# Automating EMDR Mental Health Treatment in Virtual Reality (Automating EMDR Mental Health Treatment in Virtual Reality)

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> Automating EMDR Mental Health Treatment in Virtual Reality (Automating EMDR Mental Health Treatment in Virtual Reality) Authors: Mu Mu 1, Olive Chan 1, And

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# Automating EMDR Mental Health Treatment in Virtual Reality (Automating EMDR Mental Health Treatment in Virtual Reality)

October 15, 2025Recent Articles

**Automating EMDR Mental Health Treatment in Virtual Reality*****(Automating EMDR Mental Health Treatment in Virtual Reality)***

**Authors:**Mu Mu1, Olive Chan1, Andrew Debus1, Murtada Dohan1, David Nicholls1, Paul Wallang2, Kieran Breen3

*1**University of Northampton,**2**Cardinal Clinic,**3**St Andrew’s Healthcare*

**Translated by:**Specialist Psychologist Elena Gizem Pozam

‘This is a preprint; it has not undergone peer review by a journal.’

[https://doi.org/10.21203/rs.3.rs-5829989/v1](https://doi.org/10.21203/rs.3.rs-5829989/v1)

**Abstract**

Although EMDR is an established psychotherapy for treating phobias and trauma, access is severely restricted by a shortage of trained therapists and long waiting times. To address these challenges, this paper presents the development of a Virtual Reality (VR)-based EMDR application that automates therapy delivery for phobia treatment while maintaining clinical rigor and patient engagement. The system incorporates therapist-informed designs, natural virtual environments, and game-inspired interaction mechanics to enhance usability and immersion.

The application follows a comprehensive EMDR protocol, integrating features such as bilateral stimulation through an interactive metronome, intuitive free-hand interactions, and calming environments tailored to therapeutic needs.1 Patient safety and autonomy are prioritized through safeguards such as pacing controls and customizable therapy experiences. A cloud-based data management system supports remote therapist monitoring and treatment evaluation.

A five-day pilot study evaluated the system's feasibility and usability. Quantitative results showed reductions in Subjective Units of Disturbance (SUD) scores and increases in Validity of Cognition (VOC) scores; four out of five participants reached subclinical phobia levels on the IAPT Phobia Scale. Qualitative feedback highlighted the system's accessibility, calming design, and potential to enhance patients' confidence in managing phobias. These findings underscore the potential of VR-based solutions for accessible and scalable psychotherapy delivery. Future work will explore applications for complex mental health conditions and validate the system's efficacy through large-scale clinical trials.

1. **Introduction**

One in eight people worldwide lives with a mental disorder, a leading cause of disability and suicide. Although mental health needs are high globally, responses to these needs remain inadequate and incomplete (World Health Organization 2022). In the United Kingdom, National Health Service (NHS) mental health services face increasing pressure due to negative patient experiences. These experiences include a waiting list exceeding 1.2 million people for community mental health services (Committee of Public Accounts 2023).2

Cognitive Behavioral Therapies (CBT), such as Exposure Therapy (ET), are among the most empirically supported components of interventions for phobias and Post-Traumatic Stress Disorder (PTSD). Virtual Reality (VR) techniques have been successfully used in Exposure Therapy (ET) for phobias and trauma because of their ability to simulate encounters safely and gradually. However, Exposure Therapy is unsuitable for many patients due to factors such as the potential iatrogenic effects of in vivo exposure, inability to tolerate exposure, and ethical challenges. Eye Movement Desensitization and Reprocessing (EMDR) is a widely used psychotherapy that improves patients' mental health by helping them reprocess memories of traumatic experiences (Shapiro 2017).3 It has broad applications in treating PTSD, depression, and anxiety disorders (Khan et al. 2018). Unlike exposure therapy, EMDR's memory processing protocol does not involve direct exposure. Instead, it guides patients to transform distressing past experiences into an adaptive, healthy, and non-distressing form so that negative images, beliefs, and emotions become less vivid and less valid. EMDR is also offered to children who do not respond to trauma-focused CBT.

Unfortunately, the shortage of trained EMDR therapists and other resource constraints are making this treatment increasingly inaccessible, particularly for patients in the United Kingdom. For example, some healthcare providers have reported waiting times of more than 14 months for EMDR trauma therapy (BNSSG NHS 2024). In addition to excessively long waiting lists, patients' need to travel to distant specialist centers frequently prevents access to EMDR therapy. Further research is needed to assess the feasibility and safety of delivering automated EMDR therapy using a VR platform, as well as how game design and immersive technologies can improve patients' memory reprocessing experiences.

This paper presents a VR-based solution to provide faster and more affordable access to life-changing EMDR therapy. Patients wear a VR headset to enter a natural, peaceful virtual environment where they feel safe and in control. An audio guidance system helps them move through different areas of the virtual environment for specific therapeutic steps. Integrating the comprehensive EMDR protocol into an immersive virtual environment enables patients to disengage from distractions and fully participate in effective treatment anywhere, anytime. A VR EMDR treatment study was conducted in a week-long trial with participants using this solution for phobia treatment. The results showed that participants found it easy to interact with the virtual environment and follow the treatment with little or no external assistance. A reduction in the impact of negative emotions and an improvement in positive thoughts were observed on each day of the treatment week and between daily sessions. All participants reported improvements (reductions) in their IAPT Phobia Scale scores, with 4 participants' scores falling to subclinical levels. Qualitative results from post-study interviews provided strong evidence of increased confidence in coping with fear and reduced distress.

