3.1 Participant and practice characteristics
A total of 18 therapists were interviewed (Table 1). Most participants identified as female (89%; 16 female, 2 male), white (72.2%; 13 white, 3 black, 1 asian, 1 multiracial), non-hispanic (94.4%; 17 non-hispanic, 1 hispanic), and middle-age (M = 44 years, SD = 10.13, range 27 to 71). Professional titles included psychologist (39%, 7/18), mental health counselor (28%, 5/18), social worker (16.5%, 3/18), and marriage and family therapist (MFT; 16.5%, 3/18). Main disorders treated were anxiety (100%, 18/18) and trauma (100%, 18/18), with some providing therapy for personality disorders (61%, 11/18), depression (39%, 7/18), and substance abuse (5%, 1/18). Primary therapeutic approaches included cognitive behavioral therapy (50%, 9/18), dialectical behavioral therapy (28%, 5/18), and acceptance and commitment therapy (22%, 4/18). All participants treated adults (100%, 18/18) as their primary clientele, with some also providing services for children (22%, 4/18), families (5%, 1/18), or individuals across the lifespan (5%, 1/18). Some therapists (33%, 6/18) reported adopting telehealth between 2013 and several months before the COVID-19 pandemic, but most (67%, 12/18) started providing telemental health care after the pandemic had begun.
Table 1. Participant and practice characteristics
Sex
Female
Male
Other
|
N (%)
16 (89%)
2 (11%)
0 (0%)
|
Age, Mean (SD, range)
|
44 (10.13, 27-71)
|
Race
White
Black
Asian
Multiracial
American Indian/Alaska Native
Native Hawaiian/Pacific Islander
|
13 (72.2%)
3 (16.6%)
1 (5.6%)
1 (5.6%)
0 (0%)
0 (0%)
|
Ethnicity
Hispanic
Non-Hispanic
|
1 (5.6%)
17 (94.4%)
|
Professional title
Psychologist
Mental health counselor
Social worker
Marriage and family therapist
|
7 (39%)
5 (28%)
3 (16.5%)
3 (16.5%)
|
Main disorders treated*
Anxiety
Trauma
Personality disorders
Depression
Substance abuse
|
18 (100%)
18 (100%)
11 (61%)
7 (39%)
1 (5%)
|
Primary therapeutic approach*
Cognitive Behavioral Therapy
Dialectical Behavioral Therapy
Acceptance and Commitment Therapy
|
9 (50%)
5 (28%)
4 (22%)
|
Primary client age groups*
Adults
Children
Families
Full lifespan
|
18 (100%)
4 (22%)
1 (5%)
1 (5%)
|
Started using telehealth
During COVID-19
Before COVID-19
|
12 (67%)
6 (33%)
|
* = responses not exclusive
|
3.2 Benefits of telemental health care
We asked therapists about their history, practices, and preferences with telemental health care. In response, therapists described how telehealth made it easier for their clients to receive mental health services, reduced the effort to conduct in-session therapeutic exercises, and provided a more holistic view into clients’ everyday lives (Table 2).
Table 2. Benefits of telemental health care.
Benefits
|
Description
|
N (%)
|
Representative Quote
|
Reduced barriers
|
Clients could access care privately, comfortably, and with less need to travel or disrupt daily schedules.
|
16 (88.9%)
|
“Clients like it remotely because they don't have to deal with driving afterwards or feeling like they have to be seen by other people walking through a waiting room.” (Therapist 14)
|
Enhanced practices
|
Remote care reduced the complexity of care, allowed therapists to customize their workflows, and take on more clients and staff with lower overhead costs.
|
11 (61.1%)
|
“[Support groups were] always really difficult. Childcare and transportation were always issues. Going to telemedicine, my support groups have exploded. People come all the time.” (Therapist 9)
|
Access to naturalistic settings
|
Telehealth allowed therapists to better assess client wellbeing by seeing personal surroundings (e.g., living situations, home relationships, work, school).
|
7 (38.9%)
|
“They can take me around their house and I can actually see if they've been doing the dishes and cleaning the bathroom. Those kinds of things that've been helpful to get a different perspective in their life than I might just have in the office.” (Therapist 17)
|
3.2.1 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 traffic 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 in-person 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 benefit 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)
3.2.2 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 confident 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 flushed 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 workflows. 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 flow 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 offices, reduce expenses enough to justify taking on additional staff or supervisees, and more flexibility 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 office a little bit at night also. There's a lot of flexibility there. None of this would've been possible without telehealth.” (Therapist 11)
3.2.3 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)
3.3 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).
