Speaking AnxietySocial Communication

Harvard Review of Psychiatry narrative review of virtual reality in the treatment of anxiety and other psychiatric disorders - historical development, empirical evidence, benefits, and integration recommendations

Maples-Keller JL et al. · 2017 · Harvard Review of Psychiatry · Systematic Review 0 · Narrative review of VR treatment studies for anxiety and other psychiatric conditions · DOI
Evidence certainty: Moderate certainty
How this was rated

Systematic literature review (qualitative / narrative synthesis rather than meta-analysis). Published in Harvard Review of Psychiatry (Wolters Kluwer / Lippincott, high-impact peer-reviewed psychiatry review journal). Authored by Maples-Keller and Rothbaum at Emory - Rothbaum is one of the most-cited VRET clinical researchers globally. Limitations inherent to narrative reviews: synthesis is qualitative rather than effect-size-pooled; selection of cited studies reflects authorial judgment. As an overview reference the contribution is methodological context, integration recommendations, and field-shaping rather than precise effect-size estimates.

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.

A systematic literature review of VR-based treatment for anxiety disorders and other psychiatric conditions, published in the Harvard Review of Psychiatry. Covers the history of VR-based clinical technology, an overview of the empirical evidence (particularly exposure-based intervention for anxiety disorders), the benefits of using VR for psychiatric research and treatment, recommendations for incorporating VR into psychiatric care, and future directions. Authored by the Emory group (Rothbaum's lab), this is the authoritative narrative review of clinical VR for the 2017 era - frequently cited as the canonical reference for clinicians and trainees entering VRET practice.

Clinical bottom line

The canonical Harvard Review of Psychiatry narrative review of clinical VR for anxiety and psychiatric disorders, authored by Maples-Keller, Bunnell, Kim, and Rothbaum (Emory). For SLPs, psychologists, psychiatrists, or other clinicians wanting an authoritative overview of WHEN, WHY, and HOW to integrate VR into clinical practice, this is the review to read first. Complements the quantitative meta-analyzes (Powers & Emmelkamp 2008, Opris 2012, Wechsler 2019, Carl 2019) with narrative depth on history, benefits, recommendations, and future directions. Especially useful for procurement and grant-writing contexts where a single authoritative reference is needed.

Key findings

  • Systematic literature review of VR-based treatment for anxiety and other psychiatric disorders, published 2017 in Harvard Review of Psychiatry
  • Authorship: Maples-Keller, Bunnell, Kim, Rothbaum - the Emory group, with Barbara Rothbaum among the most-cited VRET clinical researchers globally
  • Coverage organized into: (a) HISTORY of VR-based clinical technology development, (b) empirical EVIDENCE for VR-based treatment with focus on exposure-based intervention for anxiety disorders, (c) BENEFITS of using VR for psychiatric research and treatment, (d) RECOMMENDATIONS for how to incorporate VR into psychiatric care, (e) FUTURE DIRECTIONS for VR-based treatment and clinical research
  • Narrative / qualitative synthesis rather than quantitative meta-analysis - complements rather than replaces the Powers / Opris / Wechsler / Carl quantitative meta-analyzes
  • Anxiety disorders are the primary focus, but the review also covers VR applications across OTHER PSYCHIATRIC DISORDERS - making it useful for clinicians considering VR beyond the anxiety-disorder evidence base
  • Includes practical recommendations for clinical integration - relevant to SLP and psychology services planning VR adoption
  • Published in Harvard Review of Psychiatry - high-impact peer-reviewed psychiatry review journal

Background

By 2017, the clinical VR literature was extensive enough that a comprehensive narrative review could synthesize the empirical evidence, history, benefits, and clinical-integration recommendations for psychiatrists, psychologists, and allied clinicians. Such a synthesis would complement the quantitative meta-analyzes (Powers & Emmelkamp 2008, Opris 2012) by providing the conceptual and practical framing that effect-size estimates cannot deliver alone.

The Emory group (Rothbaum’s lab), with first authorship by Maples-Keller, set out to provide this overview in the Harvard Review of Psychiatry.

