Virtual-reality exposure therapy

1. Introduction

Version followed: the Emory/USC therapist-delivered VR exposure (VRE) protocols for PTSD, Rothbaum et al. 2001 (Virtual Vietnam) and the Virtual Iraq/Afghanistan and BRAVEMIND protocols described by Rizzo and colleagues (2014–2015, including the military sexual trauma pilot); for specific phobia, Rothbaum's fear-of-flying protocol (8 sessions, VRE vs standard exposure) and, as a contrasting automated variant, the Oxford fear-of-heights programme (Freeman et al. 2018). Where these differ, the difference is named. [source: Rothbaum et al. 2001; Rizzo 2015 BRAVEMIND annual report; Kenardy commentary on Rothbaum et al.; Freeman et al. 2018]

Virtual-reality exposure therapy is exposure therapy in which the feared situation or trauma-related context is presented through a head-mounted display with head tracking and spatial audio, while the therapist watches the same scene on a monitor and controls what appears. It is a delivery medium for exposure, not a separate theory: the commentator on the fear-of-flying trial described VRE as an effective medium for exposure rather than a treatment in itself. [source: Kenardy commentary, Evidence-Based Mental Health] The PTSD protocols are grounded in emotional processing theory: fear structures are activated by realistic multisensory cues, the person stays with the memory or situation without escape, and new corrective information is incorporated, with anxiety habituating within and across sessions. [source: Rothbaum et al. 2001; Rizzo et al. 2014 as reprinted in the BRAVEMIND report] The Oxford heights programme frames change instead as building memories of safety that counter existing fear associations. [source: Psychiatric News 2018 on Freeman et al.]

Who delivers it: in the Emory/USC protocols, a trained exposure therapist conducts every session; the VR software is a tool the therapist operates. Automated, coach-led programmes (Oxford heights; gameChange, see 093) are a different model in which a virtual coach delivers the therapy and a staff member is present for headset and safety support. [source: Rothbaum et al. 2001; Psychiatric News 2018]

Regulatory and equipment status, as of October 2026 per the FDA's Augmented Reality and Virtual Reality in Medical Devices page (content current as of 4 September 2026): FDA's AR/VR device list names no device explicitly indicated for anxiety, phobia or PTSD; the mental-health-adjacent entries are pain and pain-related systems (e.g. AppliedVR's EaseVRx/RelieVRx, CognifiSense VRNT, Smileyscope). FDA states the list is not comprehensive, so absence from it does not settle a product's status. Research systems such as BRAVEMIND were built on off-the-shelf PCs and consumer headsets. Consumer headsets (e.g. Meta Quest 3) are not medical devices according to the manufacturer's safety guide. Check the current status of any commercial VR-therapy platform yourself before relying on vendor claims; status changes. [source: FDA AR/VR page; Rizzo 2015 report; Innerspace reproduction of the Meta Quest 3 safety guide, 2024] [uncertain: status of commercial VR-therapy platforms outside the FDA list, CE/UKCA marking and NICE positions for VRE in anxiety or PTSD not verified]

Related guides: the Domain II exposure guide gives the general exposure method (prolonged exposure, in-vivo hierarchies, inhibitory-learning variants) that this guide assumes; 093 gameChange covers automated, coach-led VR for agoraphobic avoidance in psychosis.

2. Framework

Phase A: Assessment, suitability, safety screening and consent (usually 1 session, often within session 1)

Goals: confirm the diagnosis and target (index trauma or phobic situation); check that an available virtual environment matches the client's feared context; screen medical, seizure, vestibular and cybersickness risk; obtain informed consent including data handling. [source: Rothbaum et al. 2001 exclusions; Meta Quest 3 safety guide via Innerspace]
Move on when: the environment fits, no unmanaged exclusion applies, the client has tried the headset in a neutral scene without significant sickness, and consent is documented. [synthesis]

Phase B: Preparation (sessions 1–2 in the PTSD protocols; first half of the flying protocol)

PTSD (BRAVEMIND MST pilot): session 1 history, treatment planning, rationale and breathing retraining; session 2 common reactions to trauma, in-vivo rationale and in-vivo hierarchy construction. [source: Rizzo 2015 report]
PTSD (Virtual Vietnam): session 1 information gathering, emotional-processing rationale, brief breathing relaxation, and familiarisation with the equipment in a neutral environment. [source: Rothbaum et al. 2001]
Fear of flying: four sessions of information gathering, treatment planning, brief breathing retraining and cognitive restructuring. [source: Kenardy commentary on Rothbaum et al.]
Move on when: the client can state the rationale in their own words, has a hierarchy, and has tolerated the neutral environment. [synthesis]