Table 3. Limitations of telemental health care
Limitation
|
Description
|
N (%)
|
Representative Quote
|
Technology problems
|
Sessions could be interrupted by inconsistent internet connection or restrictive web security.
|
11 (61.1%)
|
“For whatever reason, we have a lot of cutouts and we have to finish it in audio or on the phone. We get these weird, awkward transitions halfway through and that's exhausting because they get settled and then they get unsettled and we have to go back.” (Therapist 7)
|
Less formal session arrangements
|
Joining telehealth sessions from home introduced interruptions or distractions.
|
10 (55.6%)
|
“When I was in person, I always had spaces that were specifically structured to be welcoming. [Telehealth] is different, right? There's a lot more effort on my end.” (Therapist 9)
|
Communication difficulties
|
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)
|
3.3.1 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 horrified.” (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.
“Normally in [prolonged exposure], I might pull out something in session. I have to do it on my phone oftentimes because my [work] computer will not let us access YouTube. I might pull up a sound that is particularly triggering and we're gonna sit here and play it until it gets darn boring. I haven't done that sort of thing by telehealth. The crazy thing is, [clinic admins] send us links like, ‘we've just produced this lovely YouTube video, check it out.’ And I'm like, ‘how are we checking that out?’ I'll click on that link, but it's going to say, ‘access forbidden.’” (Therapist 4)
3.3.2 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 notifications 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’ office, driving in traffic, 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)
3.3.3 Communication difficulties
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 fidgeting 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 fiddling with their fingers? 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 benefit from positive side effects of in-person 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)
3.4 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 difficulty 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 workflows (Table 4).
Table 4. Adaptations of exposure therapy over telehealth
Adaptation
|
Description
|
N (%)
|
Representative Quote
|
Incorporating telehealth tools
|
Using internet resources or built-in tools to share informative websites, images, videos, transfer files, and work on documents.
|
12 (66.7%)
|
“I've had a handful of people with [fear of vomiting]. You can share YouTube clips of people throwing up, like that chug a gallon of milk challenge. People vomit and watch them and rank their SUDS.” (Therapist 15)
|
Preparing client expectations
|
Building rapport with clients and establishing the challenging, extensive, and rewarding effort of exposure therapy.
|
10 (55.6%)
|
“Emotional containment with complex PTSD is a real problem. I can't go to even imaginal exposure until I can get that emotional Tupperware for safe containment.” (Therapist 7)
|
Workload adjustments
|
Adopting telehealth and the COVID-19 pandemic created the need to write notes efficiently, limit certain clientele, and build trust with clients.
|
5 (27.8%)
|
“I haven't worked with [children] on telemedicine yet and I have a whole bunch of [colleagues] that just won't do it with little ones.” (Therapist 14)
|
3.4.1 Incorporating telehealth tools into exposure therapy
Therapists reported utilizing various features of their telehealth platforms to enhance how they provided exposure therapy to clients remotely. Many therapists (66.7%, 12/18) reported finding exposure stimuli in the form of videos or audio on YouTube. Most therapists (55.6%, 11/18) reported using telehealth tools to transfer files between themselves and their clients. Files transferred included informational pamphlets, clinical forms and questionnaires, worksheets, and client-generated media such as photos, voice recordings, or video. Many of these file transfer tools were built into the telehealth platforms or electronic health records, and some therapists used email as per client preference. Most therapists (55.6%, 10/18) reported screen sharing clinical documents, educational materials, and multimedia for exposures such as photos, videos, and websites that displayed strobing content designed for eye movement desensitization and reprocessing. Half the therapists (50%, 9/18) reported directing clients to informative websites authored by reputable clinical organizations such as Barnes Hospital or Mayo Clinic. Some therapists (16.7%, 3/18) reported using collaborative documents to work with clients (e.g., Google Docs or digital whiteboards). One therapist (6%, 1/18) reported recommending their clients try smartphone apps for meditation such as Calm, Headspace, and Insight Timer.
