Enhancing Therapist Training in the Delivery of Exposure Therapy for Individuals with Anxiety Disorders Using Virtual Reality Simulation: Randomized Feasibility Trial.

Background: Exposure-based cognitive behavioral therapy is among the least used evidence-based practices for anxiety disorders in routine care. Providers' negative beliefs about exposure (eg, fears of harm or intolerability) are a major barrier. Experiential methods can reduce these beliefs but are limited by accessibility, standardization, and fidelity. Virtual reality (VR) offers a scalable way to deliver standardized experiential practice. Guided by an "exposure to exposure" (E2E) framework, we conceptualized VR training as an exposure intervention targeting therapists' own anxious beliefs about exposure. Objective: This feasibility study examined a VR-based exposure training program (SET-VR) (1) to evaluate usability and effects on therapist learning targets (knowledge, self-efficacy, attitudes) and (2) to test whether a high-immersion head-mounted display (HMD) format provides added benefit over a lower-immersion desktop format. Eligibility included holding an active caseload. Methods: Eligible clinicians (ie, aged >21 years with an active caseload; n=41) completed a 4-hour didactic workshop on exposure and were randomized (1:1, blinded) to the desktop or HMD condition. In the experiential phase, therapists delivered 3 rounds of exposure with a virtual patient. They titrated exposure intensity (increase, decrease, continue as is) at fixed decision points based on state-dependent visual (character animations) and auditory (prerecorded verbalizations) cues reflecting the patient's distress. Exposure knowledge, self-efficacy, and beliefs about exposure were measured at baseline, post-didactic, post-experiential, and follow-up. Participants also rated the acceptability, usability, and authenticity of the program. Results: Both groups (desktop and HMD) showed significant improvement in exposure knowledge (d=0.52, P=.006; d=0.58, P=.002), self-efficacy (d=0.88, P<.001; d=1.36, P<.001), and beliefs (d=0.61, P=.001; d=1.05, P<.001) from baseline to post-didactic training using binomial generalized estimating equations. There were no significant differences between the low- and high-immersion groups on any measure after didactics. Both groups demonstrated significant improvement in exposure self-efficacy (d=0.66, P<.001; d=0.93, P<.001) and beliefs (d=0.46, P<.01; d=0.66, P<.001) from post-didactic to post-experiential. Both groups gave positive ratings for acceptability, usability, and authenticity. No adverse events or side effects were reported. Conclusions: In this feasibility randomized controlled trial, an E2E-guided VR training program produced promising improvements in therapists' self-efficacy and negative beliefs about exposure beyond gains from didactic training alone. This work is innovative in testing immersion as a dose parameter while also applying an explicit framework (E2E) to target a key mechanism (ie, therapist beliefs) in the underuse of exposure therapy. Compared to prior VR training studies focused on skills and knowledge acquisition, our findings support the standardization of an emotionally engaging exposure practice context that shifts therapist-level mechanisms linked to actual delivery. The lack of clear advantages for HMD over desktop VR suggests that lower-immersion, more scalable implementations may provide a sufficient experiential "dose." Larger, more diverse trials are needed to confirm effectiveness and determine the real-world impact of VR-based exposure training on access to evidence-based care.