(1) Background: Virtual reality (VR) has been investigated in a variety of psychiatric disorders, including addictive disorders (ADs); (2) Objective: This systematic review evaluates the current evidence of immersive VR (using head-mounted displays) in the clinical assessment and treatment of ADs; (3) Method: PubMed and PsycINFO were queried for publications up to November 2020; (4) Results: We screened 4519 titles, 114 abstracts and 85 full-texts, and analyzed 36 articles regarding the clinical assessment (i.e., diagnostic and prognostic value; n = 19) and treatment (i.e., interventions; n = 17) of ADs. Though most VR assessment studies (n = 15/19) showed associations between VR-induced cue-reactivity and clinical parameters, only two studies specified diagnostic value. VR treatment studies based on exposure therapy showed no or negative effects. However, other VR interventions like embodied and aversive learning paradigms demonstrated positive findings. The overall study quality was rather poor; (5) Conclusion: Though VR in ADs provides ecologically valid environments to induce cue-reactivity and provide new treatment paradigms, the added clinical value in assessment and therapy remains to be elucidated before VR can be applied in clinical care. Therefore, future work should investigate VR efficacy in randomized clinical trials using well-defined clinical endpoints.

Background: Immersive virtual reality (IVR) has been investigated as a tool for treating psychiatric conditions. In particular, the practical nature of IVR, by offering a doing instead of talking approach, could support people who do not benefit from existing treatments. Hence, people with mild to borderline intellectual disability (MBID; IQ=50-85) might profit particularly from IVR therapies, for instance, to circumvent issues in understanding relevant concepts and interrelations. In this context, immersing the user into a virtual body (ie, avatar) appears promising for enhancing learning (eg, by changing perspectives) and usability (eg, natural interactions). However, design requirements, immersion procedures, and proof of concept of such embodiment illusion (ie, substituting the real body with a virtual one) have not been explored in this group. Objective: Our study aimed to establish design guidelines for IVR embodiment illusions in people with MBID. We explored 3 factors to induce the illusion, by testing the avatar’s appearance, locomotion using IVR controllers, and virtual object manipulation. Furthermore, we report on the feasibility to induce the embodiment illusion and provide procedural guidance. Methods: We conducted a user-centered study with 29 end users in care facilities, to investigate the avatar’s appearance, controller-based locomotion (ie, teleport, joystick, or hybrid), and object manipulation. Overall, 3 iterations were conducted using semistructured interviews to explore design factors to induce embodiment illusions in our group. To further understand the influence of interactions on the illusion, we measured the sense of embodiment (SoE) during 5 interaction tasks. Results: IVR embodiment illusions can be induced in adults with MBID. To induce the illusion, having a high degree of control over the body outweighed avatar customization, despite the participants’ desire to replicate their own body image. Similarly, the highest SoE was measured during object manipulation tasks, which required a combination of (virtual) locomotion and object manipulation behavior. Notably, interactions that are implausible (eg, teleport and occlusions when grabbing) showed a negative influence on SoE. In contrast, implementing artificial interaction aids into the IVR avatar’s hands (ie, for user interfaces) did not diminish the illusion, presuming that the control was unimpaired. Nonetheless, embodiment illusions showed a tedious and complex need for (control) habituation (eg, motion sickness), possibly hindering uptake in practice. Conclusions: Balancing the embodiment immersion by focusing on interaction habituation (eg, controller-based locomotion) and lowering customization effort seems crucial to achieve both high SoE and usability for people with MBID. Hence, future studies should investigate the requirements for natural IVR avatar interactions by using multisensory integrations for the virtual body (eg, animations, physics-based collision, and touch) and other interaction techniques (eg, hand tracking and redirected walking). In addition, procedures and use for learning should be explored for tailored mental health therapies in people with MBID.

Background: People with mild to borderline intellectual disability (MBID; IQ=50-85) are at risk for developing an alcohol use disorder (AUD). One factor contributing to this risk is sensitivity to peer pressure. Hence, tailored trainings are needed to practice alcohol refusal in impacted patients. Immersive virtual reality (IVR) appears promising to engage patients in dialogs with virtual humans, allowing to practice alcohol refusal realistically. However, requirements for such an IVR have not been studied for MBID/AUD. Objective: This study aims to develop an IVR alcohol refusal training for patients with MBID and AUD. In this work, we cocreated our peer pressure simulation with experienced experts in addiction care. Methods: We followed the Persuasive System Design (PSD) model to develop our IVR alcohol refusal training. With 5 experts from a Dutch addiction clinic for patients with MBID, we held 3 focus groups to design the virtual environment, persuasive virtual human(s), and persuasive dialog. Subsequently, we developed our initial IVR prototype and conducted another focus group to evaluate IVR and procedures for clinical usage, resulting in our final peer pressure simulation. Results: Our experts described visiting a friend at home with multiple friends as the most relevant peer pressure situation in the clinical setting. Based on the identified requirements, we developed a social-housing apartment with multiple virtual friends present. Moreover, we embedded a virtual man with generic appearance to exert peer pressure using a persuasive dialog. Patients can respond to persuasive attempts by selecting (refusal) responses with varying degrees of risk for relapse in alcohol use. Our evaluation showed that experts value a realistic and interactable IVR. However, experts identified lacking persuasive design elements, such as paralanguage, for our virtual human. For clinical usage, a user-centered customization is needed to prevent adverse effects. Further, interventions should be therapist delivered to avoid try-and-error in patients with MBID. Lastly, we identified factors for immersion, as well as facilitators and barriers for IVR accessibility. Conclusions: Our work establishes an initial PSD for IVR for alcohol refusal trainings in patients with MBID and AUD. With this, scholars can create comparable simulations by performing an analogous cocreation, replicate findings, and identify active PSD elements. For peer pressure, conveying emotional information in a virtual human’s voice (eg, paralanguage) seems vital. However, previous rapport building may be needed to ensure that virtual humans are perceived as cognitively capable entities. Future work should validate our PSD with patients and start developing IVR treatment protocols using interdisciplinary teams.