Phase C: Graded VR exposure (core phase)

BRAVEMIND/Virtual Iraq: an introductory immersion of about 25 minutes exploring the environment with no narrative and no trigger stimuli, then full VRE with narration in the following sessions. [source: Rizzo et al. 2014 as reprinted in the BRAVEMIND report]
Virtual Vietnam: sessions 2–3 exposure to the environments; sessions 4–5 environments plus triggered memories, described in detail and repeated; later sessions environments plus imaginal exposure to the worst memories identified before treatment. [source: Rothbaum et al. 2001]
Typical VRE session (BRAVEMIND MST pilot): 90 minutes; about 15 minutes check-in on functioning, anxiety and homework; up to 45 minutes of exposure; processing and discussion; homework assignment. [source: Rizzo 2015 report]
Fear of flying: four VRE sessions, twice weekly over 2 weeks, simulating sitting in the plane, take-off, landing, and calm and stormy flights. [source: Kenardy commentary]
Fear of heights (automated): about six 30-minute sessions over 2 weeks; session 1 explanation and cognitive approach, sessions 2–6 increasingly challenging tasks in a ten-storey virtual office complex. [source: Psychiatric News 2018; Freeman et al. 2018 abstract]
Move up the hierarchy when distress at the current step has clearly fallen within and across sessions (SUDS trend) or, in a safety-learning frame, when the client reports that the feared outcome did not occur and they feel safer. [source: Rothbaum et al. 2001 for habituation; Psychiatric News 2018 for the safety question]

Phase D: Generalisation to in-vivo exposure (runs alongside C, completes it)

In-vivo hierarchy built in session 2 of the BRAVEMIND protocol and worked through as homework; in the flying trial the behavioural endpoint was an actual round-trip flight. [source: Rizzo 2015 report; Kenardy commentary]

Phase E: Review and ending

BRAVEMIND MST pilot: minimum 6, maximum 12 sessions, weekly or twice weekly; end when PCL-5 shows 70% improvement from baseline or clinician and client agree maximum benefit has been reached. [source: Rizzo 2015 report]
Virtual Vietnam: typically ten 90-minute sessions twice weekly over 5–7 weeks, range 8–16 according to progress; non-VR processing sessions could be interspersed. [source: Rothbaum et al. 2001]
Emory 2014 trial: an introductory session plus five VRE sessions (six in total), with follow-up at 3, 6 and 12 months; that trial tested medication augmentation, which is the prescriber's and researchers' domain and not part of routine VRE. [source: Rothbaum et al. 2014, Emory repository record]

3. Guiding principles

VR is a medium, the therapist is the treatment: you run every immersion live, watching the monitor and adjusting stimuli; do not hand a client a headset and leave. Rizzo, commenting on automated programmes, said VR "should be integrated with a therapist". [source: Psychiatric News 2018; Rizzo 2015 report]
Match the world to the memory: choose and tune scenes, time of day, weather, sounds and triggers to the client's own account; a poor match weakens activation (in the Vietnam study three people were excluded because their trauma was too dissimilar to the environments). [source: Rothbaum et al. 2001; Rizzo 2015 report]
Titrate, do not ambush: introduce triggers (gunfire, explosions, a perpetrator figure) gradually and strategically, and keep a quick way to remove them. [source: Rizzo et al. 2014 and Rizzo 2015 report]
Stay in contact through the headset: the client keeps their eyes open in the scene and talks to you; you prompt, encourage and ask for ratings at fixed intervals (SUDS every 5 minutes in the PTSD protocols). [source: Rothbaum et al. 2001; Rizzo 2015 report]
Repetition until distress comes down: repeat the narrative or the hierarchy step within the session until distress falls, rather than stopping at the peak. [source: Rothbaum et al. 2001]
Safety first, in body as well as mind: screen for seizures, motion sickness and medical conditions, and stop at the first sign of physical discomfort. [source: Meta Quest 3 safety guide via Innerspace]
Generalise outside the headset: VR gains must be carried into real situations through in-vivo homework. [source: Rizzo 2015 report; Kenardy commentary]
Consent is ongoing: the client can stop immersion at any moment with an agreed signal; data handling is explained up front. [synthesis]
Privacy by default: treat headset motion, voice and session data as health data, since motion data alone can reveal personal attributes. [source: Nair et al. 2023 preprint] [synthesis for the clinical application]
Infection control is part of the procedure: clean between every client as healthcare guidance describes. [source: NSW Clinical Excellence Commission guidance v3.0, 2023]
Measure and decide: use standard symptom measures at baseline and during treatment to decide when to end (e.g. PCL-5 in the BRAVEMIND protocol). [source: Rizzo 2015 report]