“They're bringing up all kinds of things on the platform that I can use as a clinician. They've got practice sessions with breathing and with assessments, and they've got a whiteboard. So now my children [clients] can draw and I can do all that stuff now. I can share my screen, I can play videos. It feels as if I can do more on telehealth than what I could do sitting face to face, because I don't have to deal with pulling out a tablet or turning on the television to show a video.” (Therapist 13)
3.4.2. Preparing clients expectations
Most therapists (55.6%, 10/18) reported making efforts to prepare clients for exposure therapy over telehealth. Therapists described the potentially stressful nature of exposure therapy with transparency, and how it could take several months to more than a year to achieve clinical success.
“I consistently normalize how much exposure sucks, especially for trauma patients. It’s the worst treatment in the world. It's so effective, but it's the worst. Exposure sucks until it doesn't and then it's great.” (Therapist 15)
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. There's a lot of shame or guilt around what has happened. A lot of times it's really setting up the platform of them feeling comfortable.” (Therapist 13)
3.4.3 Workload adjustments for telemental health care
Some therapists (27.8%, 5/18) described how pre-pandemic burnout compounded with mid-pandemic mental health surges into greater overall stress. Strategies to navigate this stress included sketches or shorthand instead of written session notes, limitations on new clientele (e.g., refusal to use telehealth for child clients due to distractibility), and shared expectations of patience while co-navigating challenges.
“You never know what format you're going to get [client data] in. If you can't open the document, if it's too big they can't send it. Thank goodness for people who understand how to compress a PDF or know how to take screenshots. Or they actually just pick it up and show it to me on the screen and then I'm writing it down on the other side. I think everybody had a lot of patience with everybody. They're frustrated and I'm frustrated, but we're not really frustrated with each other.” (Therapist 1)
3.5 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).
Table 5. Previous experience and perceptions of VR
Experience with VR
None
Professional
Casual
Own a VR device
Use VR regularly
|
N (%)
5 (27.8%)
8 (44.4%)
8 (44.4%)
6 (33.3%)
0 (0%)
|
Impressions of VR*
Positive
Neutral
Negative
|
10 (55.6%)
6 (33.3%)
6 (33.3%)
|
Knowledge about clinical VR*
None
Professional
Casual
|
3 (16.7%)
13 (72.2%)
2 (11.1%)
|
* = responses not exclusive
|
Therapists defined VR as consisting of three common components: an immersive experience (83.3%, 15/18), video games (61.1%, 11/18), and a head-mounted display (55.6%, 10/18).
“I guess there could be multiple levels to it because in some sense even a standard video game has some sense of virtual reality to it. However, I think that we nowadays think of VR as something where your own body movements impact the place, impact the environment directly, right? On the Oculus, you have like these [controllers], the movements of them and of your hands. It's not just, ‘hit the button.’ It's that sense in which your own body's movements will affect the environment. And then because we have that feedback, then it makes the experience feel more realistic so that you then can have more engagement of your physical system, to trigger your vestibular system more successfully and that sort of stuff.” (Therapist 4)
Most therapists (72.2%, 13/18) had hands-on experience with VR while only some (27.8%, 5/18) had never tried VR. Of those who had tried VR, 8 (44%) tried VR in a professional setting such as conferences or in their institutions, and 8 (44%) tried VR in a casual setting such as theme parks or a friend’s house. One therapist tried VR for the first time when a client brought their headset into the office and showcased how they had been treating their own agoraphobia with VR house creation and Beat Saber. Some therapists (33.3%, 6/18) reported personally owning a VR device; however, none used VR regularly as it was purchased as a gift for other members of their household.
