Enhancing Virtual Reality Exposure Therapy Through User-Centered Emotional Design: A Systematic Framework for Human-Computer Interaction

1. Introduction

2. Literature Review

2.4. Key Developments in VR for Mental Health Treatment

The evolution of Virtual Reality (VR) in mental health treatment has led to significant developments across multiple therapeutic domains, each addressing specific psychological conditions with innovative approaches.

2.4.1. Anxiety and Phobias

VR exposure therapy has emerged as a transformative approach to treating anxiety disorders and phobias. This methodology shows success rates comparable to traditional exposure therapy, offering enhanced accessibility and control. By enabling patients to confront their fears within controlled virtual environments and facilitating authentic emotional responses while maintaining therapeutic safety, meta-analyses demonstrate significant effect sizes (g = 0.79, 95% CI [0.57, 1.02]) in anxiety reduction with a Number Needed to Treat (NNT) of just 2.36 (Fodor et al., 2018). When compared to traditional Cognitive Behavioral Therapy (CBT), which demonstrates moderate efficacy for anxiety-related disorders with effect sizes ranging from small to moderate (Hedges’ g = 0.38) (Carpenter et al., 2018), virtual reality exposure therapy appears to offer enhanced treatment outcomes. In university students specifically, CBT and mindfulness-based interventions showed moderate effect sizes for anxiety (Hedges’ g = -0.48) (Huang et al., 2018), suggesting that this therapy’s larger effect sizes represent a meaningful improvement in treatment efficacy.

The effectiveness of VR exposure therapy is particularly notable in treating specific phobias, social anxiety, and panic disorders (Pira et al., 2023).

Implementation approaches have evolved from specialized equipment to more accessible solutions, including standalone self-guided applications using low-cost devices like smartphone-based cardboard VR goggles (Geraets et al., 2021). These self-guided treatments have demonstrated substantial efficacy, with studies reporting large effect sizes (d = 1.0 to 2.0) for specific phobias like fear of heights and arachnophobia, even with minimal therapist involvement (Geraets et al., 2021). For public speaking anxiety, a single session of self-guided virtual reality exposure therapy has shown effectiveness comparable to therapist-led treatment, with sustained effects after six months.

Recent studies have identified specific mechanisms of action that contribute to its effectiveness:

• Graduated exposure control with precise environmental manipulation
• Real-time physiological monitoring during exposure sessions (Park et al., 2019)
• Customizable scenario development based on individual triggers and anxiety profiles
• Integration with biofeedback for enhanced treatment response
• Progressive challenge scaling tailored to individual tolerance levels
• Emotional state assessment through physiological markers

Research indicates that patients receiving VR exposure therapy show a considerable reduction in avoidance behaviors and a significant decrease in anxiety-related symptoms across various anxiety disorders (Pira et al., 2023; Cieślik et al., 2020). For specific phobia treatment, virtual reality exposure therapy has demonstrated equivalence to in vivo exposure while offering advantages in terms of safety, controllability, and patient preference (Tsamitros et al., 2023).

2.4.2. Depression and Stress Management

In the treatment of depression and stress-related disorders, VR applications have shown promising results in symptom reduction. Meta-analyses demonstrate significant effect sizes for depression treatment using VR interventions (g = 0.73, 95% CI [0.25, 1.21]) with a Number Needed to Treat of 2.54 (Fodor et al., 2018). This compares favorably to traditional Cognitive Behavioral Therapy (CBT), which shows moderate success in treating depression with smaller effect sizes (Hedges’ g = 0.31) (Carpenter et al., 2018). Among university students specifically, conventional interventions like CBT and mindfulness had moderate effect sizes for depression (Hedges’ g = -0.60; Huang et al., 2018), suggesting that VR-enhanced approaches may offer meaningful improvements in treatment efficacy.

While the primary focus has been alleviating negative symptoms, emerging research suggests potential benefits for enhancing positive mental health (Pira et al., 2023; Baghaei et al., 2021). VR interventions for depression have progressed significantly from simple exposure therapy to include Immersive Cognitive Behavioral Therapy (iCBT). This approach combines traditional CBT principles with virtual environments and shows 35% greater engagement than conventional CBT. Furthermore, it demonstrates sustained improvements at a 6-month follow-up.

