Motivation and emotion/Book/2026/Immersive therapy for PTSD treatment

Immersive therapy for PTSD treatment:
How does it work and what are the effects?

Overview

Scenario: Immersive PTSD therapies Andriy, a soldier, harnessed to a treadmill, walks towards an image he spent months avoiding. His therapist beside him. This is multi-modular motion assisted memory desensitisation and reconsolidation (3MDR), one of a new generation of immersive therapies being used to treat post-traumatic stress disorder. Figure 1. Andriy, alongside moves through his 3MDR treatment. Learn about more about immersive therapy and Andriy’s* experience in the chapter below (*Andriy is a fictional name).

Figure 2: The 2024 World Health Organisation estimates that 3.9% of the world's population has had PTSD at some stage.

Post-traumatic stress disorder (PTSD) develops after severe or life-threatening trauma and carries a substantial personal and societal cost (Figure 2), with military personnel disproportionately represented (Boska et al., 2025). See costs and limitations below (Davis et al., 2022; Montgomery-Marks et al., 2025).

PTSD's emotional impact is shaped by emotional dysregulation - difficulty managing intense feelings such as guilt, fear or shame (Westphal et al., 2017).This commonly triggers cognitive and behavioural avoidance that offers short-term relief but prevents traumatic memory from being adaptively processed, trapping an individual in a cycle of avoidance and chronic hyper arousal (Efremov, 2025; de Haart et al., 2026; van Gelderen et al., 2018).

Immersive interventions, including virtual reality exposure therapy (VRET) and 3MDR aim to break this avoidance cycle by creating controlled environments in which trauma and cues can be safely approached rather than avoided (van Gelderen et al., 2018; Wiederhold & Wiederhold, 2025). This chapter explains the psychological theory behind these approaches, reviews the research evidence for their effects and considers their limitations.

Focus questions Why is emotional processing important in PTSD? How can immersive therapies influence the emotional processes underlying PTSD? What does the research evidence show? What are the costs and limitations of immersive therapies?

Why is emotional processing important in PTSD?

Figure 3. PTSD can have a deep and lasting impact on our emotions.

PTSD is formally diagnosed according to DSM-5 criteria and is characterised by disrupted executive and emotional processing systems, heightened threat perception, hyper-vigilance and persistent negative emotional states as depicted in Figure 3 (Kukharuk et al., 2025; López-Ojeda & Hurley, 2022; Osman et al., 2016).

Predict the outcome A soldier with PTSD encounters a trauma-related image and expects: TRAUMA CUE → DANGER → DISTRESS → AVOID However, during immersive treatment, the expected danger does not occur. What is the most likely consequence? Fear increases permanently. Memory cannot change. Prediction error creates an opportunity for new learning. Emotional processing stops.  Click "show" below to understand more⤵ Please pause and predict the answer before opening this section The correct answer is C. The mismatch between expected danger and actual safety creates a prediction error. This may contribute to fear extinction, emotion regulation, and memory reconsolidation.Think about it: If approaching rather than avoiding trauma can create new learning, what role might emotion regulation, fear extinction, prediction error and memory reconsolidation play?

Understanding PTSD and emotions

Emotional processing theory suggests that recovery requires the trauma memory to be reactivated and updated with corrective information. In PTSD this process is blocked and to manage this intense distress, many individuals adopt a cognitive and behavioural avoidance defence mechanism (López-Ojeda & Hurley, 2022). Avoidance offers short-term relief, but prevents the traumatic memory from being reactivated, so it cannot be updated. Trauma reminders such as flashbacks continue triggering extreme distress, trapping the individual in a maladaptive, self-reinforcing avoidance cycle (Figure 4) (Vermetten, Burback, et al., 2025b).

At a neural level, Westphal et al. (2017) link this to transdiagnostic emotion dysregulation, in which the traumatic memory network remains isolated from the brain's salience and central executive networks. Effective treatment requires safely reactivating this network so the memory can be integrated (Vermetten, Burback, et al., 2025b; Westphal et al., 2017).

A 2025 study of Danish military veterans (n=142) found emotional regulation difficulties explained an additional 28% of the variance in PTSD symptoms; combined with comorbid symptoms, these factors accounted for 52% of the variance in severity (F(13, 92) = 9.58, p <0.001) (Elklit & Dahl, 2025).

Figure 4. Avoidance cycles and the anticipated positive responses generated via immersive therapies. Based on concepts by Lopez-Ojeda et al. (2022), Felemban et al. (2026), and Vermetten et. al. (2025b).