**2.1 Anxiety Disorders and Phobia**

Anxiety disorders are the most common mental disorders, affecting more than 300 million people worldwide in their daily lives (Global Health Data 2021). Typical anxiety disorders include specific phobias, panic disorder, social anxiety disorder, and generalized anxiety disorder. People with anxiety disorders may experience excessive fear or worry about a particular situation, such as encountering a certain type of insect or a social situation; in generalized anxiety disorder, this worry extends to a wide range of everyday situations. Other symptoms include difficulty concentrating or making decisions, irritability, feelings of tension or restlessness, nausea or abdominal discomfort, and sleep problems. The impact of anxiety disorders on quality of life (QoL) has also been extensively studied. Anxiety disorders are estimated to have the highest lifetime prevalence rates of all psychiatric disorders (Kessler et al. 2012) and to cause substantial functional impairment and economic burden (Konnopka and König 2020).

Phobia is a common type of anxiety disorder. People with phobias experience an overwhelming and persistent fear of an object, place, situation, feeling, or animal when they encounter the source of their phobia directly or think about it without direct contact. Specific phobia is defined as an unwanted fear elicited by a particular entity or situation, such as fear of animals, flying, or heights. The consequences of specific phobias are long-lasting, leading to severe physical and psychological reactions that cause numerous difficulties in patients' daily social lives (Albakri et al. 2022). Typical examples of specific phobias include animal phobias, such as fear of spiders, snakes, and dogs; environmental phobias, such as fear of heights, deep water, and germs; situational phobias, such as fear of dental treatment or flying; and bodily phobias, such as fear of blood or needles (NHS 2025).

**2.2 CBT and EMDR Treatment**

Treatment for anxiety disorders, including phobias, generally involves psychotherapy, medication such as antidepressants, or a combination of both. In psychotherapy, patients work with a therapist to reduce anxiety symptoms. Cognitive Behavioral Therapy (CBT) is the most common form of psychotherapy for anxiety disorders. It focuses on teaching patients specific skills to reduce symptoms and gradually return to activities avoided because of anxiety. Some CBT approaches, such as Exposure Therapy (ET), gradually expose patients to anxiety-provoking objects or situations to help them build confidence in coping with these situations in real life.

EMDR is an effective psychotherapy treatment with broad applications in treating post-traumatic stress disorder (PTSD), depression, and anxiety disorders (Shapiro 2017). EMDR was first introduced in 1989 with the publication of a randomized controlled trial evaluating the effects of a single treatment session in individuals who had experienced trauma (Shapiro 1989). In subsequent years, EMDR was widely adopted and developed as a psychotherapy approach using an eight-phase treatment model comprising Client History, Preparation, Assessment, Desensitization, Installation, Body Scan, Closure, and Reevaluation. The main phases of treatment are Assessment, Desensitization, and Installation. During the Assessment phase, patients are asked to focus on predominant feelings such as humiliation, fear, anxiety, or insecurity. Patients are then asked to identify: (a) an image representing the target experience, such as an encounter and the associated fear of spiders; (b) a negative belief that verbalizes how they feel about themselves, referred to as a negative cognition (NC) (e.g., "I am vulnerable."); (c) how disturbing it feels on the Subjective Units of Disturbance (SUD) scale (0 = no disturbance to 10 = the highest possible disturbance); (d) a desired positive belief, referred to as a positive cognition (PC) (e.g., "I can handle this."); (e) how true this positive belief feels on the Validity of Cognition (VOC) scale (1 = completely false to 7 = completely true); and (f) the location in the body of the emotions and physical sensations experienced.

During the Desensitization phase, patients are asked to concentrate on the target memory (e.g., the NC, image, and feeling of fear) while simultaneously following bilateral stimulation consisting of rapid bilateral eye movements as they track a therapist's moving fingers. This process allows patients to access memories as they are currently stored, stimulates the information processing system, and enables the information to move toward an adaptive resolution. At the end of each stimulation set, patients are asked to reassess the disturbance caused by negative emotions (SUD). An effective desensitization phase gradually reduces the SUD rating to "no distress" (0 SUD). The Installation phase follows an eye movement and memory processing procedure similar to the Desensitization phase, but enables patients to strengthen positive cognitive associations; that is, the aim is for the VOC rating of a positive belief such as "I can handle this (encountering spiders)." to gradually increase to "completely true" (7 VOC). Further details on the eight-phase EMDR treatment can be found in (Shapiro 2017).

Typically delivered over 8 to 12 weekly sessions, EMDR helps the brain reprocess memories of traumatic events or frightening experiences, reducing the impact of the negative images, emotions, and physical sensations they cause. Research shows that, compared with ET, EMDR can lead to a greater reduction in patients' self-reported depression ratings and improvements in social functioning, achieved with fewer treatment sessions (Power et al. 2002).

Although highly effective treatments for anxiety disorders are available, only about 1 in 4 people in need (27.6%) receives any treatment, according to data from 23 community surveys in 21 countries in the World Mental Health (WMH) surveys (Alonso et al. 2018). Barriers to treatment include a lack of awareness that this is a treatable health condition, underinvestment in mental health services, a shortage of trained healthcare providers, and social stigma. In the United Kingdom, staff shortages and resource constraints in the National Health Service (NHS) mean that some high-intensity psychotherapy treatments are becoming increasingly inaccessible to patients. For example, one NHS Trust reports waiting times of more than 14 months for certain CBT and EMDR therapies (BNSSG NHS 2024). Digital technologies such as VR therefore need to be introduced to offer faster and more affordable access to life-changing mental health therapies.