4. Intervention inventory

4.1 Suitability assessment and environment matching

Purpose: decide whether VRE is the right exposure format and whether an available environment fits the client's trauma or phobia.
Steps: (1) Confirm diagnosis and severity with a standard interview and self-report (the BRAVEMIND protocol uses the PCL-5). (2) Identify the index trauma (and at most one secondary event, given the short course) or the phobic situation. (3) Walk through the available scenes and stimuli and check the match with the client's account: setting, vehicle, terrain, time of day, sounds, people. (4) Check the protocol exclusions: active addiction, serious heart conditions, psychosis or bipolar disorder, an unstable medication regimen, uncontrolled suicidal intent, and lack of agreement from the treating physician or team. (5) If the match is poor, offer imaginal or in-vivo exposure instead (Domain II exposure guide). [source: Rothbaum et al. 2001; Rizzo 2015 report]
Example language (illustrative): "Before we decide on VR, I want to check whether the scenes we have actually look and sound like what happened to you. If they do not, standard exposure without the headset may suit you better."
Watch for: a client choosing VR to avoid talking about the memory; trauma types for which no scene exists; substance misuse or suicidality that needs stabilising first. It is working when the client recognises cues in the scene as "like it was". [synthesis]

4.2 Medical, seizure and cybersickness screening

Purpose: identify people for whom immersion carries physical risk.
Steps: (1) Ask about any history of seizures, epilepsy-related symptoms, blackouts, or sensitivity to flashing lights or patterns; the headset maker warns that virtual content can trigger seizures even in people with no history, and advises consulting a doctor first if there is such a history. (2) Ask about pregnancy, older age, binocular vision problems, heart conditions, psychiatric disorders and other serious medical conditions, each of which the manufacturer lists as reasons to consult a doctor before use. (3) Ask about pacemakers, defibrillators and hearing aids, which headset magnets and radio emissions can affect. (4) Ask about motion sickness, migraine and vestibular problems (dizziness, vertigo) [synthesis]. (5) Ask about alcohol or drug use, fatigue or illness on session days, since use when impaired is advised against. (6) Where any of these apply, obtain the client's physician's view before immersion, as the Vietnam protocol required approval from the treating physician or team. [source: Meta Quest 3 safety guide via Innerspace 2024; Rothbaum et al. 2001]
Example language (illustrative): "Headsets can occasionally trigger seizures or make people feel sick. I need to ask you some health questions first, and for some answers I will want your doctor's opinion before we start."
Watch for: undisclosed epilepsy, current vertigo, recent head injury [synthesis]. Record the screening in the notes.

4.3 Informed consent for VRE

Purpose: consent to exposure itself and to the technology.
Steps: (1) Explain that exposure deliberately raises distress for a time, and why (emotional processing rationale). (2) Explain physical side effects: eye strain, nausea, dizziness, disorientation, blurred vision, headache, neck strain, skin irritation from the face pad, and rare seizures. (3) Explain the stop signal (verbal or hand-raise) and that you can remove triggers or end the scene immediately. (4) Explain what data the system records (motion, voice, audio recordings of narratives, SUDS logs, any cloud account) and where it is stored (4.20). (5) Explain the plan to move from VR to real-world practice. (6) Document consent. [source: Meta Quest 3 safety guide via Innerspace; FDA AR/VR page on cybersickness and neck strain; Rothbaum et al. 2001 rationale] [synthesis for the consent sequence]
Example language (illustrative): "You will be in a scene that brings back parts of what happened. You are in charge of stopping: say 'stop' or raise your hand and I will pause the scene at once. Some people get headaches or feel queasy; if that happens we stop and wait until it passes."
Watch for: consent given under pressure (e.g. from a unit or employer); misunderstanding that VR is a game or a shortcut. [synthesis]