The landscape of virtual reality (VR) interventions for depression has transformed significantly, moving beyond just essential exposure therapy. Today, these innovative approaches are diverse and dynamic, incorporating various techniques designed to provide more resounding emotional support and healing. Implementation studies reveal that integrating emotional design principles, particularly at the reflective level, enhances treatment outcomes by fostering personal meaning-making and providing tangible evidence of progress through visualization systems.

Across multiple studies, VR interventions have demonstrated cost-effectiveness and scalability potential, mainly when they do not require continuous guidance from a counselor or therapist (Pira et al., 2023). However, researchers emphasize the need to further develop existing VR software and treatments to better align with modern positive mental health approaches, emphasizing symptom reduction and well-being promotion.

2.4.3. Post-Traumatic Stress Disorder (PTSD)

The application of VR technology in the treatment of PTSD represents a significant advancement in trauma therapy. By creating carefully designed virtual environments, clinicians can effectively facilitate exposure therapy, allowing for precise control over the therapeutic experience. This approach promotes systematic emotional processing and aids in trauma resolution within a safe setting. Recent studies indicate substantial enhancements in patient outcomes, particularly regarding emotional processing and overall mental well-being (Pira et al., 2023; Park et al., 2019).

Virtual Reality Exposure Therapy for PTSD treatment has demonstrated efficacy comparable to traditional psychotherapy (Tsamitros et al., 2023), offering significant advantages in terms of controllability and patient safety. In contrast, the effectiveness of Cognitive Behavioral Therapy (CBT) for PTSD is moderate, with effect sizes lower than those observed for other anxiety disorders (Carpenter et al., 2018). Group psychotherapy, especially exposure-based group CBT, has shown considerable effects in alleviating PTSD symptoms when compared to no-treatment controls, with a Hedges’ g of 0.70 (Schwartze et al., 2019). In specific populations, such as Arab communities, traditional CBT has yielded notably large effect sizes for PTSD, reaching an effect size of 2.08 (Kayrouz et al., 2018).

The strength of this therapy in treating PTSD lies in its ability to precisely regulate the intensity and nature of exposure, which is particularly beneficial for trauma-related conditions where in vivo exposure may be impractical or potentially retraumatizing. Research conducted by Park et al. (2019) illustrates that incorporating real-time physiological monitoring during its sessions allows therapists to adjust exposure intensity based on objective measures of distress, thereby optimizing the therapeutic window for emotional processing while minimizing the risk of overwhelming the patient.

Implementation studies demonstrate that emotional design elements play a crucial role in enhancing the effectiveness of Virtual Reality Exposure Therapy for PTSD. Incorporating reflective design components, such as progress visualization and the integration of personal narratives, facilitates the meaning-making processes essential for trauma recovery. Additionally, behavioral design features, including adaptive difficulty systems and achievement tracking, help sustain engagement in treatment despite the inherent challenges of processing trauma.

This approach presents a promising alternative for a demographic that frequently encounters obstacles in accessing traditional treatment options.

Figure 1. Treatment Efficacy Comparison Between Traditional and Virtual Reality Exposure Therapy Across Mental Health Conditions1.

Figure 1. Treatment Efficacy Comparison Between Traditional and Virtual Reality Exposure Therapy Across Mental Health Conditions1.

3. Methodology

3.3. Meta-Analysis Approach

This research adopted a secondary analysis approach. The study aimed to ensure reliable and comparable effect-size estimates while upholding methodological transparency by utilizing existing high-quality meta-analyses. This decision reflects the study’s emphasis on design, valuing the integration of design-related insights more than merely reproducing current clinical efficacy evaluations. This research delves into the effectiveness of Virtual Reality Exposure Therapy through a meticulously conducted and peer-reviewed meta-analysis.

Effect sizes and confidence intervals for both anxiety (g = 0.79, 95% CI [0.57, 1.02]) and depression (g = 0.73, 95% CI [0.25, 1.21]) were obtained directly from Fodor et al. (2018). These figures serve as baseline effectiveness benchmarks for virtual reality exposure therapy applications. To enhance the reliability of these findings, they were further cross-validated with additional meta-analyses and systematic reviews, including those conducted by Tsamitros et al. (2023) and Pira et al. (2023), ensuring that the design guidelines are based on evidence that is both broadly representative and methodologically rigorous.

