Virtual Reality in Therapy
Rabbit Holes of Discovery
By Dan Kelley
Illustrations by Christian A. Vera
Four years ago, my son’s stepfather attempted to take his own life. The inexplicability of his survival speaks to a miracle, but my little boy never did see him again. Fortunately, Calvin was with me that night. His mom called the next day to inform me. I didn’t know what to say other than, “What can I do to help?” She sighed deeply. “I don’t know … Just make sure he has a good weekend.”
I lingered on the porch and leaned on the guardrail, racking my brain for “good weekend” ideas while simultaneously trying to side-step the dark, yet familiar, catastrophizing thoughts of childhood abandonment pushing in on my mind. These are the moments when balancing life as a trauma therapist and single dad feels impossible—the boundaries of compartmentalization blur, roles entangle, and everything feels out of control.
With Calvin in mind, I went out to Best Buy and bought a brand-new virtual reality headset for us. That afternoon, we had a blast using the force as untrained Jedi, controlling time with our body movements to defeat our enemies, and exploring the coolest places on earth in a variety of apps. After playing a combat game called SUPERHOT VR for a few minutes, it hit me. The game’s mechanics, inherently coupled with the mind-body connection, were actively teaching my son impulse control! We even tried Parkline Interactive’s app Wander, which uses 360-degree imaging for virtual traveling and exploring pretty much anywhere on earth based on map data drawn from Google. While it was an adventure for my son, who has yet to explore the world, the virtual experience brought a flood of emotions for me. Nostalgia, loss, excitement, even forgotten memories.
The exploration with my son quickly sparked the realization: I can take clients anywhere, even into their past, to revisit experiences and heal.
Beyond Games
I am a gamer-affirmative trauma therapist with over a decade of experience integrating video games into therapy. Since 2011, my training and expertise have centered on teens and young adults living with trauma using gamification and video game–based approaches, combined with traditional psychotherapy models and techniques. So, with the growing accessibility of virtual reality headsets like the Meta Quest and what I was beginning to see for myself, I was all the more excited to apply these established methods to this new platform.
It wasn’t long after my first dive into VR that I discussed my idea with Jack, one of my teen clients in residential treatment who was working toward trauma processing. I shared that, to my knowledge, no research regarding trauma processing had been done with this particular headset and app; however, there was a growing body of studies investigating a variety of treatments, including trauma processing, with VR headsets producing promising results. I informed him we would integrate Wander VR with several evidence-based methods, that this particular approach was new to me, and that he could say no. Jack was all for it and opted to try it out in the following session to process the shootout he survived.
During the final minutes of this session, I suggested Jack find and save a nearby spot on the map a few blocks away from the location of the shootout to save time next session. He eye-balled the map, found a familiar spot, clicked, and unknowingly appeared right on the scene of his trauma. His body trembled as he ripped off the headset, catapulted into fight-or-flight. Jack was in visible agony, pulling at his hair and rocking back and forth, trapped in a relentless loop of horrifying images. I suggested using the container method, a mental imagery technique guiding individuals to visualize a “container” in their mind used to compartmentalize and store overwhelming thoughts and feelings to help let the mind rest. But it was futile—he couldn’t visualize anything outside the chaos playing out in his mind. Watching him unravel, I felt myself spiral too, questioning my clinical judgment. Had I misjudged his readiness, or worse, ignored his needs for the sake of my ambitions? As guilt, doubt, and helplessness gripped me, I had to push aside my inner turmoil—Jack needed me present, not lost in my own baggage.
Snapping out of the gravitational field of my countertransference, I turned to gamification and booted up Minecraft on Xbox. Video games have been found to help alleviate symptoms of anxiety and depression, even if just temporarily, so I hoped gameplay could assist Jack back to baseline. I also considered the connection between visual information, hands-on experience, and memory recall: If he created a virtual representation of his “container” in the game, he might later be able to access it in his mind more easily, relying on tangible memory rather than conjuring an image from scratch. Within minutes, his breathing steadied, his face relaxed, and his body followed suit as he focused on building. Though he didn’t finish his container that session, Jack left saying he felt much better—a small but significant step forward.
That night, I reflected on what had clouded my clinical judgment. Was I driven by a need for catharsis, attempting to resolve Jack’s trauma to ease my own fear and helplessness tied to my child’s struggles? Or maybe a part of me wanted to prove my competence, compelled by the underlying core belief that I’m “not good enough,” a narrative shaped by childhood abandonment and early academic failures? Perhaps it was both. What I learned, however, was clear: Neither of us was ready. Moving forward, I resolved to take a gentler approach—testing the waters, using proximity in the virtual environment to gradually close the gap and gauge readiness. Above all, I knew I had to ensure this kind of oversight never happened again.