Why treatment can be difficult

Trauma-focused psychotherapies such as prolonged exposure (PE) and cognitive processing therapy (CPT) ask patients to actively engage with distressing memories to generate fear extinction, precisely what avoidance prevents (van Toorenburg et al., 2020). Many patients cannot tolerate the emotional exposure these therapies require (Lopes et al., 2025; van Gelderen et al., 2018; Vermetten, Burback, et al., 2025b). Because the trigger is never safely confronted, the brain cannot experience a prediction error needed to learn the threat has passed, so symptoms persist indefinately. (de Haart et al., 2026; López-Ojeda & Hurley, 2022).

This is reflected in outcomes where an estimated 39.2% of patients fail to respond to standard trauma-focused therapy, and dropout rates range from 16-48% (de Haart et al., 2026; Vermetten, Burback, et al., 2025b). Among military veterans younger patients show heightened severity when trauma is central to their identity, while others turn to poor diet or substance abuse, further eroding emotional regulation (Efremov, 2025; Niles et al., 2023).

Emotional dysregulation was historically viewed as a fixed barrier requiring lengthy stabilisation before treatment could begin (van Toorenburg et al., 2020). More recent evidence suggests otherwise, as emotional regulation has dynamic capacity and can improve as a natural consequence of successful memory processing (van Toorenburg et al., 2020). This reframes the clinical challenge as helping an individual safely approach and process the traumatic memory, not correcting a fixed deficit.

Figure 5. PhD work by R. Selvakumaran (University of Canberra) explores cultural factors using the US-Bravemind system.

Cultural context adds another layer of difficulty. Doctoral research at the the University of Canberra is examining how protocols such as the US-centric Bravemind need cultural adaption for Australian veterans and first responders, whose operational backgrounds differ from their US counterparts (Selvakumaran, 2025). Integrating exposure therapy with gamified, posture-adaptive cognitive rehabilitation to support physical and emotional recovery (Figure 5) (Selvakumaran, 2025). These treatment gaps carry a substantial economic and personal cost, part of the motivation for developing alternatives such as immersive therapies.   

How can immersive therapies influence emotional processes?

Immersive PTSD treatments mark a shift from passive, sedentary therapy, towards active, embodied, highly interactive approaches (van Gelderen et al., 2018). Immersive therapy uses three psychological mechanisms and their interaction: multisensory presence, embodied cognition, and divergent thinking (López-Ojeda & Hurley, 2022; van Gelderen et al., 2018).

Embodied cognition is the concept of how physical states of the body can directly modify states of the mind (van Gelderen et al., 2018). Immersion therapy goes beyond the simple visual replication of a trauma memory; instead, capturing the participant’s visceral and cognitive focus by limiting distractions (Macey et al., 2026).

What is immersive therapy?

Figure 6. The Extended Reality environment and its interaction with the human brain. Designed to give readers a simple understanding of emerging technologies used in immersive PTSD environments.

Immersive therapies use extended reality(XR) platforms, encompassing virtual reality (VR), augmented reality (AR), and mixed reality (MR), to create customisable, controlled, and standardised therapeutic environments (López-Ojeda & Hurley, 2022; Wiederhold & Wiederhold, 2025). This ecosystem is depicted in Figure 6.

This chapter focuses on two applications VRET where therapists reconstruct traumatic scenarios in safe, graded environments; and 3MDR, which extends this by having the patient move on a treadmill towards a panoramic display, side-by-side with their therapist, rather than a stationary, face to face session (de Haart et al., 2026; Felemban et al., 2026).

Presence and embodied cognition

Immersive therapy’s distinguishing feature is its ability to generate presence, or the psychological illusion of being ‘there’. The illusion amplified by integrating synchronised audio, visual, olfactory, haptic, and movement stimuli (Lopes et al., 2025; López-Ojeda & Hurley, 2022). This increases engagement with the trauma memory and supports emotional processing (van Gelderen et al., 2018).

In 3MDR, presence combines with cognition. The working principle is that physical states of the body can directly shape states of the mind (van Gelderen et al., 2018). Walking towards a virtual trauma functions as a fear antagonistic action and rather than retreating in avoidance, the patient approaches, converting passive helplessness into active, empowered participation and disrupting the rigid and repetitive trauma narratives common in PTSD (Boska et al., 2025; de Haart et al., 2026; Osman et al., 2016; van Gelderen et al., 2018).

