Staying grounded in evidence-based practice in a tech-driven world
Summary
Understanding the ethics of virtual reality therapy starts with informed consent, client safety screening, and HIPAA-compliant data privacy practices.
VR treatment guidelines are still emerging, so clinicians must exercise independent judgment and maintain competence in the technology they use.
Know when VR is appropriate by weighing each client's diagnosis, contraindications, and treatment goals before introducing the modality.
Manage side effects like cybersickness and dissociation by keeping sessions short, using graded exposure, and debriefing clients after every session.
Measure effectiveness using validated tools like the PHQ-9, GAD-7, or PCL-5 alongside regular treatment reviews and client self-reports.
Virtual reality offers an innovative way to treat mental health conditions. While new interventions are exciting to the field, especially when they offer positive outcomes for treatment-resistant conditions, we still have a responsibility to critically examine the ethics of virtual reality therapy, as with any new treatment.
As more research emerges in this field, we have an opportunity to shape VR treatment guidelines to ensure appropriateness, client safety, privacy, and informed consent as we develop our practice alongside technology.
What is virtual reality?
Virtual reality involves wearing a head-mounted display that shows realistic, three-dimensional images and environments you can interact with, creating the illusion of being fully immersed in a lifelike world. VR works through a combination of cognitive-behavioral principles, exposure-based therapy, mindful meditation, stress reduction, extinction learning, and the spotlight theory of attention.
For example, extinction learning involves repeated exposure to feared stimuli without negative consequence, gradually reducing the fear response—a process VR can simulate safely and repeatedly.
In mental health treatment, VR can be used in a safe, controlled environment where clinicians can monitor each client’s response, including heart rate and temperature.
VR was first used in the 1990s, with one of the first publications about its use in 1995, when VR was used to treat acrophobia. Since then, virtual reality has been used to treat a wide range of physical and mental health conditions, including:
Chronic pain
Substance use disorders
Anxiety disorders
Eating disorders
Trauma and stress-related disorders
Mood disorders
Schizophrenia
Vestibular disorders
Stroke rehabilitation
Movement disorders
VR has other applications in mental health, including stress management and clinical assessment, and it is used in the University of Kentucky’s College of Social Work program for child welfare investigation simulations.
VR has also been used to support neurodivergent people in obtaining jobs by simulating interview scenarios that allow them to practice responding to specific interview questions.
VR treatment guidelines
Currently, there are no formal VR treatment guidelines by any counseling or professional body.
The National Association of Social Workers asks social workers to exercise judgment when using technology in its standards of clinical practice. There is also a Society for Virtual Reality Therapy, which promotes the responsible use of VR for psychotherapy by providing resources for therapists and clients.
The primary treatment considerations with VR include:
Clinician competence: Therapists using VR as a modality will need sufficient training and experience to safely deliver VR, obtain informed consent, and manage side effects or adverse experiences. Clinicians should also be aware that the immersive nature of VR may alter the therapeutic relationship, potentially reducing the sense of interpersonal connection that is central to effective treatment.
Client suitability: As with other modalities, such as EMDR, VR must fit within the scope of the treatment plan and address each client's specific needs and risks.
Informed consent: Clinicians must be able to describe how VR works, what to expect, potential side effects, and other relevant information to help patients make an informed decision about consenting to VR as part of their treatment.
Accessibility: VR requires specific equipment, subscriptions or software, and training, and can be expensive to set up. As with any modality, clinicians can weigh the costs and benefits. Therapists may also encounter glitches, underscoring the importance of the clinician's technological competence. These barriers are worth noting because they risk limiting VR therapy's availability to clients with greater financial resources, potentially widening existing disparities in access to mental health care.
Preparing the client: As with EMDR, clients must be ready for a VR exposure session. They might first use visualizations, try on the headset, and make adjustments before the first session.
Monitor for side effects and overall progress: Monitor clients' real-time responses to VR, check for side effects, and adjust treatment as needed. There should also be regular reviews using appropriate measures to assess the effectiveness of VR in reducing symptoms and achieving treatment goals.
Electronic safeguards: Ensure the VR platform is HIPAA-compliant, has a business associate agreement, documents its data handling and protection, and stores data on US-based HIPAA-compliant servers.