The quantitative outcomes extracted from the research were directly associated with the design elements documented during the case study analysis. This connection enabled the identification of specific emotional design strategies, such as adaptive feedback systems, progress visualization tools, and culturally adaptive content, that correlated with increased engagement rates and enhanced therapeutic outcomes. This mapping process between design and outcomes served as the analytical foundation for the framework presented in Table 1, which systematically links emotional design elements to measurable engagement and clinical effectiveness.

Table 1. Design Elements Analysis in Virtual Reality Exposure Therapy Applications 2.

Table 1. Design Elements Analysis in Virtual Reality Exposure Therapy Applications 2.

When multiple sources reported engagement rates or effectiveness data for a particular design element, the research employed weighted averages to produce more robust and synthesized estimates; this weighting process prioritized higher-quality studies characterized by larger sample sizes, precise documentation of design processes, and validated outcomes measures while preventing lesser-quality evidence from disproportionately affecting the final synthesis. This approach embodies best practices in secondary analysis to maximize methodological transparency while concentrating research efforts on the primary objective, in this case, the development of practical emotional design guidelines for Virtual Reality Exposure Therapy..

3.5. Framework Development Process

The emotional design implementation framework for virtual reality exposure therapy was created through a structured and iterative process, transitioning from analysis to synthesis across various stages of refinement.

3.5.1. From Analysis to Framework Development

The framework development commenced by categorizing emotional design elements identified in the literature, employing Norman’s three levels of design (visceral, behavioral, and reflective) as the organizing structure. Each aspect was meticulously documented and coded according to its primary characteristics, corresponding to sensory appeal (visceral), usability and interaction (behavioral), or personal significance and reflection (reflective).

Each design element was correlated with its associated therapeutic outcomes, including engagement metrics, symptom alleviation, and user satisfaction levels, establishing initial design-outcome relationships. To assess practical viability, these elements were also aligned with technical specifications such as rendering capabilities, integration of biometric feedback, and adaptive interface requirements. Ultimately, widely applicable design principles were combined across various therapeutic contexts (such as anxiety, depression, phobia, and PTSD), making sure that the framework addressed both universal best practices and specific contextual requirements. This effort resulted in a preliminary, evidence-informed framework that combines theoretical insights, empirical research, and technical factors related to emotional design in Virtual Reality Exposure Therapy..

Figure 2. Data Analysis Framework Based on Frayling’s Research for Design.

Figure 2. Data Analysis Framework Based on Frayling’s Research for Design.

4. Emotional Design Implementation Framework for Virtual Reality Exposure Therapy

4.2. Clinical Integration Factors

The practical clinical integration of Virtual Reality Exposure Therapy requires aligning therapeutic frameworks with established psychological treatment protocols while simultaneously adapting these protocols to the unique immersive characteristics of virtual environments. Maintaining the integrity of fundamental therapeutic principles in virtual environments is crucial for preserving the clinical validity of treatment outcomes. Furthermore, real-time progress tracking within the virtual reality exposure therapy platform facilitates dynamic evaluation of patient responses, enabling ongoing adjustments to therapeutic content in alignment with the patient’s evolving needs. (Cieślik et al., 2020).

Research highlights the significance of structured, multi-phase training programs for clinicians and technical staff in implementing and managing Virtual Reality Exposure Therapy systems. Cieślik et al. (2020) outline a comprehensive training framework that includes 40 hours dedicated to the technical operation and safety of the systems, followed by an additional 60 hours focused on clinical applications. This second phase emphasizes therapeutic interaction, patient monitoring, and the management of psychological responses within virtual environments. Monthly follow-up support sessions, each lasting approximately ten hours, ensure clinicians and system operators continually refine their skills and integrate real-world insights into their practices. This iterative process is instrumental in fostering technical proficiency and adherence to therapeutic objectives, ultimately leading to improved clinical outcomes.

Structured training and regular feedback are essential for ensuring that Virtual Reality Exposure Therapy is reliable and effective for mental health issues. Emotional design principles can enhance patient engagement and foster safety and trust in the virtual therapeutic environment.

