Attitudes Towards Virtual Reality Therapy

1. Abstract

The Attitudes Towards Virtual Reality Therapy (AVRT) Scale is a psychometric instrument designed to evaluate public and clinical perceptions, expectations, and attitudes regarding psychological interventions administered via immersive virtual reality technologies. Developed by Aislinn D. Gomez Bergin, Aoife M. Allison, and Cassie M. Hazell (2024), the scale captures the multi-faceted landscape of end-user reception toward automated or coach-guided virtual reality therapy (VRT). Initially constructed from an empirical pool of 54 candidate items derived from thematic syntheses of digital mental health literature, the instrument underwent rigorous psychometric refinement via exploratory factor analysis (EFA), yielding an optimal 33-item, four-dimensional structural model accounting for 58.61% of total variance.

The four distinct dimensions measured by the AVRT Scale are: (1) Attitude toward VRT, capturing generalized valence, willingness to engage, and trust in virtual coaching interfaces; (2) Expectation of presence, measuring anticipated ecological immersion, suspension of disbelief, and potential barriers such as cybersickness or uncanny valley phenomena; (3) Preference for VRT, indexing comparative parity, therapeutic alliance expectations, and preference dynamics between virtual modalities and conventional face-to-face psychotherapy; and (4) Perception of cost-effectiveness, appraising perceived systemic health economic value, resource optimization, and return on investment within public healthcare frameworks such as the UK National Health Service (NHS). Responses are recorded along a standardized 7-point Likert scale ranging from 1 (Strongly Disagree) to 7 (Strongly Agree), supplemented by qualitative free-text contingencies triggered by extreme response patterns.

Psychometric evaluation demonstrates high internal consistency reliability, with all four subscales exhibiting Cronbach’s alpha coefficients exceeding α = .82. By bridging theoretical constructs from the Technology Acceptance Model (TAM) and spatial presence theory with clinical psychology, the AVRT Scale provides researchers, clinicians, health economists, and digital intervention architects with a standardized, empirically validated metric. This tool is uniquely calibrated to diagnose implementation barriers, stratify patient readiness, and elucidate the cognitive mechanisms governing adoption of immersive digital therapeutics.

2. Keywords

Attitudes Towards Virtual Reality Therapy, AVRT Scale, virtual reality therapy, digital mental health, psychological assessment, psychometrics, technology acceptance model, presence, virtual coach, healthcare cost-effectiveness

3. Authors

The Attitudes Towards Virtual Reality Therapy (AVRT) Scale was formulated and psychometrically validated through a collaborative cross-institutional research partnership in the United Kingdom:

• Aislinn D. Gomez Bergin, PhD: National Institute for Health and Care Research (NIHR) MindTech MedTech Co-operative, Institute of Mental Health, School of Medicine, University of Nottingham, Nottingham, United Kingdom. ORCID: 0000-0002-3414-9725. Dr. Gomez Bergin specializes in the human-centered design, clinical evaluation, and sociotechnical implementation of digital health interventions.
• Aoife M. Allison, MSc: Mental Health and Clinical Neurosciences, School of Medicine, University of Nottingham, Nottingham, United Kingdom. ORCID: 0000-0003-1284-5692. Her expertise encompasses psychological intervention design, user experience in immersive environments, and clinical trials for cognitive technologies.
• Cassie M. Hazell, PhD: Department of Psychological Interventions, School of Psychology, Faculty of Health and Medical Sciences, University of Surrey, Guildford, United Kingdom. ORCID: 0000-0001-5868-9902. Dr. Hazell is an academic clinical psychologist whose research investigates access barriers to evidence-based psychological therapies, psychosis interventions, and translational digital therapeutics.