BACKGROUND Immersive Virtual Reality (IVR) has been investigated as tool for treating psychiatric conditions. Especially the practical nature of IVR, by offering a doing instead of talking approach, could support people who do not benefit from existing treatments. Hence, people with mild to borderline intellectual disability (MBID, IQ = 50-85) might profit particularly from IVR therapies, for instance, to circumvent issues in understanding relevant concepts and interrelations. In this context, immersing the user into a virtual body (i.e. avatar) appears promising for enhancing learning (e.g. by changing perspectives) and usability (e.g. natural interactions). However, design requirements, immersion procedures, and the proof of concept of such embodiment illusion (i.e. substituting the real body with a virtual one) have not been explored in this group. OBJECTIVE Our work aimed to establish design guidelines for IVR embodiment illusions in people with MBID. We explored three factors to induce the illusion, by testing the (1) avatar’s appearance, (2) locomotion using IVR controllers, and (3) virtual object manipulation. Further, we report on the feasibility to induce the embodiment illusion and provide procedural guidance. METHODS We conducted a user-centered design with 29 end-users in care facilities, to investigate the (1) avatar’s appearance, (2) controller-based locomotion (i.e. teleport, joystick, or hybrid), and (3) object manipulation. Three iterations were conducted using semi-structured interviews to explore design factors to induce embodiment illusions in our group. To further understand the influence of interactions on the illusion, we measured the Sense of Embodiment (SoE) during five interaction tasks. RESULTS IVR embodiment illusions can be induced in adults with MBID. To induce the illusion, having a high degree of control over the body outweighed avatar customization, despite the participants' desire to replicate the own body image. Likewise, the highest SoE was measured during object manipulation tasks, which required a combination of (virtual) locomotion and object manipulation behavior. Notable, interactions that are implausible (e.g. teleport, occlusions when grabbing) showed a negative influence on the SoE. Contrarily, implementing artificial interaction aids into the IVR avatar’s hands (i.e. for user interfaces) did not diminish the illusion, presuming that the control was unimpaired. Nonetheless, embodiment illusions showed a tedious and complex need for (control) habituation (e.g. motion sickness), possibly hindering uptake in practice. CONCLUSIONS Balancing the embodiment immersion, by focusing on interaction habituation (e.g. controller-based locomotion) and lowering customization effort seems crucial to achieve both a high SoE and usability for people with MBID. Hence, future work should investigate requirements for natural IVR avatar interactions by using multisensory integrations for the virtual body (e.g. animations, physics-based collision, touch), and other interaction techniques (e.g. hand tracking, redirected walking). In addition, procedures and usage for learning should be explored for tailored mental health therapies in people with MBID.

BACKGROUND Substance Use Disorders (SUDs) are prevalent and characterized by high relapse rates. Individuals with Mild to Borderline Intellectual Disability (MBID) are more likely to develop SUDs, highlighting the need for SUD treatment. However, people with MBID face challenges with treatment as usual. Cognitive Behavioral Therapy (CBT) is often difficult for this group due to the difficulties they experience with abstract thinking, verbal skills, and generalizing learned strategies to real-world contexts. These difficulties can reduce CBT’s effectiveness, requiring adapted interventions. Immersive Virtual Reality (IVR) may enhance CBT by simulating realistic, safe environments where patients with SUD and MBID can practice cognitive and behavioral skills that are tailored to their treatment needs with visual and practice-oriented materials. OBJECTIVE This study provides input for developing IVR-CBT treatment for patients with MBID and SUDs. We focus on high-risk situations and triggers inducing alcohol craving and examine coping strategies to reduce nicotine craving by using specific coping elements within the IVR. METHODS Two explorative studies were conducted at an inpatient clinic for patients with MBID and SUD in the Netherlands. Study 1 included ten adults with Alcohol Use Disorder and MBID who participated in interviews to determine relevant risk situations, triggers and therapeutic goals for IVR-CBT. Study 2 included ten adults with MBID and Nicotine Dependence who practiced coping strategies within an existing IVR featuring craving inducing and craving reduction scenarios. A multiple-method approach was used to gather input for developing IVR-CBT technology and protocols, as well as exploring feasibility and acceptability (user evaluation interviews, the Questionnaire of Smoking Urges and Visual Analog Scale ratings of craving) of the IVR. RESULTS In study 1 we identified important high-risk situations (e.g. at-home routines, supermarkets and social gatherings) and triggers (peer pressure, negative affect and sensory triggers). The participants expressed interest in using IVR to identify personal triggers, discuss affective states with their therapist, and repeatedly train refusal skills in response to craving inducing triggers within IVR. In study 2, multiple strategies (e.g. relaxation exercises with virtual therapists, distractions (e.g. virtual pets), and physical activities) embedded in IVR were found helpful in training coping skills. Participants described the IVR-CBT approach with risk-coping scenarios as highly acceptable, though some needed additional support because of anxiety or unfamiliarity with IVR technology. CONCLUSIONS The findings of this work provide concrete design insights into triggers and coping skills that can be integrated into an IVR-CBT for persons with MBID and SUD. Future work should investigate the design of IVR for CBT through an iterative, user-center design approach based on validated CBT related techniques (e.g. functional analysis, coping skills training), and evaluation of the IVR-CBT compared to CBT as usual to understand benefits and risks for both patients and therapists.