“I went over to [a colleague’s] house and he put these goggles on me. And I went to Paris and walked around and did all this cool stuff [in VR]. And he was talking to me about how this is so great for people who have to think about managing emotion and coping with situations that they're not actually in. How do you simulate that? To me, it's bringing so much more variety of experiences into the session. Historically, people who worked with anxiety would be like, ‘we're going to get in your car and go driving.’ Or, ‘I'm going to go on an airplane with you.’ I think most people just don't have that flexibility [without VR].” (Therapist 10)
When asked about their overall impressions of VR, most therapists (55.6%, 10/18) gave positive descriptions of captivating experiences and interests in clinical applications.
“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 flying. 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 benefits 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 were generally knowledgeable about VR for mental health therapy and heard about it in professional contexts (72.2%, 13/18) at conferences, through colleagues, or in research articles. Some therapists heard about VR therapy casually (11.1%, 2/18) from a family member, news story, or through video games. Only 3 therapists (16.7%) reported no awareness of VR for mental health therapy. None of the therapists had tried VR in their mental health practices.
3.6 Perspectives on telehealth-based VRET
After viewing the video demonstration of a tele-VRET session, we asked therapists about their initial reactions to the proposed system and follow-up questions about how tele-VRET could meet the needs of their telehealth practices. Most therapists (66.7%, 12/18) expressed positive reactions about how VR could simplify exposure therapy practices and help telehealth clients feel their therapist’s presence in the healing experience.
“I don't like doing in-the-field type of work with [in-person] clients just logistically…so this seems like a way that I could do both. Kind of not both, clearly they're not actually in the field but could do an actual exposure while they're in the office and or at home without it being a lot of logistics to try to figure out.” (Therapist 5)
“I like the fact that I could see their full body and they could see my full body. I liked the drawing on the wall. That was kind of interesting, it felt more collaborative than VR I've seen before where I had to imagine that I'd be sitting in the room [with clients] or watching [clients on] a TV screen. That felt like it could be way more immersive being there and for them too, to feel like they're not alone in the process.” (Therapist 7)
Some therapists’ reactions to tele-VRET were neutral (16.7%, 3/18), reporting the need for more information or hands-on experience before forming an opinion.
“What I'm not sure about is something like if the headsets are on and we're in that space, something like spiders for example can [cause] a very physical reaction and people can flail. So if their headset comes off, what does that look like? Is there a protocol for that? Do they disappear? So that's how I know they're not there? And then I rejoin them in person or in video? Just being aware of how people respond. I don't know because I'm not very familiar with virtual reality.” (Therapist 9)
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)
3.7 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).
Table 6. Requested qualities and features of tele-VRET†
Request
|
Description
|
N (%)
|
Representative Quote
|
Enhanced clinical capabilities
|
Immersive activities for in-session therapy, data collection, between-session practices, with integrated, user-friendly workflows.
|
14 (77.8%)
|
“[Building an exposure hierarchy] has always just been, brainstorm a list and then put them in order. I could imagine there's a lot more [potential in VR], but the easiest thing could be if they brainstorm and you just write it all out, then you can move those into the hierarchy [in VR]...drag them over into an actual hierarchy that's in order.” (Therapist 5)
|
Content and customization
|
A wide range of preconfigured virtual reality objects, places, and situations that can be customized within a persistent virtual space.
|
10 (55.6%)
|
“[The most important thing is] the client's ability to personalize the experience. There would have to be some large file of stock information that they can pull from or an option to upload your own. Have you ever played Minecraft? So they can build their own experiences. Or The Sims.” (Therapist 13)
|
VRET = virtual reality exposure therapy
|
|
3.7.1. Tele-VRET for enhanced clinical capabilities
The majority of therapists (77.8%, 14/18) requested tele-VRET features to replicate or enhance clinical workflows for both exposure therapy and telehealth in general. These feature requests included ways to provide client-centered therapy during sessions, VR exercises for clients to complete between sessions, and allowing therapists to complete administrative tasks efficiently in VR.
Therapists described a wide range of VR features to facilitate their in-session activities for telehealth-based 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. And then, what about an unfamiliar restaurant without a loved one [not] at a booth? That level of detail. If we could then, in that environment, actually create the hierarchy together, ‘what would you rate this? What's your predicted SUDS for this?’” (Therapist 4)
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 workflows 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 find 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 workflows or their clients’ efforts.