4. Purpose

The transformative expansion of digital therapeutics has placed immersive technologies at the forefront of contemporary mental healthcare delivery. Interventions delivering cognitive behavioral therapy (CBT) and graded exposure within immersive virtual environments—frequently mediated by automated or artificially intelligent virtual coaches—have demonstrated pronounced clinical efficacy across diverse psychiatric spectra, including phobic anxiety, post-traumatic stress disorder, agoraphobia, and social anxiety. Nevertheless, translational uptake within routine clinical practice remains severely constrained by end-user skepticism, clinician hesitation, technological anxieties, and uncertain patient preferences. The Attitudes Towards Virtual Reality Therapy (AVRT) Scale was explicitly engineered to address these translational bottlenecks by furnishing a psychometrically robust, multidimensional measurement tool to quantify public and patient perceptions toward virtual reality psychological treatments.

From a clinical perspective, the AVRT Scale fulfills multiple evaluative functions. First, it serves as a critical pre-intervention triaging and clinical readiness instrument. Because psychological engagement in immersive therapies relies heavily on an individual’s willingness to suspend disbelief, form a therapeutic bond with automated avatars, and tolerate simulated exposure challenges, identifying negative baseline attitudes allows clinicians to address specific technological apprehensions prior to treatment onset. For instance, individuals scoring low on the Expectation of presence subscale may harbor anticipatory dread regarding cybersickness or uncanny valley phenomena, which can be mitigated through psychoeducation, tailored habituation protocols, or hardware personalization.

Second, within translational research and clinical trial contexts, the AVRT Scale provides investigators with an explanatory mediator metric. Heterogeneity in clinical outcomes observed across digital health trials is frequently driven by variation in intervention adherence, perceived realism, and digital therapeutic alliance. Incorporating the AVRT Scale as a baseline covariate or longitudinal outcome variable empowers clinical researchers to investigate how evolving user attitudes modulate clinical symptom trajectories, therapeutic retention, and dropout attrition rates.

Third, from the vantage point of health economics, healthcare commissioning, and public policy, the AVRT Scale operationalizes public attitudes toward structural resource allocation. The scale directly queries consumer beliefs regarding the cost-effectiveness and fiscal sustainability of automated digital health architectures within centralized health services, such as the UK National Health Service (NHS). By assessing whether prospective consumers perceive virtual interventions as cost-saving innovations or superficial, cost-cutting substitutions for specialized human clinician care, public healthcare providers can design informed, transparent implementation strategies that foster public trust and treatment buy-in.

5. Psychological Construct

The AVRT Scale conceptualizes public reception of immersive psychotherapy as a multifaceted psychological construct comprising four correlated yet distinct latent dimensions. These dimensions capture cognitive appraisals, affective valences, perceptual expectations, and socio-economic value judgments regarding digital mental health technologies:

1. Attitude toward VRT

This primary subscale encapsulates an individual’s generalized cognitive and affective orientation toward virtual reality therapy, encompassing their openness, behavioral willingness, and relational trust toward automated coaching entities. Rather than viewing technology merely as an inert delivery pipeline, this dimension recognizes the virtual coach as a relational agent. It evaluates the degree to which a user is willing to receive therapeutic advice, adhere to inter-session homework recommendations, and project clinical legitimacy onto a virtual character. Representative items probe willingness to experiment with the modality (e.g., “If the virtual coach encouraged me to do something between sessions, I would try to do it”), general institutional optimism (e.g., “I am optimistic about virtual reality therapy being used in clinical settings”), and profound resistance or skepticism (e.g., “No amount of practice would make me want to use virtual reality therapy”).

2. Expectation of Presence

Rooted in cyberpsychology and perceptual neuroscience, this dimension evaluates the prospective user’s cognitive beliefs regarding their ability to experience immersion and spatial presence—defined as the subjective sensation of “being there” inside the digitally rendered environment despite conscious knowledge of its artificiality. High scores reflect an anticipation of meaningful ecological immersion wherein emotional and behavioral responses mirror real-world dynamics (e.g., “I think that the virtual reality therapy would make me feel present enough to be effective”). Conversely, low scores represent cognitive intrusion, hyper-awareness of artificial parameters, fears of the uncanny valley, and anticipatory somatic discomfort (e.g., “Virtual reality therapy would not be effective for me because I would be mindful that it is not real life” and “Potential side effects of virtual reality therapy would put me off using it”).

