have one. So is that something then that insurance would cover as part of their treatment or did they have to pay for that out of pocket? I know I have a lot of clients that are on Medicare and disability. Financial concerns are always an issue…[using VR in-person] might be the more cost effective way for some clients then." (Therapist 17) 3.8.3 Side effects and privacy of VR Some therapists (22.2%, 4/18) expressed the need for thorough vetting of VR's potential side effects (e.g., addiction) and compliance with privacy policies (e.g., HIPAA).
"Your body can't tell the difference and your brain can't tell the difference. I worry about how [VR] can become like when video games came out. Our brain can get very attracted and addicted to something like that because it's not reality where things are not perfect, right?" (Therapist 1)

VR may be inappropriate for certain imaginal exposure techniques
An important minority of therapists (16.7%, 3/18) described how VR may be incompatible with some speci c approaches to imaginal exposure therapy. These therapists provided imaginal exposure therapy for clients' severe PTSD related to war or sexual abuse. Therapists described emphasizing clients' own memories and interoceptive reactions rather than comfort during recreations of traumatic situations.
"The person's memory of their own experience is obviously going to be the most evocative, right? Creating a [VR] cartoon of the thing you experienced would almost make it less intense…like it wouldn't bring up as much emotion. I can't see how the imaginal part would be improved with the virtual component. The memory lives in you and any way in which you alter it seems detrimental. Sometimes people will say, 'I'm not even sure this really happened, but this is my memory. ' The memory is what's bothering you, so we're still going to do exposure to what you think happened, even if it didn't happen. It seems like I can't think of a way of using VR for an imaginal. If you could, in theory, get it perfect, then that would be great. But you could never get it perfect because it happened 20 years ago." (Therapist 10)

Other opportunities of VR for telemental health
Therapists shared ideas for how they would like to use tele-VR for mental health practices other than exposure therapy. These other mental health therapies included biofeedback, roleplay or empty chair therapy, social anxiety, mindfulness exercises, gender identity exploration, and treatment of addiction (Table 9). Two therapists (11.1%) described how customizable tele-VR avatars could help clients seeking therapy for sexuality or gender identity.
"I have a client that has sexual orientation fears. They worry that they're actually a lesbian. For now, their exposures are seeing imagery of heterosexual couples, but what would be cool with virtual reality is that we could position them with a man to where they might be touching or something like that. That, I think, would be something that they would never actually have the capacity to do in real life. But virtual reality could make that possible." (Therapist 5) "I sometimes nd myself working with people who have body dysmorphic disorder. In virtual reality, they can change [their avatars], which is really a tough thing because that's what's happening. They're photoshopping everything on Snapchat, then they look in the mirror and they don't see that same [person]. So it may even help where they can see themselves as a different gender and function as a different gender and see if they can integrate that into who they are or if it is still a dissonance that they experience in a safe place without doing major changes. You know, hormone replacement, surgical changes. VR would be a nice start for that as well." (Therapist 13) One therapist (5.6%) expressed interest in tele-VR for addiction, particularly substance abuse. They described discussion in their organization to guide clients in VR to reduce binge drinking in addictionrelated situations (e.g., bars, parties, concerts).
"We had talked about [VR for addiction therapy] at the hospital; having exposures where people go to a bar and have to be around virtual reality people and not drink. There's drinking ones and certain drug ones and bars and parties and things like that. Raves or bands. And when you're at a concert and stuff, like you could have certain ones set up for that too." (Therapist 17)

Discussion
The goal of this study was to understand therapist perspectives on VR for telehealth-based exposure therapy. We interviewed 18 practicing telemental health therapists between October and December 2022. Therapists in this study expressed concerns about the implementation of VR into their telemental health practices. The most critical concern was that VR avatars could be perceived as unrealistic and therefore not useful for clinical purposes. There are many nuances to be explored in end-user preferences for tele-VR. Some research suggests simplistic and cartoonish VR avatars were perceived as comforting and trustworthy in the context of mental health therapy (Matsangidou et al., 2020). However, this preference for stylized VR avatars may be affected by factors other than aesthetics. For example, the relatively simple animations of cartoon styling may more easily avoid reactive uncanny valley effects (Ma & Pan, 2022). More research is needed to understand the relationships between VR avatar designs, provider perceptions, client preferences, and clinical outcomes. Costs were also a major concern. Previous research showed that therapists did not view costs as a leading barrier to adoption of modern clinical VR  Schöne et al., 2023). Therapists in this study described how the proposed features of tele-VRET could also expand clinical options beyond exposure therapy. While some therapists speculated that clients with dissociative disorders or schizophrenia might be poor candidates for tele-VR therapy, recent research has shown that VR may be an ideal platform to help these patients distinguish between reality and their symptomatic hallucinations (Bakk, 2023;Bisso et al., 2020). Therapists were also enthused about the ability to interact more naturally with clients in VR than over at video-based telehealth, particularly in regards to therapeutic touch (Gallace & Girondini, 2022). It may be bene cial to explore clinical risks and applications of social VR-induced body contact illusions, which VR enthusiasts refer to as "phantom sense" (Fu et  Wilczewski et al., 2022), future studies should aim to recruit from larger participant pools, ideally from across a variety of telehealth platforms. Second, most therapists in this study had used VR in casual settings, but none had used VR clinically. These therapists' perspectives, then, were largely in response to the tele-VRET video and not based on direct hands-on experience. It is likely that therapists experienced with clinical VR would have different perspectives on tele-VRET. It will be vital for future research to obtain more diverse end-user perspectives, including mental health clients whose opinions may be even more speci c than therapists' (Guillén et al., 2018). Third, descriptive percentages were presented for context in this study, but the qualitative approach and small sample size means these percentages should not be viewed as representative. The qualitative insights generated in this study should be investigated quantitatively to obtain a better understanding of therapists' perspectives on tele-VRET.

Conclusions
In conclusion, we found that experienced telemental health therapists had positive reactions to VR and

Competing Interests
Dr. Welch is a shareholder, and all other authors are employees of Doxy.me Inc., a commercial telemedicine company. The authors declare no other con icts of interest.

Availability of Data and Materials
Deidenti ed data available upon request.