**2.3 VR Mental Health**

VR is being integrated into medical solutions for assessing and treating various mental health conditions, including PTSD (Beidel et al. 2019), addiction (Mellentin et al. 2017), ADHD (Bioulac et al. 2020), and autism (Karami et al. 2021). Some VR-assisted solutions incorporate therapy automation to enable self-directed or lightly supported sessions. An automated VR ET intervention, gameChange, was developed to help patients diagnosed with psychosis overcome social avoidance problems through exposure (Freeman et al. 2022). Large-scale trials indicate that the VR-based approach is effective: patients felt that gameChange VR helped them build confidence and reduce their overall anxiety as they became more comfortable with the equipment. Both patients and staff generally found the intervention easy to use, and staff reported generally high levels of engagement among participants (Girardi et al. 2024). Health economic studies suggest that VR-based interventions can generate cost savings for mental health service providers (Altunkaya et al. 2022).

VR techniques have been used to enhance ET for the treatment of different phobias. In a study involving eight participants with clinical phobias, Hoffman and colleagues used VR to give patients the illusion of physically touching virtual spiders to improve treatment efficacy (Hoffman et al. 2003). In a study involving four participants, Banos and colleagues demonstrated how VR flight simulation could induce anxiety in people with a fear of flying and reduce fear through prolonged virtual exposure to different scenarios (Banos et al. 2002). In (Meindl et al. 2019), the authors developed a low-cost VR-based ET intervention for a patient with an extreme needle phobia. The results suggest that the intervention could remove barriers associated with traditional ET. The use of VR ET for dental phobia was investigated (Gujjar et al. 2019) in a study in which participants were gradually exposed to a dental surgery with dental instruments around the chair, a virtual dentist conducting an oral examination, a virtual dentist holding a dental syringe, and finally a virtual dentist bringing a drill toward the patient (with sound). The authors report a reduction in dental anxiety and behavioral avoidance (Gujjar et al. 2019).

Most current uses of VR in anxiety disorder treatment focus on enhancing ET through the relatively safe and programmable virtual environments provided by VR. However, because a specific environment must be developed for each source of anxiety, each VR-assisted ET intervention has a narrow audience and cannot be generalized. For example, a person with a fear of lizards must wait for a dedicated lizard phobia simulation to become available for treatment. Furthermore, ET is not suitable for all patients, particularly those with severe and complex mental health problems. Exposure to environments or objects associated with a traumatic memory can cause a loss of control and severe adverse reactions. Intolerance of anxiety during external exposure is considered a major factor in the relatively high dropout rates for ET (9–21% for generalized anxiety treatment and 45% for dental phobia treatment (Choy et al. 2007; Taylor et al. 2012)).

Research indicates that patients with PTSD discuss the possibility of self-administered EMDR on various online forums, with many users reporting that they have tried it at home (Waterman and Cooper 2020). One user of an online PTSD support forum stated that, although unsure whether self-administered EMDR was a good idea, they viewed it as 'better than the alternative of crippling reexperiencing' when they did not have access to an EMDR therapist. Although there have been recent attempts to automate EMDR for home use, these remain very limited. Goga and colleagues developed a prototype system that could guide users through eye movements and memory processing using a dialogue engine (text-to-speech), with bilateral stimulation delivered through a PC window on a computer monitor displaying a red ball moving horizontally from one side of the screen to the other. The visual guide was accompanied by sound that shifted from left to right and back again, and a pair of small vibration motors attached to the patient's wrists to provide tactile stimulation (Goga et al. 2022). The authors claimed that their study provided evidence for the efficacy of an automated EMDR intervention for people experiencing mild PTSD symptoms who could not access immediate psychological support. A literature review by Waterman and Cooper showed that, of 277 articles retrieved from seven medical databases using relevant keywords, only one concerned research into the efficacy, tolerability, feasibility, or safety of self-help EMDR therapy (Waterman and Cooper 2020). Psylaris offers a VR-based EMDR solution in which users can follow a ball moving horizontally within a virtual office space (IJdema et al. 2023).

Although VR-based solutions for ET have been well studied, their application in automating EMDR remains limited. Existing systems, such as those developed by Goga et al. (2022), rely on rudimentary designs, such as a bouncing ball for bilateral stimulation, that lack the immersive and interactive qualities needed for effective therapeutic engagement. Similarly, Psylaris's VR EMDR system shows potential but is constrained by static backgrounds and limited patient interaction. These shortcomings underscore the need for more versatile and engaging VR solutions that move beyond static designs and narrow therapeutic frameworks.

Our VR EMDR system addresses these gaps by integrating immersive virtual environments, free-hand interaction, and automated therapy workflows. By shifting the focus from static, narrowly targeted VR exposure therapy systems to a flexible memory reprocessing approach, this platform emphasizes patient autonomy, engagement, and accessibility. Its design prioritizes immersive and calming environments, user-friendly interactions, and safeguards for independent use. Designed to enhance engagement and ease of use, these features broaden access to EMDR therapy even without direct therapist supervision, while paving the way for rigorous clinical validation.