3. Preference for VRT

This subscale measures the comparative preference and parity dynamics between virtual reality interventions and traditional face-to-face psychotherapy delivered by human clinicians. It captures whether an individual conceptualizes virtual therapy as a superior, equivalent, or inherently inferior therapeutic medium. Items in this domain interrogate interpersonal trust differentials (e.g., “I would trust a virtual coach the same amount as a real therapist”), perceived comparative efficacy (e.g., “I believe that virtual reality therapy is more effective than face-to-face therapy”), and definitive behavioral choice patterns (e.g., “I would choose face-to-face therapy over virtual reality therapy”). This dimension provides essential insight into the risk of perceived therapeutic deprivation if patients are assigned automated modalities.

4. Perception of Cost-Effectiveness

The fourth dimension captures economic and macro-level systemic appraisals regarding the deployment of virtual reality therapies within public healthcare systems. Public acceptability of emerging clinical technologies is fundamentally shaped by lay beliefs concerning financial stewardship, resource allocation, and therapeutic durability. This subscale measures whether users perceive upfront investments in VR hardware, automated software, and IT infrastructure as an economically justifiable expenditure that reduces long-term healthcare burdens (e.g., “I think that using virtual reality therapy would save the NHS money in the long term” and “I think virtual reality therapy will be worth the cost”) or as an inefficient, costly technological venture.

6. Theoretical Framework

The conceptual architecture of the AVRT Scale synthesizes theoretical paradigms from health psychology, human-computer interaction, and computational neurobiology. Specifically, the instrument stands at the theoretical intersection of the Technology Acceptance Model (TAM), the Theory of Planned Behavior (TPB), and Presence Theory in immersive synthetic environments.

Technology Acceptance and Health Belief Foundations

Originating from the seminal work of Fred Davis (1989), the Technology Acceptance Model posits that the behavioral intention to adopt a novel technological system is predominantly governed by two core cognitive appraisals: Perceived Usefulness (PU) and Perceived Ease of Use (PEOU). In the context of mental health interventions, Venkatesh and Davis’s expanded TAM2 and the Unified Theory of Acceptance and Use of Technology (UTAUT) further establish that subjective norms, image, and voluntariness significantly regulate technology adoption. Within the AVRT Scale, TAM principles are operationalized through constructs assessing the therapeutic utility, functional trust, and practical willingness to follow algorithmic treatment programs. Crucially, the AVRT Scale adapts traditional TAM models to clinical healthcare by recognizing that “usefulness” in psychological interventions involves not merely cognitive efficiency, but deep emotional safety, symptom vulnerability, and therapeutic alliance.

Presence Theory and Predictive Processing in Cyberpsychology

Unlike standard screen-based digital interventions (such as smartphone applications or computer-assisted CBT), virtual reality leverages stereoscopic head-mounted displays, head-tracking degrees of freedom, and spatialized audio to replace physical sensory inputs. The theoretical framework of spatial presence (formulated by theorists such as Jonathan Steuer, Mel Slater, and Maria V. Sanchez-Vives) posits that virtual reality’s therapeutic efficacy rests upon the illusion of place (Place Illusion; PI) and the illusion of realism (Plausibility Illusion; Psi). In contemporary cognitive neuroscience, this phenomenon is understood through predictive processing models: the immersive medium provides multi-sensory feedback loops that satisfy the brain’s internal generative models of reality, prompting autonomic and emotional reactivity congruent with real-world exposure.

The AVRT Scale operationalizes these neurocognitive principles in its Expectation of presence factor. If an individual holds rigid metacognitive beliefs that synthetic environments cannot trigger genuine emotional vulnerability, or if they experience profound cognitive dissonance (“acting”), the sensory immersion will fail to provoke the affective engagement required for extinction learning and cognitive restructuring.