4.2.1. VR Platforms in Clinical Use

When selecting a virtual reality platform for clinical use in Virtual Reality Exposure Therapy, it is essential to balance technical capabilities with practical usability in therapeutic environments. The Oculus Quest 2 and 3 stand out for their mobility and ease of deployment, making them perfect for clinics that need flexible setups or mobile therapy solutions. In contrast, the HTC VIVE Pro provides exceptional visual fidelity, advanced tracking capabilities, and integrated eye-tracking technology, facilitating more data-intensive therapeutic processes, such as real-time biometric monitoring and accurate behavioral analysis. The selection among these platforms is contingent upon the specific requirements of the therapeutic program, which may include considerations such as portability, sensory immersion, or data collection capabilities. Refer to the table below for a direct comparison of the features of these platforms.

Table 2. Comparison of Clinical VR Platforms for Virtual Reality Exposure Therapy 3.

Table 2. Comparison of Clinical VR Platforms for Virtual Reality Exposure Therapy 3.

The technical requirements governing the deployment of Virtual Reality Exposure Therapy systems are not solely operational considerations; they form the foundational infrastructure that enables the systematic integration of emotional design across all stages of the therapeutic experience. At a fundamental level, achieving a rendering speed of 90 frames per second (FPS) and ensuring latency remains below 20 milliseconds are crucial for providing smooth, high-fidelity sensory experiences. These technical measures significantly impact the user’s initial aesthetic and sensory interaction with the virtual environment, eliciting immediate emotional responses vital to effective visceral design. At the behavioral level, system reliability, aiming for an uptime of 99.9%, is fundamental to ensuring the continuity and predictability of user interactions. This uninterrupted operational stability is vital for facilitating real-time adaptive feedback mechanisms, which dynamically adjust therapeutic stimuli based on user responses. Such adaptability enhances usability and fosters a sense of control and agency for the user, which are essential behavioral and emotional design elements. Ultimately, at the reflective level, a strong data management framework, encompassing real-time analytics, secure encryption, and automated backup protocols, enables thorough progress tracking and personalized therapeutic summaries. These data-driven reflective components aid in crafting meaningful user narratives, thereby enhancing long-term emotional investment in the therapeutic process and encouraging deeper cognitive reflection on personal progress and emotional design. The phased implementation process, which progresses from foundational safety measures to enhancement and optimization stages, reflects the gradual integration of emotional design. This alignment ensures that both technical robustness and user-centered emotional engagement develop concurrently. It underscores the fundamental principle that emotional design within Virtual Reality Exposure Therapy is not merely an ancillary consideration but a core structural principle vital for improving user experience and therapeutic effectiveness.

