Speaking AnxietyImplementation

First RCT showing consumer VR delivers effective one-session exposure for public speaking anxiety, in clinic or at home

Lindner P et al. · 2019 · Journal of Anxiety Disorders · RCT · n = 50 · Adults with elevated public speaking anxiety · DOI
Evidence certainty: Moderate certainty
How this was rated

Pre-specified RCT design with formal randomization, n=25 per arm initially (later n=25 self-led at home), large within-group effects (d=1.67 and d=1.35) supported by linear mixed effects modeling, durable at 6 and 12 months. Peer-reviewed in Journal of Anxiety Disorders (Elsevier, established peer-reviewed venue). Limitations: the design is one-session therapist-led VRET followed by a 4-week internet-administered transition program - so the d=1.67 figure reflects the combined therapist-led + transition package, not VR alone. The waitlist-as-self-led-treatment crossover is a creative design but limits between-group comparison. The sample is community-recruited PSA, not strictly DSM-diagnosed SAD. The consumer-hardware result is the key contribution and is robust.

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Twenty-five participants were randomized to one-session therapist-led VR exposure therapy for public speaking anxiety using consumer VR hardware and software, followed by a 4-week internet-administered VR-to-in-vivo transition program; another 25 served as a waiting-list. Therapist-led VRET produced a very large effect on self-reported PSA (within Cohen's d = 1.67). The waiting-list then received internet-administered, SELF-LED VRET at home, followed by the same transition program - producing a large effect (d = 1.35). Results were maintained or improved at 6-month and 12-month follow-ups. This is the first published RCT demonstrating that off-the-shelf consumer VR hardware and software can deliver effective PSA exposure therapy in both clinician-supervised and home-based formats.

Clinical bottom line

The first RCT to show that consumer-grade off-the-shelf VR hardware and software can deliver effective public-speaking-anxiety exposure therapy in both therapist-led and self-led-at-home formats, with large within-group effects (d=1.67 and d=1.35) maintained or improved at 6 and 12 months. This is the consumer-hardware deployment study that makes contemporary clinical and home VRET practical - relevant to any clinician choosing between research-grade VR systems and Meta Quest-class consumer hardware. For PWS with PSA comorbidity, this RCT supports the case that consumer-hardware VRET delivered by SLPs (or even self-administered between sessions) is a viable treatment-augmentation strategy.

Key findings

  • n=25 + n=25 RCT design: therapist-led one-session VRET arm (n=25) vs waiting-list (n=25). After waitlist completion, the waitlist participants received the internet-administered SELF-LED home version of the same VRET protocol
  • Hardware: FIRST GENERATION of consumer VR hardware and software - establishing that off-the-shelf consumer kit is sufficient for clinically effective VRET, not just research-grade systems
  • Therapist-led VRET protocol: ONE session of in-person VR exposure followed by a 4-week internet-administered VR-to-in-vivo transition program
  • Therapist-led arm produced a LARGE within-group effect on self-reported PSA: Cohen's d = 1.67 (linear mixed effects modeling)
  • Self-led home VRET arm (delivered to the former waitlist participants) produced a LARGE within-group effect: Cohen's d = 1.35
  • Results were MAINTAINED OR IMPROVED at 6-month and 12-month follow-ups - durable long-term gains, not transient
  • Crossover design (waitlist becomes self-led treatment) is creative and ethically generous (no one stays untreated long) but limits clean between-arm comparison at follow-up
  • First demonstration that low-cost, off-the-shelf VR can be used to conduct PSA exposure therapy in both clinic and home settings - foundational for contemporary consumer-hardware VRET deployment

Background

Earlier RCTs of VRET for public speaking anxiety (PSA) and social anxiety disorder (SAD) used research-grade VR hardware (eMagin z800, VFX-3D, Virtual-I/0) - costly systems unsuited to routine clinical deployment. By 2018, consumer VR hardware (Oculus Rift, HTC Vive) and consumer VR software platforms had matured. The clinical question: could this off-the-shelf technology deliver effective VRET without research-grade hardware? And could a self-led home-administered VRET work in addition to therapist-led clinic VRET?