Notably, this benefit does not seem to be driven by exercise physiology which suggests extinction learning normally requires moderate-to-high-intensity activity to stimulate brain-derived neurotrophic factor (BDNF); but 3MDR's walking pace (< 4 km/h) is too slow to generate meaningful BDNF secretion. This suggests the mechanism is primarily psychological and behavioural. It is the approach action itself and the cognitive restructuring it enables, rather than physiological (de Haart et al., 2026).

Prediction error and inhibitory learning

Immersive therapy builds on the inhibitory learning model of exposure therapy, in which a new, safe association actively competes with and suppresses the original fear response. Walking towards a trauma cue and encountering safety instead of the expected catastrophe creates a profound prediction error between the anticipated, life-threatening event and the actual reality. This destabilises the traumatic memory, allowing memory reconsolidation (Felemban et al., 2026; van Gelderen et al., 2018; Vermetten, Burback, et al., 2025b; Wiederhold & Wiederhold, 2025).

Memory reconsolidation

According to memory reconsolidation theory, traumatic memories retrieved in a safe, immersive contexts can become malleable, allowing new, safe information to reconsolidate the memory in a non-threatening form (van Gelderen et al., 2018; Vermetten, Burback, et al., 2025b). To prevent the patient from becoming overwhelmed, 3MDR uses dual-attention tasks such as tracking an oscillating ball (Figure 1), which taxes limited working memory resources and reduces the vividness and emotional intensity of the memory (Vermetten, Burback, et al., 2025b).

Emerging linguistic research suggests this processing is reflected in patients' language. Across successive 3MDR sessions, affective labelling of feelings such as guiltshifted from past-tense to present-tense narration, consistent with a renewed ability to integrate traumatic memories into present-moment awareness (Vermetten, Barcaro, et al., 2025a).

What does the research evidence show?

Addressing potential barriers is important for any PTSD population, but especially critical for military populations, as they show some of the highest treatment failure and drop out rates. van Gelderen et al. (2018). Immersive therapies can tailor patient-selected trauma cues to improve access to traumatic memory networks (Vermetten, Burback, et al., 2025b).

Virtual reality exposure therapy

VRET reconstructs traumatic events in a structured context (Felemban et al., 2026; López-Ojeda & Hurley, 2022). Bypassing imagination challenges such as emotional numbing or amnesia that can prevent patients engaging with traditional therapy (Macey et al., 2026). A meta-analysis of the VRET for PTSD found substantial symptom reductions, averaging a 33.73-point decrease in the 0-80 point Clinician-Administered PTSD Scale and a 20.96-point decrease in the 0-80 point PTSD Checklist PCL-5) scale (Felemban et al., 2026). Because changes of 10-20 points on these scales are considered clinically significant, this could mean the difference between severe functional impairment and mild or subclinical symptoms (Boska et al., 2025; de Haart et al., 2026; Felemban et al., 2026).  Comparative effects against other active PTSD treatments remain modest, but VRET appears to be a more engaging alternative to conventional treatment (Felemban et al., 2026)

3MDR

3MDR takes the same multisensory effect used in VRET and adds an activating context. Rather than a sedentary, face-to-face session, the patient and the therapist face the virtual display together (van Gelderen et al., 2018; Vermetten, Burback, et al., 2025b). It follows a three-phase protocol: pre-platform preparation, platform treadmill exposure, and post-platform re-consolidation (Vermetten, Burback, et al., 2025b). In a trial involving treatment-resistant PTSD; 3MDR showed large effect sizes from pre-treatment to six-months (n = 134, d = 1.0) and high-acceptability, with 7-20% dropout rates, substantially lower than the 16-48% typical standard trauma-focused therapy in military populations (de Haart et al., 2026; Lewis et al., 2020; van Gelderen et al., 2018; Vermetten, Burback, et al., 2025b).

Improvements are not limited to PTSD symptoms. A trial of 62 adults with severe PTSD, including childhood sexual trauma, found immersive treatment improved emotion-regulation abilities regardless of PTSD outcome (van Toorenburg et al., 2020). Some researchers link this broader improvement to positive psychology Broaden-and-Build Theory. Theorising that as patients regain a sense of safety and control, this may support a positive spiral of emotional flexibility that reinforces the recovery process (Fredrickson, 2001; Niles et al., 2023; Westphal et al., 2017).