4.4 Psychoeducation and rationale

Purpose: make the work make sense so the client stays in the scene.
Steps: (1) Review common reactions to trauma (BRAVEMIND session 2) or the nature of the phobia. (2) Explain how avoidance maintains fear and how staying with realistic cues lets fear come down and new learning occur. (3) For the safety-learning framing (heights programme), explain that the aim is to learn the situation is safer than feared. (4) Ask the client to restate the rationale. [source: Rizzo 2015 report; Rothbaum et al. 2001; Psychiatric News 2018]
Example language (illustrative): "Each time you stay with the scene instead of escaping, your brain gets new evidence that you can face this memory and that it is not happening now."
Watch for: the client hearing "get used to danger" rather than "learn the memory is not the present". [synthesis]

4.5 Breathing retraining

Purpose: a brief, portable calming skill taught early in the Emory protocols; used at the end of sessions, not as an escape during exposure.
Steps: (1) Teach slow breathing with a lengthened exhale and a calming word. (2) Practise in session. (3) In the Vietnam protocol, breathing practice was done at the end of each session. [source: Rothbaum et al. 2001; Rizzo 2015 report] [synthesis for the breathing detail]
Example language (illustrative): "Breathe in normally, then breathe out slowly while you say 'calm' to yourself. We will use this at the end of today, after the exposure."
Watch for: breathing used as a safety behaviour during immersion, which can blunt learning; discuss it if it appears. [synthesis]

4.6 Hierarchy building (VR and in-vivo)

Purpose: a graded plan for both the virtual stimuli and real-world practice.
Steps: (1) List situations and cues the client avoids and rate each 0–100 SUDS. (2) Build an in-vivo hierarchy (BRAVEMIND session 2). (3) Build a VR stimulus plan from the scene options, from neutral exploration up to the most distressing triggers. For flying: sitting in the cabin, take-off, landing, calm flight, stormy flight. For heights in the Oxford programme: progressively higher floors and tasks in a ten-storey office complex (e.g. a high platform over the lobby). (4) Agree which steps are done in VR, which in vivo, and which in both. [source: Rizzo 2015 report; Kenardy commentary; Psychiatric News 2018]
Example language (illustrative): "Let's list what you avoid, from mildly uncomfortable up to the hardest thing you can imagine, and rate each from 0 to 100."
Watch for: gaps between steps that are too large; hierarchies containing only VR items. [synthesis]

4.7 Equipment familiarisation in a neutral environment

Purpose: fit the headset, test for sickness, and learn controls before any trauma or fear cues are introduced.
Steps: (1) Clear the play area, set the boundary and seat or support the client as the scene requires (the Vietnam clearing used a raised platform with handrails; the helicopter used a seat with a vibrating woofer). (2) Fit the headset, check focus and adjust for glasses. (3) Let the client look around a neutral scene (Virtual Vietnam session 1) or explore the environment without narrative or triggers (about 25 minutes in the Virtual Iraq protocol). (4) Ask about dizziness, nausea and eye strain at the end. [source: Rothbaum et al. 2001; Rizzo et al. 2014 as reprinted; Meta Quest 3 safety guide via Innerspace]
Example language (illustrative): "Just look around and get used to moving your head. Nothing will happen in this scene. Tell me straight away if you feel dizzy or sick."
Watch for: early cybersickness (pallor, sweating, yawning, nausea [synthesis]); claustrophobic reactions to the headset itself.

4.8 Cybersickness monitoring and management

Purpose: prevent and manage nausea, dizziness, disorientation and eye strain, which FDA lists as a probable risk of VR devices.
Steps: (1) Ask about symptoms before and after each immersion; a standard simulator-sickness questionnaire can be used [uncertain: specific instrument and cut-offs not verified]. (2) Start with short sessions and gentle content; the manufacturer gives an example of a 30-minute maximum followed by a 15-minute break, increasing gradually. (3) Prefer seated scenes and minimise artificial locomotion where clinically possible [synthesis]. (4) Stop immediately at symptoms and do not resume until the client has fully recovered. (5) After immersion, advise avoiding activities that need balance or hand-eye coordination until any symptoms have resolved; also check before the client drives home [synthesis]. (6) If symptoms persist or are serious, the client should consult a doctor. [source: FDA AR/VR page; Meta Quest 3 safety guide via Innerspace]
Example language (illustrative): "On a scale of 0 to 10, how is your stomach and your head right now? If it goes up during the scene, tell me and we will pause."
Watch for: confusing cybersickness with anxiety (both raise sweating and nausea); ask which it feels like and look at timing in relation to triggers [synthesis].