**3.1 Aim and Objectives**

VR EMDR aims to enable automated EMDR phobia treatment so that patients can receive effective treatment in the comfort of their own surroundings, whenever they wish, with the option of remote support from a therapist. This aim is supported by the following objectives:

- The application should automate the EMDR therapy process so that any patient who has been prescreened for suitability by a therapist can receive the treatment they need at a convenient time.
- The application should provide a natural and relaxing virtual environment where patients feel calm and in control, a prerequisite for effective EMDR treatment.
- A typical EMDR session can last more than an hour. The visual design should minimize the risk of VR sickness during long treatment sessions.
- Users' interactions with the virtual environment should be intuitive and require no additional learning.
- Session data from the VR headset should be captured so that a therapist can evaluate the treatment session remotely.

**3.2 Integration of the EMDR Clinical Protocol**

The VR EMDR solution incorporates a comprehensive clinical procedure based on the established EMDR protocol (Figure 1). The procedure considers three aspects of VR-based EMDR treatment. First, it preserves the integrity of the eight-step EMDR protocol. It does so by blending human therapist input with VR automation. Steps such as history taking and initial assessment are conducted by trained therapists to ensure that each patient's mental health condition is suitable for EMDR and VR-based treatment. This will form part of an initial in-clinic triage before VR EMDR treatment is prescribed to the patient.

Second, safeguards are built into the system, including patient-controlled sequencing and exit routes. Patients use VR interactive features to set the pace of treatment and take short breaks as needed. If they encounter difficulties during treatment, patients have options to request remote therapist assistance. Finally, the procedure guides the design of the VR environment. Different immersive scenes are specifically designed with their own audiovisual styles, spatial layouts, and user-interactive features to meet patients' psychological needs at different treatment stages. Automating a comprehensive therapy such as EMDR requires a large amount of audio guidance, which must be activated and deactivated during different parts of treatment. Audio segments fall into three main categories: general information about the treatment and virtual spaces, instructions for treatment steps (including eliciting patients' responses and encouraging them to perform a memory reprocessing task), and words of encouragement and reassurance in response to patients' actions. The audio guidance must also adapt to each patient's positive cognition, negative cognition, SUD and VOC ratings, and progress. The procedure is therefore used as a data management pipeline for game development.

**3.3 VR Scenes**

The solution is set in a typical, idyllic English cottage, offering indoor and outdoor spaces for patients to relax or engage in treatment. The design principle is to provide a warm and welcoming environment that is new to patients but includes elements such as garden furniture, plants, and a familiar cottage style. This design encourages patients to achieve a peaceful state of mind for treatment. Patients can see virtual hands that track their hand movements. Free-hand interaction is the primary user interaction method for the VR EMDR application. Patients touch virtual objects to start and stop a process, select items, and rate their emotions. Visual and auditory feedback is provided during virtual interactions to enhance the user experience. All user interactions are logged and stored in an online database to track treatment progress.

Patients begin the VR treatment session by entering the well-being cottage garden (Figure 2). Seated on a bench in a corner of the walled garden, patients enjoy views of colorful plants, various pots, water fountains, and well-maintained garden furniture while listening to birds and a small stream flowing on the other side of the garden. The garden adjoins a two-story thatched cottage. Patients are given a few minutes to look around and become familiar with the garden before the audio guidance begins. The voice greets patients and then provides a brief introduction to EMDR therapy and patient information for VR-based treatment. Patients are asked to relax, enjoy their time in the garden, and begin treatment only when ready. This outdoor garden scene helps patients ease any initial anxiety about a VR-based intervention. Patients can always return to the garden to take a break from the treatment steps. When ready for EMDR treatment, patients press a garden urn in front of the bench to enter the cottage.

The living room inside the cottage is where the main EMDR therapy takes place (Figure 3). The room contains simple soft furnishings, a fireplace, an upright piano and stool, and a metronome resting on a low bookcase. The room is well lit and has a window overlooking the well-being garden outside. The minimalist design provides an authentic and peaceful setting in which patients can fully engage in memory processing without distractions. As patients sit on the piano stool by the window to follow the treatment, they can see the garden by turning their heads to the left. This design helps patients quickly orient themselves after entering the living room; they are not far from a familiar place, the well-being garden. It also reassures patients that they can always return to the garden outside for a break.

After patients enter the living room, the audio guide introduces the room, specifically mentioning the metronome on the left. Users then have an opportunity to take time to look around while listening to a short, peaceful piece of piano music. When ready, users touch a sheet of music on the piano to begin treatment.

**3.4 Assessment, Desensitization, and Installation Process**

The Assessment phase begins by identifying the negative cognition, positive cognition, and baseline VOC and SUD ratings. For negative and positive cognitions, users are guided to recall memories of encounters related to their phobias. When ready, users select the most appropriate option from eight common statements expressing feelings that appear in front of them on the piano (Figure 4). Such a cognition list is commonly provided by EMDR therapists in clinical practice when patients need help expressing their feelings about traumatic memories. Users simply touch their chosen statement with their fingers to continue.

SUD and VOC ratings are also collected through simple user interactions. For the SUD rating, 11 color-coded buttons are arranged horizontally, with the low-disturbance and high-disturbance ends clearly marked (Figure 5). The negative cognition selected in previous steps is also displayed to support further memory processing for the SUD rating if needed. The VOC rating interface is positioned to the user's right and uses a different design (Figure 6). This design choice was made to minimize any confusion between SUD and VOC ratings. The panels are positioned at users' seated eye level, and all options are within reach. The buttons move back and forth when pushed by users to mimic the feedback of a physical button.