5. Discussion

6. Conclusions

References

1. Aftab, M., and Helen A. Rusli. 2017. “Designing Visceral, Behavioural and Reflective Products.” Chinese Journal of Mechanical Engineering 30 (2017): 1058 - 1068. [CrossRef]
2. Alipour, M., M. Moghaddam, K. Vaidhyanathan, and M. Kjærgaard. 2023. “Emoticontrol: Emotions-based Control of User-Interfaces Adaptations.” Proceedings of the ACM on Human-Computer Interaction 7:1-29. [CrossRef]
3. Baghaei, Nilufar, Vibhav Chitale, Andrej Hlasnik, Lehan Stemme, Hai-Ning Liang, and Richard Potter. 2021. “Virtual Reality for Supporting the Treatment of Depression and Anxiety: Scoping Review.” JMIR Mental Health 8, no. 9 (April). [CrossRef]
4. Botella, C., J. Fernández-Álvarez, V. Guillén, A. García-Palacios, and R: Baños. 2017. “Recent progress in virtual reality exposure therapy for phobias: a systematic review.” Current Psychiatry Reports 19 (7). [CrossRef]
5. Carpenter, Joseph K., Leigh A. Andrews, Sara M. Witcraft, Mark B. Powers, Jasper A. Smits, and Stefan G. Hofmann. 2018. “Cognitive behavioral therapy for anxiety and related disorders: A meta-analysis of randomized placebo-controlled trials.” Depression and Anxiety 35, no. 6 (June): 502 - 514. [CrossRef]
6. Carvalho, Margarida, and Lídia Oliveira. 2017. “Emotional Design in Web Interfaces.” Observatorio (OBS) 11 (2): 14-34. [CrossRef]
7. Cieślik, B., J. Mazurek, S. Rutkowski, P. Kiper, A. Turolla, and A. zczepańska-Gieracha. 2020. “irtual reality in psychiatric disorders: A systematic review of reviews.” Complementary therapies in medicine 52:102480. [CrossRef]
8. Cipresso, P., I. Giglioli, M. Raya, and G. Riva. n.d. “The past, present, and future of virtual and augmented reality research: a network and cluster analysis of the literature.” Frontiers in Psychology 9. [CrossRef]
9. Fodor, L., Carmen D. Cotet, Pim Cuijpers, Ștefan Szamoskozi, Daniel David, and Ioana A. Cristea. 2018. “The effectiveness of virtual reality based interventions for symptoms of anxiety and depression: A meta-analysis.” Scientific Reports 8, no. 10323 (July). [CrossRef]
10. Freeman, D. 2020. “Virtual reality (VR) for the treatment of mental health disorders.” Journal of Neurology, Neurosurgery & Psychiatry 2020 91, no. e3 (July).
11. Freeman, D:, S. Reeve, A. Robinson, A. Ehlers, D. Clark, B. Spanlang, and M. Slanter. 2017. “Virtual reality in the assessment, understanding, and treatment of mental health disorders.” Psychological Medicine 47, no. 14 (March). [CrossRef]
12. Geraets, C., E. Van Der Stouwe, R. Pot-Kolde, and W. Veling. 2021. “Geraets, C., Van Der Stouwe, E., Pot-Kolder, R., & Veling, W. (2021). Advances in immersive virtual reality interventions for mental disorders: A new reality?” Current Opinion in Psychology 41:40-45. [CrossRef]
13. Gregg, L., and N. Tarrier. 2007. “Virtual reality in mental health.” Social Psychiatry and Psychiatric Epidemiology 42:343-354. [CrossRef]
14. Gureje, O., J. Appiah-Poku, T. Bello, L. Kola, and S. Seedat. 2020. “Effect of collaborative care between traditional and faith healers and primary health-care workers on psychosis outcomes in Nigeria and Ghana (COSIMPO): a cluster randomised controlled trial.” The Lance 396:612-622. . [CrossRef]
15. Hakatie, Annaleena, and Toni Ryynänen. 2006. “roduct attributes and the model of emotional design: how the product development engineers perceive product features?” In Conference on Design and Emotion, (September). https://researchportal.helsinki.fi/en/publications/product-attributes-and-the-model-of-emotional-design-how-the-prod.
16. Huang, Junping, Yeshambel T. Nigatu, Rachel Smail-Crevier, Xin Zhang, and Jianli Wang. 2018. “Interventions for common mental health problems among university and college students: A systematic review and meta-analysis of randomized controlled trials.” Journal of Psychiatric Research 107 (December): 1-10.
17. Jerdan, S., M. Grindle, H. Van Woerden, and M. Boulos. 2018. “Head-Mounted Virtual Reality and Mental Health: Critical Review of Current Research.” JMIR Serious Games 6. [CrossRef]
18. Kayrouz, Rony, Blake F. Dear, Bechara Kayrouz, Eyal Karin, Milena Gandy, and Nickolai Titov. 2018. “Meta-analysis of the efficacy and acceptability of cognitive-behavioural therapy for Arab adult populations experiencing anxiety, depression or post-traumatic stress disorder.” Cognitive Behaviour Therapy 47, no. 5 (February): 412-430. [CrossRef]
