CHAPTER 2 - REVIEW OF RELATED LITERATURE

Background of Virtual Reality Therapy

VR systems consist primarily of a computer setup and VR headset; however, chairs, gloves, and

sensors are additional accessories that enhance the overall experience. These accessories transmit

various physical sensations through haptic feedback systems. Virtual Reality Therapy (VRT)

involves utilizing Virtual Reality (VR) technology to provide therapy by immersing patients in

manageable and frequently engaging virtual settings. (Ali Adjorlu, 2024). VR is characterized by

three fundamental attributes - immersion, a feeling of presence, and the ability to interact

(Sokołowska, 2024). These attributes come together to support the core of VR, which engages

participants in the interactive generated worlds of computers. Sensory data is provided with the

help of a head-mounted display along with specialized interface devices. These monitor head

movements, enabling the visuals to adjust fluidly by tracking head motion, thus enhancing the

feeling of immersion (Maples-Keller et al., 2017).

Exposure therapy is the primary function regarding therapy, primarily due to the near-immediate

recreation of real-world settings which helps to ensure a higher reproducibility (Bell et al., 2020).

Virtual Reality Therapy (VRT) provides a safe, controlled environment for individual patients

that can be adapted by therapists in real time based on the patient’s response. One of its key

strengths lies in its immersive aspect and the gradual effects that occur over multiple sessions

(Hembree et al., 2003). Patients adapt and learn behavioral skills to be able to prepare themselves

when confronted with fear stimuli upon returning to the real world (Carl et al., 2019). The

practice itself has been proven effective with various mental health conditions, and is viewed as a

potential solution (Bell et al., 2020).

thoughts, situations, physical symptoms, objects, and bodily sensations with that traumatic event

and those are usually called fear stimuli (Abramowitz et al., 2011). Despite the fear stimuli

present in these immersive environments, it is considered safe to undergo Virtual Reality

Therapy as the patients are being guided and supervised by the therapists, monitoring any

changes in behavior and patient response to the virtual scenario over time. However, as effective

as it can be, patients still may refuse treatment or drop out of Virtual Reality Therapy, especially

when exposed to their fear stimuli for periods of time (Deacon et al., 2013). It however has also

been shown to provide benefits to patients suffering from post-traumatic stress disorder (PTSD),

by giving patients a platform to be exposed and pull away from the stressor (Park et al., 2019).

Virtual Reality Therapy is an interactive form of therapy that collects information from the user’s

sensory system while the VR glasses display a replication of the user’s specific experience with

the fear stimuli present (Diemer et al., 2015). In real-time, the user or patient’s position and head

movement behaviours are recorded with the help of a head tracking system placed on them

(Wilczyński et al., 2016). These are usually done to accommodate those with anxiety disorders.

When treating agoraphobia and social phobia, it becomes effective in multiple short sessions of

at least 15 minutes or longer, 45 to 180 minutes. It’s noted that it’s effective in treatment when

there’s no other pre-existing mental health condition that might affect the immersion or the

interaction in the virtual world scenario (Meyerbroeker et al., 2013). The first study to

investigate the effectiveness of VR therapy was Rothbaum et al., who tested the efficacy by

treating acrophobia in college students; it was proven to have mitigated their fear of heights.
VR and Traditional Therapy

Traditional forms of exposure therapy, particularly cognitive-behavioral therapy (CBT), have

been the standard for the treatment of anxiety as they have been known to significantly reduce

the symptoms of the patients (Wolitzky-Taylor et al., 2008). When integrating the cognitive

reframing strategy and exposure therapy, the treatment improved significantly than CBT alone

(Norton & Price, 2007). Exposure therapy is grounded in the Emotional Processing Theory as the

stimuli trigger fear and trauma in each person who has undergone a traumatic experience (Foa &

Kozak, 1986).

In comparison, Virtual Reality Therapy (VRT) is a new form that is flexible and is able to tailor

to the individual needs in their specific situations. This is due to the VR’s ability to manipulate

the immersive scenario based on the patient’s set of fear stimuli that can be used to replicate the

settings and environment as closely as possible. As it is new, there are still some hindrances to

the patients as they may experience motion sickness, and derealization that results in conflicts

when interacting with their therapist after each session with the VR (Benbow & Anderson,

2019).