How to ensure client safety using VR
Knowing how to ensure client safety is central to any VR practice. Until formal VR treatment guidelines are established, clinicians should consider suitability carefully after a thorough assessment and treatment plan. VR can have side effects, called cybersickness and aftereffects, which may occur in 60% to 95% of VR sessions.
These side effects include dizziness, eye strain, vision changes, nausea, fatigue, dissociation, retraumatization, re-experiencing, and motion sickness. People with neurological disorders, such as epilepsy, can experience seizures.
What about informed consent?
As with any treatment, the use of VR must involve informed consent, with the risks, benefits, and what is involved explained by the clinician before consent is obtained.
Informed consent is a cornerstone of the ethics of virtual reality therapy. Clients should understand how VR works, what to expect, potential side effects, and how their data will be handled before agreeing to treatment.
When is VR appropriate?
Virtual reality is appropriate for a range of psychological and medical conditions. It is often used for anxiety disorders, such as exposure treatment for specific phobias. There is also research to support its use in pain management, PTSD, and ADHD, and growing evidence to support its use for the treatment of eating disorders.
However, any treatment must be considered in view of the client's specific needs, circumstances, risk factors, and goals. For example, VR is not appropriate for clients with medical contraindications, such as people with active ear infections or vestibular conditions, a seizure disorder, traumatic brain injuries, or individuals who experience motion sickness.
While the evidence base for VR therapy is growing and outcomes for anxiety disorders have been particularly promising, results vary across conditions and study quality, and low adoption rates among clinicians suggest that practical and clinical questions remain unresolved.
How to handle side effects
Knowing how to handle side effects before they occur is part of responsible VR practice. There are several strategies to handle VR side effects, including:
Keep sessions short, around 10 to 15 minutes, and gradually increase the duration.
Find the right display latency and display refresh rate that allows users to adjust from 80Hz to 144Hz.
Ensure clients have the right headset. If they wear glasses, they can insert a spacer so they can wear them during the session.
Avoid VR after a large meal.
Take regular breaks.
Practice grounding activities.
Ensure proper headset lighting.
Keep the room cool.
Remove the headset and reorient to the room before moving.
Screen for dissociative symptoms before and after VR treatment.
Debrief with the client after each session before they leave.
Use graded exposure.
Monitor the client's breathing and heart rate.
Maintain voice contact with the client and have a safety protocol.
Ensure the client has a safe word and knows they can stop a session at any time.
What about data privacy?
Privacy and confidentiality are the most significant things to consider in the ethics of virtual reality. Maintaining HIPAA compliance as this technology advances rapidly is challenging.
As clinicians, however, our challenge is to balance adapting to new technologies with our ethical responsibilities by monitoring privacy risks, regulatory requirements, best practices, and ethical guidelines from our regulatory body and the state of practice.
Some of the VR treatment guidelines regarding privacy include data collection, third-party analytics, recording without consent, servers outside the U.S., and cloud storage.
The bottom line is to ensure your VR software and equipment (including third-party VR providers) are HIPAA-compliant with a business associate agreement in place.
How to measure effectiveness
As the ethics of virtual reality therapy continue to take shape, measuring effectiveness is a key part of responsible practice. It’s crucial, when measuring the effectiveness of any intervention, to first clearly define the problem, use objective measures, and specify the client’s treatment goal.
Some ways to measure success include using validated measures, such as PHQ-9, GAD-7, or PCL-5; client self-reports; behavioral observations; and tracking progress through regular treatment reviews. As VR treatment guidelines develop, standardized outcome measures will likely become a core requirement.
Sources
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JMIR Mental Health. Birckhead, B., Khalil, C., Liu, X., Conovitz, S., Rizzo, A., et al. (2019). Recommendations for Methodology of Virtual Reality Clinical Trials in Health Care by an International Working Group: Iterative Study.
National Association of Social Workers. (2025). NASW Standards for Clinical Social Work in Social Work Practice.
Professional Development: The International Journal of Continuing Social Work Education. Trahan, M., Smith, S., & Benton, A. D. (2017). A new era of ethics: The use of virtual reality interventions in social work ethics.
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