4.9 VR exposure with trauma narration (PTSD)

Purpose: activate and process the trauma memory with matched sensory cues.
Steps: (1) Begin in the matched environment. (2) Ask the client to recount the trauma aloud in the first person, with sensory detail. The Vietnam protocol used present tense with eyes open, a departure from standard imaginal exposure, which uses closed eyes; the Iraq/Afghanistan report describes eyes closed in the original system. Name which you use; with a headset on, eyes open is needed to see the scene. (3) As the narrative unfolds, introduce matched events from the console (e.g. land or lift the helicopter, add gunfire or shouting at the relevant moment). (4) Ask for SUDS (0–100) every 5 minutes and record them. (5) Prompt and encourage; repeat the narrative until distress comes down. (6) Exposure time up to about 45 minutes in a 90-minute session. (7) Audio-record the narrative for homework listening. [source: Rothbaum et al. 2001; Rizzo et al. 2014 as reprinted; Rizzo 2015 report] [uncertain: the two sources differ on eyes open vs closed]
Example language (illustrative): "Tell me what is happening, as if it is happening now. What do you see? What do you hear? ... What's your number now, 0 to 100? ... Stay with it, you're doing what you came to do."
Watch for: skipping the worst moments, flat or summarised narration, dissociation (glazed, unresponsive), rising SUDS with no fall across repetitions. Working signs: SUDS peaks then declines within the session and peaks lower across sessions.

4.10 Therapist stimulus control and titration during immersion

Purpose: the therapist's live role inside the immersion: pace activation so it is strong enough to learn from but not overwhelming.
Steps: (1) Watch the monitor showing the client's view throughout. (2) Use the clinician console to choose scenario and location, and set lighting, weather, audio and atmosphere. (3) Add triggers one at a time, matched to the narration; in the original system gunfire and explosions were introduced gradually. (4) In the military sexual trauma version, adjust a perpetrator figure's appearance and behaviour and door states, and use the quick-remove option if pacing requires it. (5) Lower intensity if SUDS stays near maximum without any movement or the client starts to dissociate; raise it if SUDS is low and the narrative is detached. [source: Rizzo et al. 2014 as reprinted; Rizzo 2015 report; Rothbaum et al. 2001] [synthesis for step 5 decision rules]
Example language (illustrative): "I'm going to add the sound of the helicopter now ... I've taken that sound out for a moment. Keep telling me what's happening."
Watch for: the therapist adding triggers faster than the client is narrating; the therapist's own discomfort leading to under-dosing. [synthesis]

4.11 Hot-spot work within VR

Purpose: focus repeated exposure on the moments of the memory that carry the most distress.
Steps: in later sessions, once the full narrative has been told several times, identify the moments with highest SUDS and repeat those segments with matched cues. [synthesis: carried over from prolonged exposure (see Domain II exposure guide); the Vietnam protocol describes later sessions focused on the most traumatic memories identified before treatment, source: Rothbaum et al. 2001]
Example language (illustrative): "Today let's go to the part where the vehicle stops, and go through just that part slowly, several times."
Watch for: hot spots shifting as one is processed; new memories emerging that need to be added to the plan.

4.12 Graded VR exposure for specific phobia (flying, heights)

Purpose: approach the feared situation in steps that would be costly or impractical in vivo.
Steps (fear of flying, Emory version): after preparation sessions, four VRE sessions twice weekly, working through sitting in the cabin, take-off, landing, and calm then stormy flight, repeating each until fear falls, with SUDS ratings. Steps (fear of heights): move up the floors and through tasks of increasing difficulty, asking after each whether the client feels safer than before. [source: Kenardy commentary; Psychiatric News 2018] [synthesis for the within-step repetition and ratings in phobia sessions]
Example language (illustrative): "The plane is about to take off. Notice what your body does and stay with it. What is your fear level? What did you predict would happen, and what actually happened?"
Watch for: the client gripping seats or looking away (safety behaviours), or moving on before fear has fallen. Working signs: lower peak fear on repeat; willingness to choose the next step.