Furthermore, Virtual Reality Therapy has its fair share of pros and cons. Examples of its benefits

include convenience, reduced stigma, and much more. When discussing how such stigma can be

reduced, Virtual Reality Therapy can remove a good number of the negative feelings associated

with attending an in-person therapy session. On the other hand, the limitations of that kind of

therapy include reliance on technology, and the lack of privacy (Ko, 2024). The main selling

point of Virtual Reality Therapy is the personalization and ability to manipulate the environment

with the relevant factors or variables tailored to the patient and the capability to interact with

objects within the system. This eliminates the typical need to imagine or hire actors to replicate a
scene for the patient. Despite these setbacks, it’s still considered a more convenient and safer

alternative method of exposure therapy that’s adjustable. It provides an opportunity for its

standardization of usage for the duration and exposure of patients.

Application of VR in Therapy
Treatment of Anxiety, PTSD, Phobias, and Other Illnesses.

With the use of VR and its recent innovations, it is now entirely possible to gather all the relevant

data in real time. Included software are monitors for eye-tracking, heart rate, and skin

conductance. All of which are typical physiological indicators of psychological states such as

fear. Additionally, other centers have begun to process the integration of biosensors such as

electroencephalography (EEG) to make more accurate assessments (Selaskowski et al., 2024).

Mühlberger et. al, in particular, have developed a VR-delivered behavioral avoidance test

(VR-BAT) to automatically collect heart rate, skin conductance, rating of discomfort, and

stimulus-approach distance in order to assess the current impact of specific phobias.

Anxiety, post-traumatic stress disorder (PTSD), and specific phobias are among the most

common and disabling mental health conditions today. They often develop after individuals are

exposed to intense stress or trauma and can significantly interfere with daily functioning.

Anxiety is generally characterized by persistent worry and fear that is difficult to control, while

phobias involve intense, irrational fears of specific objects or situations. PTSD, on the other

hand, can develop after a traumatic event and involves symptoms such as intrusive thoughts,

flashbacks, hypervigilance, and avoidance of trauma-related cues (Carl et al., 2019; Parsons &

Rizzo, 2008).
The outcomes of these disorders are often serious. For instance, individuals may struggle with

maintaining personal relationships, experience academic or occupational difficulties, and have a

decreased overall quality of life. Anxiety disorders and PTSD are also frequently comorbid with

other mental health problems like depression, which compounds the psychological burden

experienced by the individual (Fodor et al., 2018). Emotional avoidance, hyperarousal, and fear

generalization are common coping responses that further reinforce the problem and prevent

recovery.

Virtual Reality Therapy (VRT) is a relatively new but promising form of treatment that addresses

the challenges and inadequacies of traditional therapy, particularly when patients are reluctant or

unable to face feared stimuli in real-world settings. Virtual Reality Therapy allows individuals to

confront their fears in a controlled and customizable virtual environment with multi-sensory

stimulation. Its computer-generated nature gives the opportunity for precise parameters to match

patient preferences, not limited to frame rate, resolution, and design features. With these features,

comes the phenomenon of “uncanny valley” where characters or features don’t feel human-like;

giving a feeling of disgust or revulsion. This can be tackled by opting for more stylistic decisions

creatively, as more stylized avatars tend to be easier to accept due to their lack of intentional

lifelike movement (Bell et al., 2020).

In a meta-analysis conducted by Carl et al. (2019), Virtual Reality Therapy was observed to be

highly effective in treating anxiety-related disorders, with outcomes comparable to those in vivo

exposure therapy. The patient’s exposure to triggers or cues needed emphasizes the importance

of customization in proving the effectiveness of the therapy (Bell et al., 2020). Similarly, Fodor

et al. (2018) found that Virtual Reality Therapy produced significant improvements in symptoms

of both anxiety and depression across a variety of clinical populations. Parsons and Rizzo (2008)
further emphasized that Virtual Reality Therapy is especially useful for treating phobias, as the

virtual environment can simulate specific feared situations with high realism and safety.