In our next session, Jack and I continued working on his container. He envisioned a treasure chest sealed with a padlock, featuring a glass floor with lava beneath it—“because that’s what this feels like,” he explained, speaking to the somatic and cognitive experience he endures in fight-or-flight. I encouraged him to elaborate, and his description was detailed, thoughtful, and deeply meaningful. The Minecraft approach appeared to be an effective tool for grounding, helping him return to baseline from trauma states. This success gave us both a renewed sense of confidence about attempting VR exposure again. Though there was still work to be done, it wasn’t long before Jack demonstrated readiness to step back into the VR headset.
Over time, Jack gradually increased the duration of exposure to his trauma in the virtual environment using the structure of progressive counting, a method of imaginal exposure in which the client repeatedly plays out the traumatic experience like a story in their mind at increasing intervals; and he further enhanced the details of his narrative each session using elements from a social information processing model, the signal cycle model. Between trauma sessions, he often revisited his “container” in the game, and eventually he transitioned from relying on Minecraft to traditional mental imagery, successfully grounding himself independently—such a win! The Minecraft approach had served as training wheels, preparing him to stay within his window of tolerance as he recounted his trauma while immersed at the scene of the incident in VR. Months later, Jack reported he no longer experienced flashbacks, and not long after, he was discharged from the residential treatment facility.
Every traditional tool I trained in became an opportunity to refine VR techniques and adapt off-the-shelf games and apps for therapy.
Diving Deeper
This case was groundbreaking for me. It became a turning point in the direction of truly embracing mistakes, even looking forward to them. I was always taught “It’s okay to make mistakes.” But did I truly believe it? I recognized the hurt little boy inside me who still resisted this idea, carrying unresolved pain despite the progress I had made in my own trauma therapy. Keeping this in mind, I approached my work in VR with greater care, especially before we returned to the dark places from the past.
I emphasize “we” because I can see everything my clients see, whether it’s projected on a screen or experienced alongside them in another VR headset. Clients walk me through their narratives quite literally, showing me where it happened and how it unfolded in detail. My mind, imaginative as it is, naturally constructs images and details when hearing their trauma stories, but VR takes it a step further. Now I find myself standing “at the scene of the crime,” like a detective stepping past the red tape, observing the aftermath of the horrors that occurred. My brain synthesizes new information with the known client-information in a way that feels far more vivid and visceral than relying on mental imagery alone—I am immersed.
Whether the client finds themself reexperiencing or simply looking back in time void of emotion, I am no longer observing, I am experiencing. Because of the intimacy and intensity of this method, my immersion is a willing invitation for vicarious trauma. Without adequate preparation, I may find myself on my own couch, staring at the ceiling, feeling heavy, swirling in the images tattooed on my mind. I must be ready, mind and body—getting enough sleep, actually eating my lunch instead of doing progress notes, taking a moment to acknowledge my own internal world, the hurt little boy within and my present anxieties before placing them on the backburner. I do what I can to have my compartmentalization skills primed and ready, and if possible, have something for self-care, usually my guitar, at the ready after VR sessions.
I began sharing my use of VR with colleagues, inviting them to explore virtual worlds firsthand. Within minutes of trying a few apps, one colleague declared, “I’m sold.” Where I saw a novel way to improve impulse control in one app, he saw the ability to increase interoception—using the body’s anxiety signals to build self-awareness and tolerance. Where I saw trauma processing in another app, he saw rapport building through exploring “Where’s the coolest place you’ve ever been?” Every traditional tool I trained in became an opportunity to refine VR techniques and adapt off-the-shelf games and apps for therapy. My approach evolved as I uncovered ways to harness hidden inner worlds (see More VR Tools below). The more I learned, the more passionate—and overwhelmed—I became, realizing how much I still didn’t know.
Two years later, I sought supervision from gamer therapist Mike Langlois, who reintroduced me to foundational theories I had learned about in grad school. I took a deeper dive into object relations, transitional objects, and the dynamics and utilization of transference and countertransference. Mike also introduced me to Winnicott’s squiggle game, a simple yet ingenious tool for building rapport and gathering insight in early sessions. We adapted it to a virtual whiteboard app with digital markers, where colors added depth and meaning through unconscious associations. Inspired, I knew exactly what to do next—I bought another VR headset.
Looking Back, Moving Forward
It’s been a while since I put the VR headset on to use Wander by myself. I’m usually in my office helping a client into it, asking, “Is it okay if I touch your head?” or “Do you mind if I touch your hands?” before strapping them in comfortably. I gave up on going home, my first home. Nearly every person I’ve invited into this virtual world was able to go home using Wander—everyone but me. Wander uses data from Google Street View, and of the estimated 220 billion 360-degree images they’ve captured of over 10 million miles worldwide, my rural childhood home wasn’t among them. All I could do was stand at the edge of 96B, stare down Steam Mill Road, and trace the familiar path disappearing from view beneath the trees into the rolling hills, never to walk down it, with a weight in my chest and a deep feeling of longing.