“The ease of use, user friendliness would be important. You don't want to make things more complicated or more difficult for clients when they're doing this kind of work because it's already really difficult 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)
3.7.2 VR content and customization
Most therapists (55.6%, 10/18) requested an expansive menu of preconfigured VR stimuli with options to customize stimuli creatively. Driving was the most commonly requested exposure stimulus but therapists also requested heights, flying, social situations, public places, injury or contamination, violence such as war or domestic abuse, and small animals such as snakes and spiders (Table 7). Therapists described how the process of finding an effective exposure was often surprising and unpredictable. To meet clients’ needs for remote exposure therapy, therapists emphasized the abilities to experiment with clients in VR, directly incorporate client feedback into VR arrangements, and retain those arrangements across sessions (e.g., persistent room configurations).
“It’s about how I can adapt it to my client. My client might not have an issue with elevators. My client might have an issue with being in tight spaces, and the elevator will create that. My client might have an issue with spiders, not ants, but maybe the ant can evoke that kind of response as well. It's about me as a clinician taking the [VR] curriculum and adapting to my clients in a way that works for them.” (Therapist 11)
Table 7. Specific objects, situations, and places requested for tele-VRET†.
Stimulus
|
Description
|
N (%)
|
Representative Quote
|
Driving
|
Virtual simulations in which a client sits in or drives a car in busy traffic or down a quiet road.
|
9 (50%)
|
“There's an accident in front of you or you have to make a turn and then there's a lot of oncoming traffic. You want the person to have that experience as much as possible. Or maybe that there's like her [level] zero, which is just driving around a calm neighborhood and there's no kid [running into traffic].” (Therapist 1)
|
Heights
|
Situations or places in which one could fall such as hiking, bridges, elevators, or staircases.
|
6 (33.3%)
|
“Hiking and people falling. Like pushing people off of a higher ridge or an overpass or something.” (Therapist 5)
|
Flying
|
Being a passenger on a commercial airplane and precursor situations such as packing for a trip, traversing security lines, and boarding the plane.
|
5 (27.8%)
|
“Flying is a great example. Most people don't have the time or money to get on a flight every [session], or even go to an airport. It's a big hassle for a lot of people and it's just not realistic. So I think that's a great example where [tele-VRET] could be really helpful.” (Therapist 16)
|
Social situations
|
Situations in which the client must interact with real or imagined others such as public speaking, job negotiations, classrooms, or parties.
|
5 (27.8%)
|
“I could definitely see it being useful for social phobias, like people who are really afraid to go into groups to have conversations. Just practicing interaction and reading social cues and asking questions and managing your internal experience. I wonder if there could be an interesting virtual play space, because
I do try to do exercises online but they worked better in person. Certain kinds of icebreakers and just being able to be a little more interactive and animated.” (Therapist 10)
|
Public places
|
Places that require leaving the home and entering uncontrolled spaces such as clinic offices, grocery stores, or restaurants.
|
4 (22.2%)
|
“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.
|
4 (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.
|
4 (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.
|
4 (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.
|
2 (11.1%)
|
“The very generalizable ones would be MRI or a train. They said it's as if you're at the very front of the train and watching.” (Therapist 15)
|
Swimming
|
Simulations of being near or in deep water.
|
1 (5.6%)
|
“There's gonna be a lot of different things they are afraid of. It can be something real that's going on, like some person actually swimming.” (Therapist 2)
|
Disasters
|
Depictions of natural or manmade disasters such as storms or housefires.
|
1 (5.6%)
|
“So a lot of the phobia stuff I feel like would be good. Like natural disasters. I've definitely worked with a number of people who've had house fires or things like that.” (Therapist 8)
|
VRET = virtual reality exposure therapy
|
|
3.8 Therapist concerns with tele-VRET
Therapists asked questions or expressed concerns about how tele-VRET might work in their practices. 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).
Table 8. Therapist concerns with tele-VRET†.