After selecting cognitions and ratings, patients are guided to perform bilateral eye movements while holding in mind the emotions and bodily sensations associated with their negative cognitions as part of desensitization treatment. Unlike traditional EMDR, in which patients follow the rapid movements of a therapist's fingers, we designed an interactive metronome that provides immersive multisensory stimulation for eye movements (Figure 7).

With a classic mechanical pyramid design, the metronome mimics the natural swing of an arm. The movement is synchronized with a spatial ticking sound that alternates between the ears to enhance the immersive experience. Patients are first introduced to the metronome's mechanics and asked to start it with a gentle push when ready. The speed of the metronome's movement, measured in beats per minute (bpm), can be configured to suit the user's preference. The default speed is 76 bpm. Audio guidance instructs users to follow the metronome arm with their eyes while processing the memory of a disturbing experience. This activity is accompanied by intermittent words of encouragement and reassurance, such as "You're doing well." As demonstrated in previous research (Goga et al. 2022), this type of immersive multisensory and game-inspired design is expected to improve EMDR therapy outcomes and patient adherence. Using the interactive metronome and its naturally swinging arm can provide patients with a more personal and enjoyable experience. This is much less intimidating than facing a therapist's finger movements while in close proximity to another person. Furthermore, patients remain in control of their own memory processing, as the metronome starts only when they instruct it to. The metronome design fits the room's musical theme, with a piano in the same corner of the living room.

In accordance with the EMDR protocol, the metronome guides patients to complete a memory processing set consisting of multiple 30-second repetitions of eye movements. Patients can take breaks between repetitions and resume by pushing the metronome when they feel ready. After each treatment set, patients are guided to reassess their negative cognitions and provide a SUD rating. Patients then continue treatment with further memory processing sets until a substantial improvement in the SUD rating is achieved or the maximum number of sets is reached. Both the number of repetitions per set and the maximum number of sets are configurable.

Following desensitization treatment, the application recommends that patients take a short break from treatment. Patients can choose to spend some time relaxing in the well-being garden or remove the VR headset and leave the VR environment. After the break, patients begin the Installation phase of treatment by pressing a sheet of music on the piano when ready. During the Installation phase, patients follow a similar memory reprocessing stage involving eye movements to work on their selected positive cognition; that is, the positive feeling they would like to experience, even if it did not feel true at the beginning of treatment. A VOC rating is collected after each eye movement set. Finally, patients are guided through a body scan and light stream exercise to complete the treatment session before removing the headset.

**3.5 Data Management System**

The application records patients' interactions with the treatment and uploads them to a cloud-based data management system. Recorded data include all patient selections and ratings (such as negative/positive cognitions and SUD/VOC ratings), the time patients spend in each scene and treatment segment (such as recalling the most recent traumatic experience), headset orientations, the date and time of treatment, and eye tracking if supported by the headset. These data can help therapists monitor patients' progress and customize therapy for individual patients. With the aid of machine learning, developers can use the data to improve the system's usability and patients' quality of life.

Figure 8 shows the design of the web portal developed with therapists, sample data on ongoing therapy outcomes, and a collection of tools for therapists to review and interact with remote sessions. Therapists can examine further details of each session and use these as a basis for discussions when messaging patients directly. The product's data-driven statistics offer therapists a considerable advantage—they help them objectively evaluate remote therapy sessions and alert them to unusual activity requiring immediate attention.

**3.6 Public Involvement**

A public involvement meeting was held with therapists and patients from veterans' services at a mental health institution. This service offers a range of intensive care and treatment for people who have served in the military, many of whom have experienced trauma. Intensive therapies are provided for conditions such as substance and alcohol misuse and PTSD symptoms resulting from stressful, frightening, or distressing events, including military conflict and violent situations. Some participating patients were already familiar with or had experience of EMDR therapy. The meeting aimed to introduce the VR EMDR application and gather participants' views on the overall acceptability of a VR-based solution for trauma treatment, as well as how VR game design techniques and user interaction features could support and potentially enhance treatment. Participating patients were asked to test the solution's functions rather than regard the session as a clinical therapy session.

Participants, particularly experienced VR users (gaming), were highly enthusiastic about the VR solution. The possibility of using the VR solution to receive EMDR therapy at any time without a long waiting list was highlighted. Other benefits identified by participants included being able to use the VR solution at home with remote therapist support. Patients reported the importance of personalization, such as virtual scene selection, audio customization, and the speed of metronome-guided eye movements. Although the well-being garden scene was well received by most participants for its calming environment, it also inspired numerous ideas for alternative virtual settings for relaxation, such as sandy beaches, wild forests, and outer space. The participant who suggested the space scene explained that they wanted to see a new environment "not connected to anything in this world" so they could leave all their worries behind while engaging in treatment. One participant expressed a preference for a softer metronome sound effect, such as "a whirring or whooshing sound," rather than the standard ticking sound.

Regarding the feasibility of suitable patients using the VR EMDR application at home, participants felt that initial VR sessions should be guided by therapists so that patients could build confidence before self-administering it at home. The availability of remote therapist support was considered vital for patients with trauma.

**4 Phobia Treatment User Study**

A pilot user study was conducted to evaluate the feasibility and safety of VR EMDR therapy for phobia treatment. Specifically, the study aimed to investigate the feasibility of daily phobia treatment over five consecutive days and whether participants could complete a VR-based EMDR session with minimal assistance from a therapist.

**4.1 Participant Recruitment and Profiles**

The study involved participants with a phobia that affected their daily lives. Because mental health problems can be highly complex and participant safety was paramount to our research, the study excluded people with diagnosed complex mental health disorders and a history of phobia-related panic attacks.

