Speaking AnxietySocial Communication

Two meta-analyzes of VRET for social anxiety: (1) 6 studies (n=233) confirmed VRET more effective than waitlist; (2) 7 studies (n=340) showed essentially no difference between VRET and in-vivo/imaginal exposure - supporting VRET as a non-inferior alternative to standard treatment

Chesham RK et al. · 2018 · Behaviour Change · Systematic Review · n = 573 · Meta-analyzes of VRET for anxiety disorders (combined) · DOI
Evidence certainty: Moderate certainty
How this was rated

Two complementary meta-analyzes with appropriate design choices (waitlist comparison + active-comparator comparison). Peer-reviewed in Behavior Change (Cambridge University Press, established peer-reviewed cognitive-behavioral therapy journal). Lead author affiliations: University of New England (Australia). Sample sizes (n=233 + n=340) are modest but adequate for the focused research questions. Limitations: 6-7 studies per meta-analysis is small for detecting modifiers; pre-2018 cutoff misses consumer-hardware VRET (Lindner 2019, Reeves 2021, Zainal 2021); subsequent larger meta-analyzes (Horigome 2020 with 22 studies) supersede for SAD-VRET-specific synthesis.

Ratings use a simplified four-tier scheme (High, Moderate, Low, Very Low) informed by the GRADE working group. Learn more about how studies are rated.

Two complementary meta-analyzes of VRET for social anxiety published in Behavior Change. The first compared VRET to waitlist control across 6 studies (n=233), showing a significant overall effect favoring VRET - confirming VRET reduces social anxiety better than no treatment. The second compared VRET to the standard treatment (in-vivo or imaginal exposure) across 7 studies (n=340), showing essentially no difference in effect sizes between VRET and in-vivo/imaginal exposure - supporting VRET as a non-inferior alternative. Together, the two meta-analyzes establish VRET as both effective in absolute terms AND clinically equivalent to the gold-standard exposure modality.

Clinical bottom line

An Australian-led 2018 meta-analysis published in Behavior Change with a clean two-part structure: (1) VRET beats waitlist (6 studies, n=233); (2) VRET is essentially equivalent to in-vivo/imaginal exposure (7 studies, n=340). This is the foundational equivalence-claim meta-analysis for VRET vs the gold standard. Subsequently incorporated as a key citation in Chard 2023's stuttering-VRET pilot trial. For clinicians making the case that VRET is a credible alternative (not a compromise) to traditional exposure, this is one of the cleanest meta-analytic citations to use.

Key findings

  • Two complementary meta-analyzes published as one paper in Behavior Change
  • META-ANALYSIS 1: VRET vs WAITLIST - 6 studies, n=233 participants, significant overall effect favoring VRET (specific Hedges' g reported in published article)
  • META-ANALYSIS 2: VRET vs STANDARD TREATMENT (in-vivo or imaginal exposure) - 7 studies, n=340 participants, ESSENTIALLY NO DIFFERENCE in effect sizes
  • Two-part design provides BOTH the absolute-effect claim (VRET works vs no treatment) AND the equivalence claim (VRET is non-inferior to in-vivo/imaginal exposure)
  • Australian-led authorship (University of New England) - geographic diversification of the VRET evidence base
  • Published in Behavior Change (Cambridge University Press peer-reviewed CBT journal)
  • Subsequently incorporated as a key citation in Chard 2023's stuttering-VRET pilot trial (in our Hub as chard-2023) - placing it in the lineage of VRET-for-stuttering research
  • Pre-2018 cutoff - misses the consumer-hardware VRET RCTs (Lindner 2019, Reeves 2021, Zainal 2021) that have transformed the modality's clinical accessibility

Background

By 2017-2018, the VRET-for-social-anxiety evidence base was substantial enough to warrant focused meta-analytic synthesis, but earlier meta-analyzes had pooled broader anxiety-disorder categories (Powers 2008, Opris 2012). What was missing was a SAD-specific meta-analysis with the dual question of (a) does VRET beat no treatment, and (b) is VRET non-inferior to the standard exposure modality?

What they did and found

Two meta-analyzes published as one paper:

The dual finding: VRET is more effective than no treatment AND essentially equivalent to gold-standard exposure.

Why it matters + Limitations

Foundational equivalence-claim meta-analysis. Limitations: 6-7 studies per meta-analysis is small; pre-2018 cutoff misses consumer-hardware VRET; superseded by Horigome 2020 (22 studies) for headline SAD-VRET synthesis. Use Chesham 2018 for the clean two-part absolute/equivalence framing; use Horigome 2020 for the most authoritative SAD-VRET effect estimate.

Implications for practice

For clinicians making the case that VRET is a credible alternative (not a compromise) to traditional exposure therapy, the two-part structure of this paper is unusually clean: (a) VRET reduces social anxiety more than no treatment, and (b) VRET is essentially equivalent to in-vivo/imaginal exposure. For PWS with SAD comorbidity considering VRET as an adjunct, this paper supports clinical equivalence with the gold-standard exposure modality - meaning the choice between VRET and in-vivo exposure can be made on accessibility, dose, and patient preference rather than expected efficacy. Subsequent larger meta-analyzes (Horigome 2020 with 22 studies) supersede for headline SAD-VRET synthesis, but Chesham 2018 remains the foundational equivalence-claim citation.

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Cite this study

If you reference this study in your work, the canonical citation formats are:

APA 7th
Chesham, R. K., Malouff, J. M., & Schutte, N. S. (2018). Meta-Analysis of the Efficacy of Virtual Reality Exposure Therapy for Social Anxiety. Behaviour Change. https://doi.org/10.1017/bec.2018.15.
AMA 11th
Chesham RK, Malouff JM, Schutte NS. Meta-Analysis of the Efficacy of Virtual Reality Exposure Therapy for Social Anxiety. Behaviour Change. 2018. doi:10.1017/bec.2018.15.
BibTeX
@article{chesham2018,
  author = {Chesham, R. K. and Malouff, J. M. and Schutte, N. S.},
  title = {Meta-Analysis of the Efficacy of Virtual Reality Exposure Therapy for Social Anxiety},
  journal = {Behaviour Change},
  year = {2018},
  doi = {10.1017/bec.2018.15},
  url = {https://withvr.app/evidence/studies/chesham-2018}
}
RIS
TY  - JOUR
AU  - Chesham, R. K.
AU  - Malouff, J. M.
AU  - Schutte, N. S.
TI  - Meta-Analysis of the Efficacy of Virtual Reality Exposure Therapy for Social Anxiety
JO  - Behaviour Change
PY  - 2018
DO  - 10.1017/bec.2018.15
UR  - https://withvr.app/evidence/studies/chesham-2018
ER  -

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Funding & independence

Affiliations: School of Psychology, University of New England, Armidale NSW, Australia. Specific funding sources reported in published article. Peer-reviewed in Behavior Change (Cambridge University Press). No withVR BV involvement. Summary prepared independently by withVR.

Last reviewed: 2026-05-17 Next review due: 2027-05-17 Reviewed by: Gareth Walkom