Virtual Reality Therapy has also been applied to the treatment of PTSD. According to Rizzo et

al. (2020), virtual exposure significantly reduced PTSD symptoms when compared to control

groups, indicating its strong potential as a therapeutic intervention for trauma-related disorders.

Carl et al. (2019) also concluded that Virtual Reality Therapy is effective for PTSD treatment

based on their large-scale analysis of randomized controlled trials. Furthermore, van ’t

Wout‑Frank et al. (2024) explored the use of Virtual Reality Therapy in combination with

transcranial direct current stimulation (tDCS) and noticed that it helped veterans with PTSD

experience reduced anxiety and improved emotional regulation. The additional usages of VR

apply to autistic or schizophrenic patients in helping to improve their social behaviour, showing

that it also helps moderate Alzheimer’s disease through cognitive reserve and training (Park et

al., 2019).

Obstacles Experienced

Despite promising findings, several challenges remain. Much of the PTSD research using Virtual

Reality Therapy focuses on military populations, particularly veterans, so further studies are

needed to assess its effectiveness in civilian populations (Rizzo et al., 2020). There is also

variability in study methods and sample sizes across current literature, which makes it difficult to

generalize findings. Moreover, there is limited data on the long-term effects of Virtual Reality

Therapy, as many studies do not assess outcomes beyond six months (Fodor et al., 2018). Finally,

combining Virtual Reality Therapy with other treatments such as pharmacological aids or brain

stimulation techniques like tDCS may increase its therapeutic potential, however, more rigorous

studies are necessary to validate these approaches (van ’t Wout‑Frank et al., 2024).
The reception to Virtual Reality Therapy has varying stances, with some claiming to reduce

PTSD symptoms significantly while others countered that there are no differences to traditional

treatments. However, it was later clarified that Virtual Reality Therapy patients experience the

most success in relieving symptoms out of any other method. Additionally, there is a significant

lack of consistency in the review compilation, being left primarily undefined and lacking clear

usage of meta-analytical techniques to evaluate the efficacy of the treatment. Additionally, PTSD

Patients are diverse in the challenges and experiences faced, however, the majority of reviewed

subjects were combat-traumatized war veterans, and this factor lowers the credibility of

effectiveness claims when it comes to PTSD.

The wide range emphasized in clinical VR research and experimentation complicates the study

conduction and result collection, as experts from fields relating to computer science and clinical

research are often required. Depending on its personalized nature, technical experts on the team

may create complex scenarios that may appear as unbelievable to clinical mental health experts.

The process of both development and approval from both fields makes it tedious and tight to

organize. Due to this nature, it results in tight deadlines and frequent compromises that keep the

research from meeting the minimum requirements for publication (Selaskowski et al., 2024).

Despite its supposed accessibility, VR programs intended for this purpose are commercially

unavailable with a lack of proper infrastructure and training in clinical care for this device. The

cost of adopting new technology can reach 400 dollars, for one set of the most recent version of

the Oculus Quest. It’s challenging to maintain due to requiring constant software and hardware

updates. Lastly, there are health concerns involved, ranging from dry eyes to VR sickness. Dry

eyes occur from long and constant exposure to its very hot display and constant blue light.

Another issue that comes up is its potential to be stressful to patients, or risk developing
addictions similar to that of online addiction (Park et al., 2019). Finally, genuine human contact

appears to be preferred over machine usage to more vulnerable people (Selaskowski et al., 2024).

Rehabilitative Capacity of VR/VR Therapy

The simulative aspect remains, with research showing that participants experience virtual

environments similarly to their real-life counterparts. It’s known to produce live emotional

responses the same way, eliciting behaviours that align with standard expectations. Contrarily,

patients who experience higher levels of paranoia have been shown to express detachment from

the virtual environment (Bell et al., 2020).