4.13 Safety-learning and belief testing in VR (cognitive variant)

Purpose: the Oxford heights model frames VR tasks as learning that the situation is safe, rather than as waiting for fear to drop.
Steps: (1) Explain the cognitive approach. (2) Before each task, ask what the client fears will happen. (3) Do the task. (4) Ask whether they now feel safer and what they learned. (5) Repeat key learning points. In the automated programme these steps are delivered by a virtual coach with empathic encouragement. [source: Psychiatric News 2018; Freeman et al. 2018 abstract] [uncertain: detailed task list and the programme's handling of safety behaviours not verified]
Example language (illustrative): "What do you think would happen if you walked to the edge of the platform? ... You did it. What does that tell you about how safe you are up here?"
Watch for: the client attributing safety to the virtual setting ("it's not real"); address this by planning real-world tasks (4.16). [synthesis] See 093 gameChange for the same coach-led model in psychosis.

4.14 Post-immersion re-orientation and physical check

Purpose: bring the client back to the room and ensure they are safe to leave.
Steps: (1) Fade or pause the scene, then remove the headset slowly with the client seated. (2) Ask about dizziness, nausea, headache and visual symptoms. (3) Orient to the room and time [synthesis]. (4) Do breathing practice at the end of the session (Vietnam protocol). (5) Advise avoiding activities that need balance or coordination until any symptoms resolve. [source: Rothbaum et al. 2001; Meta Quest 3 safety guide via Innerspace]
Example language (illustrative): "Take the headset off when you're ready. Look around the room, feet on the floor. How is your head and stomach?"
Watch for: lingering disorientation, high residual distress, dissociation. Do not let the client drive while symptomatic [synthesis].

4.15 Processing after exposure

Purpose: consolidate what was learned and integrate the memory.
Steps: after each exposure, discuss the experience: what was hardest, what the client noticed, what changed in their thinking about the event, themes of guilt, shame or responsibility, and what they learned. The protocols place processing and discussion after exposure in each session; some courses intersperse non-VR processing sessions. [source: Rizzo 2015 report; Rothbaum et al. 2001] [synthesis for the specific questions]
Example language (illustrative): "What was it like to tell it in the scene today? Did anything look different to you this time?"
Watch for: intellectualising, or returning to self-blame; working when new perspectives on the event emerge.

4.16 Homework and generalisation to in-vivo exposure

Purpose: transfer gains from VR to daily life.
Steps: (1) Assign listening to the audio recording of the session's narrative between sessions (Virtual Iraq). (2) Assign in-vivo hierarchy items each week (BRAVEMIND). (3) Review homework at the start of each session (about 15 minutes of check-in). (4) For phobias, plan the real-world target, e.g. the round-trip flight used as the endpoint in the flying trial, or real heights. [source: Rizzo et al. 2014 as reprinted; Rizzo 2015 report; Kenardy commentary]
Example language (illustrative): "This week, listen to today's recording once a day and visit the supermarket at a busy time, staying until your number comes down."
Watch for: homework skipped or done with safety behaviours; growing gap between VR progress and real-life avoidance. Working when the client reports approaching situations previously avoided.

4.17 Suicide and crisis monitoring

Purpose: exposure can raise distress temporarily; maintain safety.
Steps: screen for suicidality at intake (the protocols excluded uncontrolled suicidal intent); check mood and risk at each check-in; agree a safety plan with crisis contacts; route medication questions to the prescriber. [source: Rothbaum et al. 2001; Rizzo 2015 report] [synthesis for routine check and safety plan]
Example language (illustrative): "Sometimes people feel worse for a while during this treatment. If you have thoughts of ending your life, here is what we agreed you'll do and who you'll contact."
Watch for: increased substance use, hopelessness, or self-harm after sessions.

4.18 Progress measurement and ending

Purpose: decide when to stop and consolidate.
Steps: (1) Measure symptoms at baseline and regularly (PCL-5 in BRAVEMIND). (2) End when the predefined improvement is reached (70% in the MST pilot) or both agree maximum benefit is reached, within 6–12 sessions. (3) Review the hierarchy, gains and remaining avoidance; plan continued in-vivo practice; arrange follow-up (the Emory trial followed at 3, 6 and 12 months). [source: Rizzo 2015 report; Rothbaum et al. 2014 record] [synthesis for the relapse-prevention review]
Example language (illustrative): "Your scores have come down a lot. Let's write down what helped and how you will keep practising after we finish."
Watch for: ending before in-vivo generalisation; unaddressed comorbidity (depression, substance use) needing other treatment.