Concern
|
Description
|
N (%)
|
Representative Quote
|
Client preferences and contraindications
|
Tele-VRET may be more appealing for certain clients such as those who are younger, more experienced with video games, and without severe symptoms of anxiety, psychosis, or self harm.
|
14 (77.8%)
|
“They probably shouldn't be doing [VR] if they have hallucinations and delusions. You don't even have to have full on schizophrenia. Somebody could be going through a really distressing time or maybe somebody who's super high anxiety. They may not have the skill set to just take it off.” (Therapist 1)
|
Costs
|
Tele-VRET may be too expensive for clients if the devices or services are not covered by insurance.
|
9 (50%)
|
“Definitely the main thing would be affordability. Like I said, my clients even have hard times getting cell phones.” (Therapist 6)
|
Side effects and privacy
|
VR† may be addictive and clear guidelines have not been established around device security or privacy.
|
4 (22.2%)
|
“Thinking about the implications of confidentiality and what would that look like in practice. Even if it's just an additional consent form or something like that. It's not as if it's never been done, just thinking about how to adapt that in the VR world.” (Therapist 8)
|
Clinical appropriateness
|
VRET may interfere with therapy or be ineffective for severe traumas related to war or sexual abuse.
|
3 (16.7%)
|
“These are cartoons, these people are cartoons, these problems are cartoons.” (Therapist 3)
|
VRET = virtual reality exposure therapy
VR = virtual reality
|
|
3.8.1 Client preferences and contraindications
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 identified 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 confident 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 find a way to already find something that they have excitement or passion about and incorporate it into their treatment, that's always a good thing.” (Therapist 17)
3.8.2 Costs
Half of the therapists (50%, 9/18) mentioned cost concerns; specifically, 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)
3.8.4 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 specific 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)
3.9 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).
Table 9. Other opportunities of VR† for telemental health
Therapy
|
Description
|
N (%)
|
Biofeedback
|
Measurement and gamification of physiological responses to help clients develop control over emotions.
|
10 (55.6%)
|
Roleplay
|
Staging VR such that clients and therapists can assume the role of another to practice conversations or confront difficult topics.
|
5 (27.8%)
|
Sexuality or gender
|
Use of VR avatars to temporarily inhabit a body that is of a sex or gender different from one’s current real body.
|
2 (11.1%)
|
Addiction
|
Realistic simulations in which therapists guide clients to habituate to addiction-related triggers (e.g., bars, parties).
|
1 (5.6%)
|
VR = virtual reality
|
Ten therapists (55.6%) were interested in biofeedback in VR. These therapists emphasized the importance of teaching clients to recognize their own bodily responses as part of exposure therapy. Therapists described how VR environments could change in response to clients’ heart rate, breath rate, or galvanic skin response to train relaxation skills. Biofeedback could also be a clinically useful way to assess client affect, especially since VR avatars may not track facial expressions accurately.
“I wonder if it couldn't be programmed into the virtual reality to pick up on some of those nuances. If the client's heart rate just dropped or their body basal temperature just went up, things like that. To reinforce that they have control over their own body responses, what works and what doesn't work. VR can go a lot of places.” (Therapist 13)
“If VR is really capturing the client's movement, is there a way to get a reading on heart rate or any kind of [physiological measures]? If that can be incorporated, that would be golden because I would imagine little movements could throw you off. You're not really getting that same feel of the facial expressions [in VR]. I would see a benefit in being able to get those readings of how somebody's responding to something.” (Therapist 18)
Five therapists (27.8%) described how tele-VR could enhance their practice of roleplay therapy. Therapists reported difficulty directing or staging role play over telehealth, but imagined that immersion in VR could enhance those interactions when combined with customizable VR environments, avatars, and interactable objects. Therapists also speculated that nonplayer VR avatars could create more engaging empty chair therapy, allow clients to interact with copies of their own avatar for reflective roleplay, and how therapists could wear the avatar of another person to facilitate confrontational roleplay scenarios.
“The [empty] chair represents your father who's not here right now, and you're going to talk to him. I might prompt the discussion and ask how they felt confronting their father about that thing that happened years ago. It's just weird [in a video call] because they're talking to me on a screen and they're just looking to the left of me. But if you're in this medaverse [sic], you could have an empty chair, you could have dad's chair, you could have dad [his VR avatar].” (Therapist 11)
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 find 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 addiction-related 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)