What the researchers did

A systematic literature search identified VR-based treatment studies for anxiety and other psychiatric disorders. The synthesis was organized into:

  1. History of VR-based clinical technology development
  2. Empirical evidence for VR-based treatment, with focus on exposure-based intervention for anxiety disorders
  3. Benefits of using VR for psychiatric research and treatment
  4. Recommendations for incorporating VR into psychiatric care
  5. Future directions for VR-based treatment and clinical research

Why this matters

For clinicians, trainees, or procurement teams wanting an authoritative single-paper overview of clinical VR, this review is widely cited as the canonical reference for the 2017 era. The Harvard Review of Psychiatry venue and Rothbaum’s authorship give it standing that smaller reviews lack.

For SLP services planning to introduce VR for clients with social-anxiety or performance-anxiety comorbidities, the integration-recommendations section is particularly useful - it bridges the gap between “the meta-analyzes say VRET works” and “how do I actually integrate this into my clinical workflow?”

For grant applications needing a single high-impact VRET review alongside quantitative meta-analyzes, this paper is widely cited and authoritative.

Limitations

Implications for practice

For clinicians, trainees, or procurement teams wanting an authoritative overview of clinical VR for anxiety and related psychiatric work, this is the narrative review to read first. It complements the quantitative meta-analyzes with practical integration recommendations, historical context, and a clinical framing that the effect-size syntheses do not provide. For SLP services planning to introduce VR for clients with social-anxiety or performance-anxiety comorbidities (PWS with SAD, voice clients with performance anxiety), this paper offers the conceptual framework for how to integrate VR alongside traditional clinical work. For grant or procurement applications needing a single authoritative VRET reference alongside the meta-analyzes, Maples-Keller et al. 2017 is widely cited and high-impact.

Related Studies

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In a randomized controlled trial of 97 adults with social anxiety disorder whose primary fear was public speaking, eight sessions of virtual reality exposure were as effective as eight sessions of manualized in vivo exposure delivered in groups. Both active treatments outperformed waitlist on self-report and on a behavioral speech task, and improvements were maintained at 12-month follow-up.

Anderson PL et al. · 2013 Read Summary
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Pre-registered three-arm RCT: CBT with VR exposure was superior to in-vivo exposure on the primary social-anxiety outcome - and more practical for therapists

A pre-registered three-arm RCT randomized 59 adults with DSM-5 social anxiety disorder to 14 weekly sessions of CBT with VR exposure (n=17), CBT with in-vivo exposure (n=22), or waitlist (n=20). The pre-specified superiority hypothesis was confirmed: VR exposure was significantly more effective than in-vivo exposure on the LSAS-SR primary outcome at post-treatment and at 6-month follow-up, and significantly less cumbersome for therapists (SWEAT: 15.24 vs 24.46). Reliable change: 76.5% VR, 68.3% in vivo, 30.0% waitlist.

Bouchard S et al. · 2017 Read Summary
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Major meta-analysis (2019) of 30 randomized controlled trials of virtual reality exposure therapy for anxiety and related disorders (n=1,057): large effect vs waitlist (g=0.90) and equivalent to in-vivo exposure

An updated meta-analysis extending Powers & Emmelkamp 2008 to 30 randomized controlled trials (n=1,057 participants) of virtual reality exposure therapy (VRET) for anxiety and related disorders. Coverage: 14 trials of specific phobias, 8 of social anxiety disorder or performance anxiety, 5 of PTSD, and 3 of panic disorder. Random-effects analysis gave a large effect size for VRET vs waitlist (Hedges' g = 0.90) and a medium-to-large effect size for VRET vs psychotherapy comparator conditions. Confirms that VRET is a clinically effective option across the anxiety-disorder spectrum, with social anxiety and performance anxiety as the subset most relevant to communication work.