4.19 Headset hygiene between clients

Purpose: prevent transmission of skin, eye and respiratory infections via shared equipment.
Steps (healthcare guidance): (1) Hand hygiene before handling and after cleaning. (2) Remove and discard disposable face pads; clean reusable face pads. (3) Wipe inner and outer headset surfaces and controllers with a new detergent wipe per surface and allow to dry; disinfect reusable parts with a disinfectant approved by the regulator and the manufacturer. (4) Prefer wipeable or replaceable facial interfaces or a disposable impervious barrier; replace Velcro with a cleanable fastener. (5) Store in a clean sealable bag and label equipment as clean or dirty. (6) Do not use with clients who have cold or flu symptoms or open cuts or sores on the face or hands; the manufacturer adds contagious eye, skin or scalp conditions. (7) Follow the manufacturer's lens-cleaning instructions [uncertain: lens cleaning and UV devices not covered by the guidance]. [source: NSW Clinical Excellence Commission guidance v3.0, Nov 2023; Meta Quest 3 safety guide via Innerspace]
Example language (illustrative): "I clean the headset and change the face cover between every person. If you have a cold or a skin or eye infection, let me know and we'll do a session without it."
Watch for: skin irritation, rash or pressure marks (stop use if they appear); client concern about shared equipment.

4.20 Data privacy and security

Purpose: protect session data; FDA lists privacy and cybersecurity as probable risks of AR/VR devices.
Steps: (1) Find out what the software records and transmits (head and hand tracking, eye tracking, audio, narrative recordings, ratings) and where it is stored. (2) Use clinic-controlled accounts, not personal consumer accounts; disable unneeded cloud sync, social features and casting [synthesis]. (3) Make sure the platform meets your jurisdiction's health-data law (e.g. HIPAA in the US, GDPR in the EU/UK) and sign the required data-processing agreement [synthesis]. (4) Store narrative recordings as clinical records and agree how the client keeps homework recordings safe. (5) Tell clients that motion data alone has been shown to allow inference of many personal attributes. [source: FDA AR/VR page; Nair et al. 2023 preprint] [synthesis for steps 2–4]
Example language (illustrative): "The headset records how you move and your voice. Here is what we keep, where it is stored and who can see it."
Watch for: vendor terms that allow data reuse; recordings stored on shared devices.

4.21 Collaboration with medical and prescribing colleagues

Purpose: medical clearance and medication questions sit with physicians.
Steps: obtain physician input for seizure, cardiac, pregnancy, vision or other medical concerns; do not advise on medication. Trials have tested medication augmentation of VRE; that is a research and prescriber decision, not part of routine VRE. [source: Rothbaum et al. 2001; Rothbaum et al. 2014 record]
Example language (illustrative): "Because of your seizure history, I'd like your neurologist's view on VR before we start; we can begin preparation sessions meanwhile."
Watch for: clients asking you whether to change medicines; route those to the prescriber.