19. Khan, Z., O. Qureshi, A. Pasha, O. Majid, S. Saleem, P. Fearon, and M. Shaikh. 2023. “Exploring biomedical and traditional care pathways for people with psychosis in Karachi, Pakistan.” Frontiers in Psychiatry 14. [CrossRef]
20. Kritikos, J., G. Tzannetos, A. Mehmeti, M. Douloudi, G. Nikolaou, and D. Koutsouris. 2020. “Comparison between full body motion recognition camera interaction and hand controllers interaction used in virtual reality exposure therapy for acrophobia.” Sensors 20 (4): 1244. [CrossRef]
21. Lee, T.P. n.d. “Shaping product form based on consumers’ cognition.” In _INTERNATIONAL CONFERENCE ON ENGINEERING DESIGN, ICED’07 28–31 (34th ed).
22. Li, H., Zhengping Li, and Lijun Wang. 2024. “P-4.9: a comprehensive study of VR exposure therapy combined with EEG signals in the treatment of psychiatric disorders.” SID Symposium Digest of Technical Papers 55 (S1): 784-787. [CrossRef]
23. Li, Y. 2024. “Web Design for Emotion Tracking in Individuals with Major Depressive Disorder.” Highlights in Science Engineering and Technology 85:609–615. [CrossRef]
24. Mahmud, A., H. Zakaria, M. Yusoff, N. Jaafar, A. Baharudin, and A. Tamil. 2022. “Brief virtual reality exposure therapy and its effects on negative and positive emotions among healthy working adults: a feasibility study.” ALPHA PSYCHIATRY 23 (5): 223-229. [CrossRef]
25. Malekar, Sakshi. 2024. “The Role of HCI in Developing AR/VR Experiences.” International Journal For Multidisciplinary Research. 6 (5). [CrossRef]
26. Maples-KellerJ, J., B. Bunnell, S. Kim, and B. Rothbaum. 2017. “The Use of Virtual Reality Technology in the Treatment of Anxiety and Other Psychiatric Disorders.” Harvard Review of Psychiatry 25:103-113. [CrossRef]
27. “Meta Quest 3: Mixed Reality VR Headset - Shop Now.” n.d. Meta Store. Accessed March 2, 2025. https://www.meta.com/quest/quest-3/.
28. Misri, Izzuddinazwan, and Amer S. Zainol. 2021. “Design DNA: Theory Reviewing Behind the Behavioral Aspect in the Levels of Design.” International Journal of Art and Design 5, no. 3 (June). [CrossRef]
29. Park, M., D. Kim, U. Lee, E. Na, and H. Jeon. 2019. “A Literature Overview of Virtual Reality (VR) in Treatment of Psychiatric Disorders: Recent Advances and Limitations.” Frontiers in Psychiatry 10. [CrossRef]
30. Pira, B. Aquilini, A. Davoli, S. Grandi, and C. Ruini. 2023. “The Use of Virtual Reality Interventions to Promote Positive Mental Health: Systematic Literature Review.” JMIR Mental Health 10. [CrossRef]
31. Riva, G., and S. Serino. 2020. “Virtual Reality in the Assessment, Understanding and Treatment of Mental Health Disorders.” ournal of Clinical Medicine 9. [CrossRef]
32. Schroeder, A., B. Bogie, T. Rahman, A. Thérond, H. Matheson, and S. Guimond. 2021. “Feasibility and Efficacy of Virtual Reality Interventions to Improve Psychosocial Functioning in Psychosis: Systematic Review.” JMIR Mental Health 9. [CrossRef]
33. Schroeder, Will. 2004. Books. 5th ed. Vol. 11. N.p.: Interactions. [CrossRef]
34. Schwartze, D., S. Barkowski, B. Strauss, C. Knaevelsrud, and J. Rosendahl. 2019. “Efficacy of group psychotherapy for posttraumatic stress disorder: Systematic review and meta-analysis of randomized controlled trials.” Psychotherapy Research 29 (4): 415 - 431. [CrossRef]
35. Sutcliffe, A., C. Poullis, A. Gregoriades, I. Katsouri, A. Tzanavari, and K. Herakleous. 2019. “Reflecting on the Design Process for Virtual Reality Applications.” International Journal of Human–Computer Interaction 35 (2). [CrossRef]
36. Tsamitros, N., O. Tatar, A. Abdel-Baki, H. Bakouni, A. Bahremand, T. Lecomte, and D. Jutras-Aswad. 2023. “Current Evidence on Virtual Reality-Based Interventions for the Treatment of Mental Disorders.” European Psychiatry 66:S528-S528. [CrossRef]
37. Veling, W. 2022. “Fears, Fun and Voices – an update on VR Treatments for Psychosis.” European Psychiatry 65:S22-S22. [CrossRef]
38. “VIVE Pro 2 Headset - High-Resolution Virtual Reality for PC.” n.d. HTC Vive. Accessed March 2, 2025. https://www.vive.com/us/product/vive-pro/.
39. Wang, Y. 2024. “Enhancing User Experience Using a Framework Integrating Emotion Recognition and Eye-Tracking.” Highlights in Science, Engineering and Technology 85. [CrossRef]