But this time, new paths opened up, letting me in. Is that Jennings Pond? I click the map and I’m there. Right here. I look to my right and see the dam where I found my first water snake. Behind me, the swimming area and the beach where I used to play as a toddler. Looking around, I realize I’m standing exactly where I stood when I caught my first fish. I was 4, maybe 5 years old, grabbing the sunny excitedly and cutting my hand on its sharp, spiny dorsal fin. I remember holding the bobber with its white top and dripping, red underbelly as my dad unhooked the sunny’s gills, which heaved helplessly in his hands. A lump forms in my throat as waves of mixed emotion pass through me. The sweetness of childhood nostalgia and bitter pain of abandonment. The sight of the pond elicits such a visceral memory, it’s hard to believe 30 years have passed and I’m standing over 2,000 miles away. I look back at the map, daring to hope. Is it there? Can I finally go home? 893 Steam Mill… [search] ...
It’s 2025. My son, now 9 years old, is doing well. He is resilient, and he has me. I’ve established my own private practice, helping clients and teaching other mental health professionals how to utilize video games and VR in therapy. Yet I’m still humbled by how much I don’t know. The interplay of mistakes and successes in my journey toward mastering this technology has revealed just how creative and expansive the paths to healing can be.
Clinicians from any background can bring their expertise to the virtual world, discover how VR can enhance psychotherapy, adapt traditional methods, deepen clinical supervision, and enrich the therapeutic relationship. Within these digital spaces lie opportunities to unearth new techniques, understand clients more deeply, and even learn about ourselves. Through exploration, mistakes, and discovery in this realm, I’ve had the privilege of virtually stepping into the mind’s eye of others, and at times, experienced the vulnerability of others stepping into mine.
More VR Tools
During Jack’s case my son’s Aunt Ashlie introduced me to another VR app, Tilt. “Have you ever played the drawing game? It’s so cool—you have to try it!” she said. Intrigued, I downloaded it immediately and handed her the headset. “Show us how it’s done!”
Tilt was a single-player game, and Ashlie wasn’t kidding—it was incredible. We watched as she created giant arches that stretched from floor to ceiling and left to right, inching forward with each stroke. On the TV, we could see what she saw through the headset, and we couldn’t look away. “Okay, I’m done—check this out!” she said.
When I put on the headset, I was transported into a vibrant rainbow tunnel. The brush she used didn’t apply separate colors or strokes; it created a seamless, neon-saturated tunnel, glowing and pulsing like a nightclub sign. As I walked through it, a feeling of wonder washed over me. Could this be another therapy tool?
The creators of Tilt now have an app called MultiBrush, another three-dimensional drawing space that allows more than one person to enter, draw together, collaborate, or play side-by-side. There are 85 brushes to choose from, including 24 visually reactive brushes with sustained animation within the confines of where the line was drawn, and 29 auditory reactor brushes that provide a kind of texture through the senses while the brush is activated. After MultiBrush was released, I speculated that the app could enhance the therapeutic experience and engagement for youth through this wide variety of brush options, captivating mechanisms, sensory input relays, and immersion. I figured that, on some level, it had the capacity for evoking relevant information for therapy that a pen and paper could not access. I was not disappointed.
I’m willing to bet analysts would have a field day harnessing some of these interactive environments. In Multibrush, for example, players can adjust the physical size of their avatar or virtual body ranging from “squirrel” to “brachiosaurus.” When I’m virtually the size of a dinosaur, I feel more like a deity, looking down on the world below me as I design the sky above and mold massive, planet-sized figures beyond, in the eyes of “human” avatars. A number of clients experiencing the wonders of being the size of a “brachiosaurus” found it more entertaining to treat me like Sid does his toys in Toy Story, crushing me with their avatar’s hands, scribbling me out, or trapping me inside their drawings—annihilating me. Some preferred to make themselves so small I could barely see them, playfully telling me to find them out like hide-and-seek, others wished their drawing to be for their eyes only, and some didn't want me to see them at all. The exploration and discovery is truly awesome.
Dan Kelley, LCSW, is a psychotherapist in private practice helping teens and young adults in Utah. He trained at the University at Buffalo’s School of Social Work and has over 13 years of experience gaming with clients in therapy.
Issue 59.1, Spring 2025Potentially personally identifying information presented that relates directly or indirectly to an individual, or individuals, has been changed to disguise and safeguard the confidentiality, privacy, and data protection rights of those concerned.