5. Handling problems

Cybersickness during exposure: pause the scene, remove triggers that involve rapid movement, let the client sit with eyes on a fixed point or remove the headset, and do not resume until fully recovered; next time use shorter immersions with breaks and more seated content. If it recurs despite this, switch to imaginal or in-vivo exposure. [source: Meta Quest 3 safety guide via Innerspace; FDA AR/VR page] [synthesis for switching formats]
Seizure, twitching, blackout or severe dizziness: stop immediately, remove the headset, follow first-aid and emergency procedures, and do not resume VR until a doctor has reviewed the client. [source: Meta Quest 3 safety guide via Innerspace] [synthesis for the emergency step]
Low presence or under-engagement ("it's just a video game"): improve the match (time of day, weather, sounds, vehicle), add the client's narration in first person and present tense, add sensory details from their account, and check for subtle avoidance (looking away, closing eyes, minimal narration). If the scene simply does not fit, move to imaginal exposure. [source: Rothbaum et al. 2001; Rizzo 2015 report] [synthesis for the problem-solving sequence]
Overwhelm or dissociation: reduce intensity at once (remove the perpetrator figure or trigger sounds, change lighting), ask the client to describe what they can see in the scene, then resume at a lower step; if dissociation persists, end immersion, ground in the room and revise the plan. [source: Rizzo 2015 report for quick removal of triggers] [synthesis for grounding and revision]
Panic or claustrophobia from the headset itself: allow the client to hold the headset to the face without strapping it, start with passthrough or short neutral exposures, and treat the headset as an early hierarchy item. [synthesis]
Stuck SUDS (no fall within or across sessions): check for safety behaviours, check that the narrative includes the hot spots, slow the pace of triggers, add processing time, consider non-VR processing sessions as the Vietnam protocol did. [source: Rothbaum et al. 2001 for interspersed non-VR sessions] [synthesis for the rest]
New memories or a mismatch emerging mid-course: add the memory to the plan; if no scene fits it, use imaginal exposure for that memory. Given 6–12 sessions, focus on the index trauma and possibly one other. [source: Rizzo 2015 report] [synthesis]
Dropout and non-adherence: the Vietnam study lost five of ten participants (two after session 1, three after session 5), and those who dropped out were offered other clinic treatment. Anticipate early dropout by revisiting the rationale, scheduling twice weekly to keep momentum, reviewing homework at every check-in, and offering an alternative trauma-focused therapy rather than discharge. [source: Rothbaum et al. 2001] [synthesis for prevention steps]
Homework not done (recording not listened to, in-vivo task skipped): problem-solve barriers, shrink the task, schedule it, and do part of it in session. [synthesis]
Rupture ("you made me relive it", anger at the therapist): acknowledge, validate the distress, review the client's control (stop signal, trigger removal), renegotiate pace, and restate the rationale; do not push through without repair. [synthesis]
Client seeking VR to avoid the memory: say so gently, and show how narration is the active part of VRE. [synthesis]
Substance use, suicidality or instability arising: pause exposure, address risk, stabilise, and liaise with the medical team; these were exclusion grounds in the Vietnam protocol. [source: Rothbaum et al. 2001] [synthesis for pausing]
Children and adolescents: headset makers set age floors (for Meta, accounts require a minimum age of 10, which can vary by country) and advise adult supervision, more frequent and longer breaks, and avoiding prolonged use; use only age-appropriate content and treat paediatric use as carrying unknown risk as FDA notes. [source: Meta Quest 3 safety guide via Innerspace; FDA AR/VR page] [uncertain: no paediatric VRE protocol verified here]
Older adults, pregnancy, heart or vision problems, pacemakers or hearing aids: obtain medical advice before use, per the manufacturer's warnings. [source: Meta Quest 3 safety guide via Innerspace]
Equipment failure mid-session: keep a plan to switch to imaginal exposure for the remainder of the session, so the client is not left at peak distress without processing. [synthesis]
Neck strain or headaches from the headset weight: shorten immersions, adjust fit and offer seated scenes; FDA lists head and neck strain as a risk. [source: FDA AR/VR page] [synthesis for responses]
Client using consumer VR or self-help VR apps on their own: ask what they use, explain that therapist-integrated exposure is the model the trials used, and fold suitable practice into the plan. [source: Psychiatric News 2018 for Rizzo's view] [synthesis]
Remote or home-based VR: [uncertain: no protocol for home-delivered therapist-led VRE verified]. If used, agree supervision, a remote stop procedure, a crisis plan, and safe play-area set-up (clear hazards; boundaries do not stop collisions; indoor use only). [source: Meta Quest 3 safety guide via Innerspace for play area] [synthesis for the rest]
Evidence questions from clients: say that VRE outperformed waiting list for fear of flying and performed similarly to standard exposure, with gains kept at 6 months (Rothbaum et al. as summarised by Kenardy); that the automated heights programme produced large reductions in fear versus usual care (Freeman et al. 2018); and that VRE for PTSD has been tested in open and randomised trials at Emory and USC. On guidelines: the ISTSS PTSD guidelines (recommendations amended 19 March 2019) rate virtual reality therapy as having emerging evidence of efficacy for adults with PTSD, a lower tier than the strong recommendations for cognitive processing therapy, cognitive therapy, EMDR, trauma-focused CBT and prolonged exposure; they make no statement on VR for children and adolescents. [source: ISTSS 2019] The 2023 VA/DoD guideline synopsis names prolonged exposure, cognitive processing therapy and EMDR as the recommended manualised trauma therapies; how that guideline rates VRE specifically is [uncertain]. Practical meaning: offer VRE as a way of delivering exposure, and tell clients that the trauma therapies with the strongest guideline backing are the established non-VR protocols. [source: Kenardy commentary; Freeman et al. 2018 abstract; Rothbaum et al. 2001; Rothbaum et al. 2014 record; Schnurr et al. 2024; ISTSS 2019]

Sources

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