The success of a client’s recovery in rehabilitation is closely linked to their perception of how

positive their relationship with their therapist seems (Horvath & Symonds, 1991). Studies have

highlighted the significance of verbal and non-verbal communication, especially in informal

conversations where the therapist shares their own experiences, emotions, and opinions to

strengthen their bond with their patient. The therapeutic alliance (TA) is further supported in

Virtual Reality Therapy (VRT) where the primary purpose is to guide patients who have

Acquired Brain Injury (ABI) during their sessions. This results in patients being more motivated

and engaged in their recovery with the integration of VR therapy (Pinto et al., 2012).

A new method designed to be adaptive to the patient’s needs and facilitate the collaboration

between therapist and patient. Communication is further supported through visual, haptic, or

audio cues provided by the immersive nature of the VR. Additionally, it is a preferred method to

those who rehabilitate with their upper limb because aside from better motivation and

engagement (Aderinto et al., 2023), it directly helps with their cognitive function and
task-specific learning, making it more effective than conventional therapy methods in certain

cases (Aida et al., 2018).

Applied Theories in Research

Emotional Processing Theory

Emotional Processing Theory establishes the concept of a fear structure: a memory network that

forms when an individual experiences a traumatic event. This structure contains information

from the event, not limited to; the fear-inducing stimuli, an individual’s behavior and response to

those stimuli, and the meanings attached to them. Therefore, a person would most likely avoid

situations, places, or signs that would trigger traumatic memories (Foa & Kozak, 1986).

Virtual Reality Exposure (VRE) is a form of treatment designed to help a person gradually learn

new coping mechanisms to confront and process traumatic memories and fear stimuli. This was

done to assist those who have Post-Traumatic Stress Disorder (PTSD) through a recreation of the

event with visuals, sounds, and even smell to make the patient engage with it (Rothbaum et al.,

1995). However, research noted that there were no significant outcomes if the patients

themselves weren’t able to emotionally engage in the virtual scenario. Although there were also

reports of decreased symptoms, no major differences were found between VRE and Prolonged

Exposure (PE) therapy.

Classical Conditioning Theory

Classical conditioning theory, first proposed by Ivan Pavlov, provides a useful framework for

understanding how anxiety, PTSD, and phobias develop and persist. This theory posits that

individuals learn to associate a previously neutral stimulus (such as a place or sound) with a

traumatic or fear-inducing event. Over time, the neutral stimulus alone becomes capable of
triggering the same fear response—this is known as a conditioned response (Parsons & Rizzo,

2008). For example, a person who experienced a car accident may begin to feel extreme fear or

anxiety whenever they are near a vehicle, even in a safe context. The conditioned fear response is

further reinforced when the person avoids the stimulus, as this prevents the brain from learning

that the stimulus is no longer dangerous (Carl et al., 2019).

This theoretical framework is relevant to exposure-based therapies similar to Virtual Reality

Therapy. According to classical conditioning principles, fear can be reduced through repeated

exposure to the feared stimulus without the presence of a negative outcome. This process, known

as extinction, is what makes Virtual Reality Therapy effective—it provides individuals with

repeated, safe exposure to their triggers in a virtual setting, allowing them to “unlearn” the

conditioned fear response. Parsons and Rizzo (2008) explain that Virtual Reality Therapy builds

on techniques like systematic desensitization and flooding, both of which aim to reduce fear

through controlled exposure. In Virtual Reality Therapy, these principles are applied in a virtual

environment, offering a safe and flexible way to present anxiety-provoking stimuli at varying

levels of intensity. Carl et al. (2019) support this view, noting that the customizable nature of

Virtual Reality Therapy environments allows for graded exposure, which aligns closely with the

gradual exposure techniques derived from classical conditioning theory.

Moreover, by using virtual simulations, therapists can precisely control the intensity and duration

of exposure, ensuring that the patient stays engaged and that the therapy option is tailored to their

needs. This controlled setting minimizes the chances of retraumatization and increases the

likelihood of successful fear extinction. The incorporation of Virtual Reality Therapy into

treatment thus represents a modern adaptation of classical conditioning theory, enhancing its

application with the use of immersive technology.