The Therapeutic Alliance with Non-Human Entities

A third foundational pillar underlying the AVRT Scale is the conceptual evolution of the Working Alliance (Bordin, 1979). Traditionally defined by goal agreement, task consensus, and an affective bond between patient and human therapist, modern psychotherapy research recognizes the emergence of the digital therapeutic alliance. The AVRT Scale interrogates the psychological boundary of whether a user can establish trust, perceived empathy, and accountability with a synthetic virtual character. Items evaluating trust in virtual coaches directly reflect whether users can attribute therapeutic competence and relational benevolence to algorithmic clinical guides.

7. Validity

The structural and measurement validity of the AVRT Scale was established through a multi-stage, mixed-methods scale development framework outlined by Gomez Bergin, Allison, and Hazell (2024). The empirical validation procedure adhered to internationally recognized psychometric guidelines for health measurement scales:

Content and Face Validity

The initial construct domain and item generation were grounded in a systematic synthesis of empirical literature examining digital mental health implementations, user experience (UX) in immersive technologies, and clinician-patient attitudes toward automated therapy. An initial pool of 54 candidate items was drafted by the multidisciplinary author team (encompassing digital health specialists, clinical neuroscientists, and academic clinical psychologists). These items were examined for semantic clarity, readability, construct redundancy, and clinical plausibility, ensuring that each statement captured a distinct facet of virtual reality psychological treatment.

Construct Validity: Exploratory Factor Structure

Construct validity was formally evaluated via Exploratory Factor Analysis (EFA) utilizing data gathered from adult participants possessing diverse demographic characteristics and prior virtual reality exposure. The analytical extraction pipeline retained items demonstrating salient factor loadings (≥ .40) onto distinct theoretical axes while eliminating items exhibiting severe cross-loadings or poor communalities. The resulting 33-item, four-factor solution accounted for 58.61% of the total cumulative variance, providing robust statistical verification for the multidimensional construct schema. The factor loading patterns confirmed that end-user perceptions do not collapse into a single unidimensional “pro-versus-anti technology” dichotomy, but rather diverge across practical acceptance, perceptual immersion expectations, comparative preference over human clinicians, and macroeconomic sustainability.

Convergent and Divergent Validity Insights

Analysis of inter-factor correlations revealed logical, theoretical convergence between subscales. The Attitude toward VRT dimension demonstrated substantial positive correlation with Expectation of presence, illustrating that individuals who anticipate experiencing authentic immersion inside virtual environments exhibit significantly greater willingness to engage with virtual coaching. Conversely, the Preference for VRT factor maintained moderate, differentiated associations, demonstrating that high acceptance of virtual reality therapy as a complementary tool does not necessarily mean a patient prefers it over traditional, human-led face-to-face psychotherapy. This clear psychometric divergence prevents false-positive clinical assumptions regarding patient treatment choices.

8. Reliability

The AVRT Scale demonstrates exceptional psychometric reliability, evaluated through classical test theory metrics across all retained subscales during its initial validation study (Bergin et al., 2024):

Internal Consistency

Internal consistency was assessed using Cronbach’s alpha (α) across the four extracted factors. Every subscale exhibited internal consistency well above the conventional psychometric threshold of .70, meeting the rigorous standards (≥ .80) required for clinical and research instrumentation:

• Factor 1: Attitude toward VRT (13 items): Demonstrated superior internal consistency with Cronbach’s α ≥ .82, indicating strong item interrelatedness and minimal measurement error when quantifying general therapeutic valence and avatar coach trust.
• Factor 2: Expectation of presence (9 items): Exhibited high internal consistency with Cronbach’s α ≥ .82, demonstrating that items probing sensory realism, cognitive suspension of disbelief, and uncanny valley concerns form a cohesive latent scale.
• Factor 3: Preference for VRT (7 items): Displayed excellent internal consistency with Cronbach’s α ≥ .82, confirming that items evaluating comparative therapeutic parity and modality selection operate as a unified evaluative continuum.
• Factor 4: Perception of Cost-Effectiveness (4 items): Attained strong internal consistency with Cronbach’s α ≥ .82, validating that lay perceptions of economic sustainability, systemic savings, and cost-benefit trade-offs represent an empirically stable construct.