Participants were recruited using convenience sampling through module noticeboards and posters across the University of Northampton. Recruitment took place between June and July 2024. Eighteen volunteers underwent a comprehensive pre-intervention screening interview to establish their eligibility based on the inclusion and exclusion criteria described above and their availability for daily experiments over 5 days. Five participants were recruited for this study, each completing 5 daily VR EMDR treatment sessions, resulting in a total of 25 sessions across all participants. Ethical approval for this study was obtained from the University of Northampton Research Ethics Committee, and all participants provided informed consent before participating.

Brief participant profiles are as follows:

- **Participant 1:** Fear of experiencing G-force while maneuvering small aircraft during flight training.
- **Participant 2:** Fear of insects, particularly when insects are nearby.
- **Participant 3:** Fear of deep water, particularly the thought of drowning.
- **Participant 4:** Fear of the deep ocean, particularly marine creatures that might be lurking below.
- **Participant 5:** Fear of lizards.

**4.2 User Study Setting**

The study consisted of five consecutive daily sessions (Monday to Friday), each lasting approximately one hour. During these sessions, participants used the VR EMDR application to treat their phobias.

The study was conducted in a university classroom reserved exclusively for the study (Figure 9). Participants were seated on a standard swivel chair within a 2-square-meter seating area to minimize the risk of collisions with their surroundings. Based on findings from previous research (Paroz and Potter 2021), a low-noise oscillating electric fan provided a gentle breeze in the seating area to reduce VR sickness. The fan was positioned to participants' left to match the location of the open window in the indoor living room where treatment took place (Figure 3).

Participants took part individually, with only one participant in the study room at a time. VR EMDR therapy was delivered using Meta Quest Pro headsets. The VR EMDR application was installed on the headset as a standalone application. The absence of cables allowed participants to move freely within the designated area during the study.

**4.3 Procedure Overview**

Participants provided informed consent after reading a detailed information sheet and retained the right to withdraw within 30 days of study completion. All data were anonymized to ensure confidentiality. Carefully designed protocols were implemented for both within-session and between-session periods to minimize potential distress. Participants were informed about available mental health support services, including the host university's Mental Health and Counseling Service and on-campus General Practice (GP) clinic. Screening interviews were conducted to assess participant eligibility, and brief mental health checks were performed before and after each session to monitor participants' well-being throughout the study.

1. and 5, participants also completed two additional questionnaires: the Improving Access to Psychological Therapies (IAPT) Phobia Scale and the Simulator Sickness Questionnaire (SSQ). The IAPT Phobia Scales (IAPT toolkit 2008) are a brief screening tool developed by the National Health Service (NHS), comprising three questions addressing social phobia, panic disorder, and specific phobias. Although our study focused primarily on specific phobias, we administered the full scale to provide a comprehensive overview of participants' phobia-related avoidance behaviors. The SSQ (Kennedy et al. 1993) assesses the effects of the virtual environment on an individual's health, particularly nausea, oculomotor discomfort, and disorientation.

Each user session followed a standardized protocol. On arrival, each participant was guided through a health check and a session briefing with a researcher. Participants had an opportunity to ask questions during the briefing. Participants and the researcher agreed on a stop signal to use if a break or intervention was needed. Participants then put on the VR headset, with a researcher's assistance if necessary.

Participants were given an opportunity to adjust the headsets for optimal comfort and use the headset's fit adjustment feature for optimal visual clarity. When ready, participants could launch the VR EMDR application by clicking the application icon in the quick-access bar. The VR application then guided each participant through various steps of the standard EMDR protocol, including relaxation and introduction, assessment, desensitization, and installation. Each participant was offered a short break between the desensitization and installation phases. Participants could choose to remove the headset, keep it on during the break, or continue treatment without a break. The entire VR EMDR therapy session lasted approximately 50 minutes. The researcher remained present throughout the session to provide technical support and ensure participant safety, but involvement during the therapy component was minimal. This approach allowed assessment of the participant's ability to interact independently with the VR EMDR application.

Each participant received the full VR EMDR therapy over a total of 5 sessions from Monday to Friday. The time of therapy varied each day, but all sessions took place between 9 a.m. and 6 p.m. Post-session interviews and questionnaires were also conducted on days 1 and 5 and lasted approximately 15 minutes. Each participant received a £150 gift voucher in recognition of their time supporting the study.

**4.4 Results**

**Session Duration.** Participants spent approximately 40 minutes in VR EMDR sessions, excluding the pre-session briefing, mid-session break, and post-session interviews. On average, P1 and P5 had slightly longer sessions than the other participants (Figure 10). This can be attributed to the additional time they spent relaxing in the well-being garden and the extra time they used to process memories and provide psychological ratings. On average, participants spent less time completing therapy later in the week because of their increasing confidence in using the headset and familiarity with the application.

**Negative and Positive Cognition Selections.** As part of the EMDR therapy process, participants were asked to select negative and positive cognitions related to their phobias. Their selections offer insight into the thought patterns and beliefs associated with their fears.

Figure 11 shows participants' negative cognition selections across the 25 EMDR sessions. The most frequently selected negative cognitions were "I am not safe" and "I am vulnerable," suggesting that feelings of insecurity and vulnerability predominated among participants when confronting their phobias. "I cannot trust anyone" was not selected by any participant, indicating that it was not relevant to the specific phobias they were working on. This option might have been relevant to pistanthrophobia, a fear of trusting others that often arises following severe disappointment or the traumatic end of a relationship.