Carl E et al. · 2019 Read Summary
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Three-arm RCT (n=60) of stand-alone VR exposure therapy vs in-vivo exposure vs waiting-list for social anxiety disorder: in-vivo exposure was superior to VRET on multiple secondary outcomes - the opposite pattern to Bouchard 2017

Sixty participants diagnosed with social anxiety disorder were randomly assigned to individual virtual reality exposure therapy (VRET), individual in-vivo exposure therapy (iVET), or a waiting-list control. Both treatments improved social anxiety symptoms, speech duration, perceived stress, and avoidant-personality-disorder beliefs versus waitlist. However, iVET (but NOT VRET) also improved fear of negative evaluation, speech performance, general anxiety, depression, and quality of life. iVET was superior to VRET on social anxiety symptoms at post and follow-up and on avoidant-PD beliefs at follow-up. At follow-up, almost all improvements remained significant for iVET; for VRET only the perceived-stress effect held.

Kampmann IL et al. · 2016 Read Summary
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First RCT (n=25+25) showing that consumer VR hardware and software can deliver effective one-session VRET for public speaking anxiety - both therapist-led (d=1.67) and self-led at home (d=1.35), with gains maintained at 6 and 12 months

Twenty-five participants were randomised 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.

Lindner P et al. · 2019 Read Summary
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Meta-analysis: VR exposure works as well as evidence-based alternatives, with a dose-response pattern

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Opriş D et al. · 2012 Read Summary
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Meta-analysis: VR exposure therapy works as well as in-person exposure for anxiety

An early quantitative meta-analysis pooled effect sizes across studies of VR exposure therapy for anxiety disorders, finding VR exposure equally effective as in-vivo (real-world) exposure and significantly more effective than control conditions.

Powers MB, Emmelkamp PMG · 2008 Read Summary
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PRISMA systematic review + meta-analysis of RCTs comparing VRET to in-vivo exposure in agoraphobia, specific phobia, and social phobia - with equivalent exposure dose in both arms

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Wechsler TF et al. · 2019 Read Summary
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Cite this study

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

APA 7th
Maples-Keller, J. L., Bunnell, B. E., Kim, S. J., & Rothbaum, B. O. (2017). The use of virtual reality technology in the treatment of anxiety and other psychiatric disorders. Harvard Review of Psychiatry. https://doi.org/10.1097/HRP.0000000000000138.
AMA 11th
Maples-Keller JL, Bunnell BE, Kim SJ, Rothbaum BO. The use of virtual reality technology in the treatment of anxiety and other psychiatric disorders. Harvard Review of Psychiatry. 2017. doi:10.1097/HRP.0000000000000138.
BibTeX
@article{mapleskeller2017,
  author = {Maples-Keller, J. L. and Bunnell, B. E. and Kim, S. J. and Rothbaum, B. O.},
  title = {The use of virtual reality technology in the treatment of anxiety and other psychiatric disorders},
  journal = {Harvard Review of Psychiatry},
  year = {2017},
  doi = {10.1097/HRP.0000000000000138},
  url = {https://withvr.app/evidence/studies/maples-keller-2017}
}
RIS
TY  - JOUR
AU  - Maples-Keller, J. L.
AU  - Bunnell, B. E.
AU  - Kim, S. J.
AU  - Rothbaum, B. O.
TI  - The use of virtual reality technology in the treatment of anxiety and other psychiatric disorders
JO  - Harvard Review of Psychiatry
PY  - 2017
DO  - 10.1097/HRP.0000000000000138
UR  - https://withvr.app/evidence/studies/maples-keller-2017
ER  -

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Funding & independence

Affiliations: Department of Psychiatry and Behavioral Sciences, Emory University School of Medicine (Maples-Keller, Kim, Rothbaum); College of Nursing, Medical University of South Carolina (Bunnell). Funding sources not extracted in detail from the abstract excerpt available. Peer-reviewed in Harvard Review of Psychiatry (Wolters Kluwer / Lippincott). Rothbaum has long-standing industry relationships (Virtually Better, Inc. - she is co-founder); readers should weigh this when interpreting the recommendations sections. No withVR BV involvement in funding, study design, or authorship. Summary prepared independently by withVR using the published peer-reviewed paper.

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