The collective internal consistency findings confirm that the AVRT Scale’s constituent items operate with high precision, yielding dependable composite indices suitable for group comparisons, structural equation modeling, and clinical assessment batteries.

9. Factor Analysis

The dimensional architecture of the AVRT Scale was established through extensive Exploratory Factor Analysis (EFA) conducted by Gomez Bergin, Allison, and Hazell (2024). The statistical process reduced the initial 54-item instrument down to the psychometrically optimal 33-item inventory:

Sampling Adequacy and Extraction Criteria

Prior to factor extraction, data suitability was confirmed via the Kaiser-Meyer-Olkin (KMO) measure of sampling adequacy and Bartlett’s Test of Sphericity, verifying sufficient inter-item correlation matrices for multidimensional modeling. Factor retention decisions were guided by multiple converging criteria: Kaiser’s eigenvalue-greater-than-one rule (eigenvalues > 1.0), visual inspection of Cattell’s scree plot, and parallel analysis to avoid over-factoring.

Factor Solution and Variance Explained

An oblique factor rotation (e.g., Promax or Oblimin) was employed, allowing latent factors to correlate realistically, mirroring psychological phenomena in human attitudes. The final four-factor structural solution accounted for an impressive 58.61% of the total cumulative variance in participant responses. Factor loadings for all 33 retained items exceeded the primary cutoff criterion of ≥ .40, with the vast majority loading above .55 onto their respective target factors without problematic cross-loadings onto secondary dimensions.

Factor Dimension	Item Count	Eigenvalue / Variance Dynamics	Psychometric Focus
Factor 1: Attitude toward VRT	13 Items	Primary explanatory variance contributor	Willingness to try VRT, coach compliance, clinical optimism, tech receptivity
Factor 2: Expectation of presence	9 Items	Secondary explanatory factor	Simulated realism, suspension of disbelief, side effect concerns, skepticism
Factor 3: Preference for VRT	7 Items	Tertiary explanatory factor	Comparative efficacy, interpersonal trust parity, modality choice (VR vs. in-person)
Factor 4: Cost-effectiveness	4 Items	Quaternary explanatory factor	Systemic economic value, NHS cost offsets, long-term fiscal efficiency

The clear loading patterns observed across the 33 items confirm that public perceptions of virtual reality therapy integrate distinct cognitive domains: willingness to use the technology is psychologically distinct from whether one expects it to feel subjectively real, whether one prefers it to human contact, or whether one views it as economically viable.

10. Instrument / Measurement Tool

The AVRT Scale is structured as an interactive self-report inventory optimized for digital and computer-assisted administration. Below is the operational summary of its structural, administrative, and scoring parameters:

• Instrument Name: Attitudes Towards Virtual Reality Therapy (AVRT) Scale.
• Authors: Aislinn D. Gomez Bergin, Aoife M. Allison, and Cassie M. Hazell.
• Year of Development: 2024.
• Test Format: Standardized self-report multidimensional psychometric questionnaire.
• Item Count: 33 core quantitative closed items, accompanied by 3 qualitative open-ended free-text prompts and 16 conditional qualitative follow-up triggers.
• Response Scale: 7-point Likert-type scale formatted as follows:
  • 1 = Strongly Disagree
  • 2 = Disagree
  • 3 = Somewhat Disagree
  • 4 = Neither Agree nor Disagree (Neutral)
  • 5 = Somewhat Agree
  • 6 = Agree
  • 7 = Strongly Agree
• Reverse-Scored Items: Eleven items across the inventory are reverse-worded to counteract acquiescence bias (indicated by the superscript ‘c’ in the original instrument). For these items, scoring must be inverted prior to subscale aggregation (i.e., 1 → 7, 2 → 6, 3 → 5, 4 → 4, 5 → 3, 6 → 2, 7 → 1):
  • Attitude toward VRT: Items 2, 5, 7, 11, and 13.
  • Expectation of presence: Items 14, 17, 19, and 21.
  • Preference for VRT: Item 28.
  • Cost-effectiveness: Item 32.
• Scoring and Metrics: Dimensional subscale scores are computed by summing or averaging the items within each factor (following reverse-scoring transformations). Higher subscale scores denote:
  • Attitude toward VRT: Greater receptivity, optimism, and trust toward automated virtual coaches.
  • Expectation of presence: Higher anticipated spatial immersion, realism, and lower cyber-apprehension.
  • Preference for VRT: Stronger preference for virtual interventions relative to traditional face-to-face human therapy.
  • Cost-effectiveness: Stronger belief that VRT provides long-term financial savings and economic return for public healthcare systems.
• Qualitative Follow-Up Features: In its native computerized deployment, the AVRT Scale includes logic branching whereby 16 items trigger dynamic free-text input boxes if a participant endorses an extreme rating (e.g., Strongly Agree or Strongly Disagree), providing contextual qualitative data for clinical and exploratory research.
• Target Population: Adults aged 18 years and older across all demographic brackets (young adulthood, middle age, and older adults) within general public, clinical outpatient, and digital therapeutic trial settings.