The most frequently selected positive cognitions were "I can learn to protect myself" and "I can handle this" (Figure 12), indicating a shift toward feelings of empowerment and capability in managing their phobias. Like its corresponding negative cognition, "I can choose whom to trust" was not selected by any participant.

**SUD and VOC Ratings.** All participants reported a reduction over the course of treatment in their SUD scores, which measure phobia-related distress. This indicates that participants experienced less distress related to their phobias as therapy progressed. Meanwhile, participants reported consistent improvements in VOC scores, which indicate how true or valid a positive belief feels. This means that participants found their selected positive cognitions more believable or valid by the end of the treatment period.

Figure 13 shows SUD ratings from all participants over the 5 days of EMDR phobia treatment. Baseline ratings are the first SUD ratings of the day (before desensitization treatment). On each day of the week, there is an overall downward trend in SUD ratings from the respective baseline SUD scores, meaning that participants were less disturbed by the negative emotions associated with their fears at the end of each session. Over the 5 days, participants' SUD ratings decreased consistently. This indicates that participants as a whole responded positively to phobia treatment each day and that the effects of one treatment session carried over to the following day's session.

These observations are supported by one-tailed paired t-tests between treatment days (Table 1). For each participant, comparisons were made between Day 1 and each subsequent day of the week to examine any statistically significant changes in SUD ratings from Day 1. For all participants, the tests reported significant differences (p < 0.05) between Day 1 and Day 4 and between Day 1 and Day 5. This indicates that, by adhering to daily EMDR phobia treatment, participants showed substantial desensitization responses from Day 4 onward compared with the same responses on Day 1. The five participants showed differences in their SUD changes. P1 and P4 appeared to show marked responses to desensitization earlier, achieving improvements on Day 3 (p = 0.058).

An upward trend in participants' VOC ratings is observed throughout treatment (Figure 14), indicating increased confidence in embracing the positive feeling they wished to experience before starting treatment. This improvement is evident both within individual sessions and across the five treatment days. The "outliers" at a VOC rating of 1 were mostly contributed by one participant (P5), who did not show a substantial response to the installation process until day 5. Most other participants reported rapid improvements in VOC ratings, reaching the upper end of the VOC range.

1. VOC ratings on this day compared with those on other days, using a one-tailed t-test assuming an increase in VOC, also show significant progress toward the end of the treatment week.

**IAPT Phobia Scale Changes.** Figure 15 presents participants' specific phobia scores on Day 1 and Day 5. This question asks participants to rate their avoidance of "certain situations because of a fear of particular objects or activities (such as animals, heights, seeing blood, being in confined spaces, driving, or flying)." A score below 4 indicates that symptoms are at subclinical levels and that the phobia does not significantly affect daily functioning or meet clinical criteria for treatment. A score of 4 or higher is associated with clinically significant phobia symptoms. On Day 1, all participants rated their specific phobias above 4. On Day 5, after a week of VR EMDR treatment, four out of five participants reported a substantial reduction in phobia scores, falling below the threshold. Participant P5, despite showing improvement, retained a score slightly above the clinical threshold.

**Simulator Sickness Questionnaire.** The self-report SSQ was administered on days 1 and 5 to assess potential adverse effects of the VR experience. Participants' raw total scores were used to assess absolute levels of discomfort and changes over time. The total score can therefore range from 0 to 48, with higher scores indicating greater discomfort.

Overall, the SSQ results indicate a very low risk of sickness from VR EMDR therapy, despite its duration of approximately one hour. Three participants (P2, P3, and P4) reported reductions in simulator sickness symptoms, while two participants (P1 and P5) showed slight increases. However, day 5 scores remained low, suggesting minimal discomfort. These quantitative results are consistent with the qualitative feedback and indicate that, although some participants initially experienced mild simulator sickness, symptoms generally decreased over the study period. This indicates good overall tolerance of the VR EMDR intervention and supports its potential for safe, repeated use in therapeutic settings.

**Participant Feedback.** All participants reported a positive experience with the VR-based therapy. P1, who feared G-force during flight training, reported a significant shift in mindset: "Before the session, I was more reluctant even to go on, say, a fairground ride where I might go up and come down. I would have been more reluctant, but now I'm much more open to the experience. I'm not sure I'll go back to flight school, but I'd be open to any experience, even something like bungee jumping, that would give me that experience of the situation." This comment indicates reduced avoidance behavior and an increased willingness to face fear-provoking situations.

P2, who feared insects, shared a powerful experience of confronting their phobia on the third day of daily sessions: "Last night I was able to face the fear and overcome it at the same time. (The therapy) is helping me a lot by giving me control over the fear. Imagining the fear again (in therapy) helps a lot with how to face the situation in real life. Before it (the therapy sessions), I wouldn't have been able to face the fear the way I did last night. The first two sessions helped me a lot with myself and with being in control of myself."

P4, who feared the deep ocean and marine creatures, noticed a change in how they perceived the source of their fear. "Thinking about the phobia now, about the scenario in my head that makes me afraid of the ocean, feels better now. I've realized that the deep-sea creatures I used to fear were in my imagination. Now when I see deep water, I don't think about the creatures as much, because I know it's more in my mind than a real danger to me." This reflection indicates a cognitive shift as the participant recognizes the role of imagination in their fear and feels less threatened by the actual situation.