What the researchers did

Twenty-five participants with elevated PSA were randomized to one-session therapist-led VR exposure therapy delivered with consumer VR hardware and software, followed by a 4-week internet-administered VR-to-in-vivo transition program. Another 25 served as a waiting-list. After the waiting period, the waitlist participants received an internet-administered, SELF-LED version of the same VRET protocol to conduct at home, again followed by the same 4-week transition program. All outcomes were self-reported PSA, with linear mixed effects modeling for the analyses.

What they found

Why this matters

This was the first RCT to show that off-the-shelf consumer VR hardware and software can deliver clinically effective public-speaking-anxiety exposure therapy in both therapist-led and self-led-at-home formats, with large durable effects. For clinicians considering consumer-hardware VRET (Meta Quest-class systems, including Therapy withVR), this RCT is the foundational clinical-effectiveness justification.

The self-led-at-home arm is particularly important for accessibility - many people with PSA will not present to a clinic, but might use a self-administered home program. The d=1.35 self-led effect (smaller than but in the same large-effect range as the therapist-led d=1.67) supports a stepped-care or home-based model.

Limitations

Implications for practice

For clinicians choosing between research-grade VR systems and consumer-grade Meta Quest-class hardware, this RCT is the clinical-effectiveness justification for choosing consumer hardware: the gains are large, durable, and achievable both in-clinic and at home. The one-session-plus-internet-transition protocol is a particularly practical model for busy SLP and CBT caseloads. For PWS with PSA comorbidity, this RCT supports the case that consumer-hardware VRET delivered by SLPs - or self-administered between sessions - is a viable treatment-augmentation strategy. This study demonstrates that consumer VR hardware paired with structured exposure protocols can support PSA treatment delivery in both clinic and home settings.

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Cite this study

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

APA 7th
Lindner, P., Miloff, A., Fagernäs, S., Andersen, J., Sigeman, M., Andersson, G., Furmark, T., & Carlbring, P. (2019). Therapist-led and self-led one-session virtual reality exposure therapy for public speaking anxiety with consumer hardware and software: A randomized controlled trial. Journal of Anxiety Disorders. https://doi.org/10.1016/j.janxdis.2018.07.003.
AMA 11th
Lindner P, Miloff A, Fagernäs S, Andersen J, Sigeman M, Andersson G, Furmark T, Carlbring P. Therapist-led and self-led one-session virtual reality exposure therapy for public speaking anxiety with consumer hardware and software: A randomized controlled trial. Journal of Anxiety Disorders. 2019. doi:10.1016/j.janxdis.2018.07.003.
BibTeX
@article{lindner2019,
  author = {Lindner, P. and Miloff, A. and Fagernäs, S. and Andersen, J. and Sigeman, M. and Andersson, G. and Furmark, T. and Carlbring, P.},
  title = {Therapist-led and self-led one-session virtual reality exposure therapy for public speaking anxiety with consumer hardware and software: A randomized controlled trial},
  journal = {Journal of Anxiety Disorders},
  year = {2019},
  doi = {10.1016/j.janxdis.2018.07.003},
  url = {https://withvr.app/evidence/studies/lindner-2019}
}
RIS
TY  - JOUR
AU  - Lindner, P.
AU  - Miloff, A.
AU  - Fagernäs, S.
AU  - Andersen, J.
AU  - Sigeman, M.
AU  - Andersson, G.
AU  - Furmark, T.
AU  - Carlbring, P.
TI  - Therapist-led and self-led one-session virtual reality exposure therapy for public speaking anxiety with consumer hardware and software: A randomized controlled trial
JO  - Journal of Anxiety Disorders
PY  - 2019
DO  - 10.1016/j.janxdis.2018.07.003
UR  - https://withvr.app/evidence/studies/lindner-2019
ER  -

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Funding & independence

Affiliations: Department of Psychology, Stockholm University; Center for Psychiatry Research, Karolinska Institutet; Department of Psychology, Uppsala University; Department of Behavioral Sciences and Learning, Linköping University; Department of Psychology, University of Southern Denmark. Funding sources not extracted in detail from the abstract excerpt. Peer-reviewed in Journal of Anxiety Disorders (Elsevier). No withVR BV involvement in funding, study design, or authorship. Summary prepared independently by withVR using the published peer-reviewed paper. The VR system used was first-generation consumer hardware and software, NOT Therapy withVR or Research withVR.

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