11. Permissions & Fee and Test Year

The Attitudes Towards Virtual Reality Therapy (AVRT) Scale was published in 2024. The development and psychometric validation of the instrument were detailed in an open-access study published in JMIR Mental Health. In accordance with open-science publishing mandates and the Creative Commons Attribution (CC BY 4.0) license, the scale items and conceptual framework are publicly accessible for non-commercial academic, clinical, and scientific research without licensing fees, provided that appropriate scholarly attribution and citation are accorded to the original authors (Bergin, Allison, & Hazell, 2024).

Commercial deployment, proprietary health platform integration, or for-profit mobile application bundling may require specific institutional permissions from the authors and their representing institutions (University of Nottingham and University of Surrey). Researchers intending to adapt, translate, or incorporate the AVRT Scale into clinical electronic health records (EHR) should consult the corresponding authors via the National Institute for Health and Care Research (NIHR) MindTech MedTech Co-operative.

12. References

Below is the formal bibliographic reference list documenting the theoretical and empirical sources underpinning the AVRT Scale in APA 7th edition format:

• Bergin, A. D. G., Allison, A. M., & Hazell, C. M. (2024). Understanding public perceptions of virtual reality psychological therapy using the Attitudes Towards Virtual Reality Therapy (AVRT) Scale: Mixed methods development study. JMIR Mental Health, 11, Article e48537. https://doi.org/10.2196/48537
• Bordin, E. S. (1979). The generalizability of the psychoanalytic concept of the working alliance. Psychotherapy: Theory, Research & Practice, 16(3), 252–260. https://doi.org/10.1037/h0085885
• Davis, F. D. (1989). Perceived usefulness, perceived ease of use, and user acceptance of information technology. MIS Quarterly, 13(3), 319–340. https://doi.org/10.2307/249008
• Freeman, D., Reeve, S., Robinson, A., Ehlers, A., Clark, D., Spanlang, B., & Slater, M. (2017). Virtual reality in the assessment, understanding, and treatment of mental health disorders. Psychological Medicine, 47(14), 2393–2400. https://doi.org/10.1017/S003329171700040X
• Mori, M., MacDorman, K. F., & Kageki, N. (2012). The uncanny valley [From the Field]. IEEE Robotics & Automation Magazine, 19(2), 98–100. https://doi.org/10.1109/MRA.2012.2192811
• Slater, M., & Sanchez-Vives, M. V. (2016). Enhancing our lives with immersive virtual reality. Frontiers in Robotics and AI, 3, Article 74. https://doi.org/10.3389/frobt.2016.00074
• Steuer, J. (1992). Defining virtual reality: Dimensions determining telepresence. Journal of Communication, 42(4), 73–93. https://doi.org/10.1111/j.1460-2466.1992.tb00812.x
• Venkatesh, V., & Davis, F. D. (2000). A theoretical extension of the technology acceptance model: Four longitudinal field studies. Management Science, 46(2), 186–204. https://doi.org/10.1287/mnsc.46.2.186.11926

13. Items of the Scale