All five participants rated the ease of following EMDR therapy in the virtual environment as 10 out of 10 (with 10 meaning very easy to follow), demonstrating the VR application's high usability. In addition, participants showed and reported greater confidence in operating the VR application from Day 2 onward, as noted by the researcher during sessions. The minimal technical support required after Day 2 reflects the system's user-friendly design.

Participants identified several potential benefits of home-based VR EMDR therapy. P5 valued the control and privacy offered by VR-based therapy, appreciating the ability to engage in therapy without verbally expressing emotions to an actual therapist. They said: "I'd use it if it becomes available in the future because it gives you some control over how you recover... So you feel like you have a bit of control. You're not revealing so much of your emotions. Sometimes it's really hard to talk about your emotions even to a therapist. Personally, I find it really difficult to talk about my emotions."

P3 found VR EMDR helpful because of its convenience: "It's practical. I think once you've got this headset or whatever, you can do it wherever you want." This feedback highlights the practicality of home use, making VR therapy an accessible option for many users.

**4.5 Limitations and Discussion**

The pilot user study involved 5 participants in 25 one-hour sessions over 5 days. Although we observed positive results in both quantitative measures, such as SUD, VOC, and IAPT Phobia Scales, and qualitative feedback from participants, we acknowledge that the results are drawn from a small participant sample and are exploratory. Clinical efficacy inferred from the study should therefore not be generalized to larger populations. Furthermore, the study excluded participants with complex mental health conditions, limiting insights into broader applications, such as for participants with PTSD and panic attacks alongside their phobias. The absence of a control group makes it difficult to attribute the observed improvements solely to the VR EMDR intervention. A large-scale study is needed to further analyze the feasibility and efficacy of the VR EMDR intervention across a wider range of phobic conditions, age groups, ethnic groups, and so on. A randomized controlled trial will be necessary to compare VR-based therapy with traditional face-to-face EMDR delivery.

In our study, participants were assisted by a researcher with a psychology background for both technical support and safety. Our participants clearly gained confidence in using the technology and operating the VR headsets themselves during the 5-day study. However, VR EMDR phobia therapy was not administered independently by participants. To fully evaluate the VR application's feasibility in a self-managed scenario, future experiments will include arrangements allowing participants to take the headsets home and initiate therapy whenever they wish.

In the VR EMDR application, patients can see virtual outline hands without skin texture or color. This design offers realistic forms that contrast with the environment and are clearly visible. Full-body embodiment, such as an avatar representing the patient's body in the virtual environment, is not provided. Some VR applications provide a full-body avatar that can be controlled and used to interact with the virtual environment. Users can see the virtual body when looking down or at a reflective surface such as a virtual mirror. Such designs have been used to simulate different body shapes and sizes as treatment interventions to help patients challenge and correct distorted perceptions of body image (Bell et al. 2024). However, one study indicates that individuals are less aware of internal bodily signals during embodiment in a virtual body, with participants focusing more on what they see than on what they feel (Döllinger et al. 2023). Full-body embodiment could distract patients from the memory reprocessing therapy process and adversely affect treatment. Patients may also face an increased risk of anxiety when they notice a mismatch in their sense of embodiment. Our future work will investigate the impact of VR embodiment on phobia and trauma treatment.

**5 Conclusions**

EMDR is an effective psychotherapy for treating trauma and phobic disorders. With EMDR, patients are guided by a trained therapist through systematic memory processing with the aid of bilateral eye movements. This lifesaving treatment is particularly beneficial for many patients, including adolescents who are unsuitable for CBT-based ET. However, current access to EMDR therapy is limited by the shortage of trained EMDR therapists. Many healthcare providers have reported waiting times of more than 12 months for EMDR trauma treatment. People on waiting lists for treatment face an increased risk of self-harm or, ultimately, suicide. For patients receiving EMDR treatment, sessions are normally offered weekly for a maximum of 12 sessions. Aiming to improve patients' access to EMDR therapy, we developed a VR EMDR prototype that guides patients through EMDR treatment in a natural and relaxing virtual environment. A range of interactive features and easy-to-use free-hand operations have been integrated to help users complete therapy while ensuring they feel in control of the process. A user study was conducted to validate the solution's feasibility and safety for accelerated EMDR phobia treatment, successfully delivering five sessions within one week for each participant. The results indicate that the VR-based intervention is engaging and effective in helping process specific phobia memories.

Our future work will explore the use of VR EMDR for more complex cases such as PTSD. Additional features, such as relaxation tools and safeguarding monitoring, will need to be incorporated to support patients who have experienced trauma and have complex comorbidities. Large-scale clinical trials incorporating a randomized control group and self-administered sessions will be planned to evaluate the efficacy of VR-based therapy compared with traditional face-to-face EMDR treatment.

**Declarations**

Ethics Statement

Ethical approval for this study was obtained from the University of Northampton Research Ethics Committee (FHSHEA000372), and all participants provided informed consent before participating.

Data Availability

The data supporting the findings of this study are not publicly available due to their sensitive nature but are available from the corresponding author upon reasonable request.

Conflicts of Interest

The authors have no conflicts of interest as defined by Springer, or other interests that might be perceived to influence the results and/or discussion reported in this paper.

Author Contributions

Mu Mu and Olive Chan wrote the main manuscript text. Mu Mu, Andrew Debus, Murtada Dohan, and David Nicholls prepared the figures and tables. Paul Wallang and Kieran Breen provided guidance on methodology design and results analysis. All authors conducted the literature research and reviewed the manuscript.

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