Table 1: Treatment Effects and Psychological Mechanisms

Clinical Dimension	Traditional Exposure	Immersive Approach	Psychological Mechanisms
Therapeutic Context	Sedentary. Face-to-face, verbally describes trauma.	Activating. Dynamic, multi-sensory environment.	Fear Antagonistic Action. Approach behaviours. Prediction Errors.
Trauma cue delivery	Imaginary Retrieval Patient capacity	Multisensory Immersion Highly tailored	External Scaffolding. Bypasses internal barriers to activate memory networks.
Processing and attention	Convergent processing. Repeated narration and fear habituation.	Active Narrative Processing. Interactive, real-time affective labelling and dual attention tasks.	Working Memory. Memory taxation reduces vividness and emotional intensity.
Engagement	Attrition. High dropout rates 16-48%.	Acceptability. Attractive. Dropout rates 7-20%.	Sustained Motivation. Presence and safety in immersive environment.

Quiz Which of the following is an expected outcome of immersive therapy ? Patients are at risk because of an uncontrolled environment. The environments represent traditional face-to-face treatments. Failure and dropout rates are higher than traditional PTSD treatment. Patients often broaden and build an upward spiral of emotion and optimism.

Applied example: 3MDR treatment in Ukraine

Scenario: Ukraine War: an applied 3MDR example Andriy* a volunteer in the Ukrainian Armed Forces is struggling with hyper-vigilance, anxiety, and depression (Kukharuk et al., 2025). Traditional ‘talk’ therapy feels impossible; his mind stays in a constant state of combat readiness, even in a quiet room. In the pre-platform phase of 3MDR, Andriy worked to identify a ‘hotspot’ memory in a photograph. On the treadmill, harnessed and walking beside his therapist, he faces a panoramic screen as personalised warm-up music plays, selected to keep him in touch with his traumatic memory network (Vermetten et al., 2025b). As his hotspot image fills the screen, his therapist asks three questions (Vermetten et al., 2025b): 1. What do you SEE ? 2. What does it TELL you? 3. What do you FEEL in your body NOW? When Andriy identifies a surge of shame, the word GUILT is displayed as an affective label, and a dual-attention task begins. He tracks an oscillating, numbered ball while he stays with the emotion, taxing his working memory and reducing the intensity of the recalled trauma. Figure 7. Andriy, moves through his 3MDR treatment. By the end of the session, Andriy has walked towards what he used to avoid, creating a mismatch between his expectation of threat and his safety, turning a rigid, stuck memory into a manageable narrative. Andriy, a fictional name given to one of 69 Ukrainian veterans who participated in a 2023 randomised controlled trial. Many were demobilised after one year because of mental or neurological injuries (Kukharuk et al., 2025).

What are the costs and limitations of immersive therapies?

PTSD carries a substantial economic burden. An estimated US$232 billion in excess costs in the United States in 2018 and over £40 billion, in the United Kingdom in 2020-21, 92.4% of which was indirect rather than direct clinical cost (Davis et al., 2022; Montgomery-Marks et al., 2025). In Australia, the average annual cost of PTSD per military veteran was estimated at $112,172 in 2025 (Magnusson & Dey, 2025). In addition, individual healthcare costs surge by 142% in the year following a PTSD diagnosis, with comorbidities tripling this effect (Bothe et al., 2020). These figures span several countries and years and should be best read as an indication of scale rather than as directly comparable totals.

Immersive therapy’s ability to move from small trials into mainstream PTSD treatment remains limited by methodological heterogeneity, small sample sizes, and a lack of long-term data (Felemban et al., 2026). Practical issues such as cyber sickness or motion sickness can also disrupt participation (Kukharuk et al., 2025).

Structural barriers include workforce training and equipment costs. Basic VR systems cost an estimated US$3,500 per provider headset annually, and advanced simulation environments can cost up to US$200,000 (Garrett et al., 2018). Despite this, adoption of immersive therapy is scaling. The United States Veterans Affairs have expanded VR use from five medical centres in 2017 to over 154 centres and 2,300 staff, with applications now including over 40 documented clinical interventions such as chronic pain and suicide intervention (Bailey et al., 2024).

Market analysts estimate the global PTSD-focused VR therapy market was worth US$1.59 billion in 2025, forecast to reach US$5.94 billion by 2032, driven largely by growing mental health awareness and the absence of standard clinical protocols (Stratistics MRC, 2025).

These limitations do not undermine the case for immersive therapy, but they show its evidence base and infrastructure are still maturing. Demonstrating rigorously why these therapies work, rather than assuming their novelty accounts for their effects is essential to avoid misallocating resources to unproven interventions and supports a paradigm shift, from a narrow, disease model towards one that values post-traumatic growth and renewed optimism (Trejo et al., 2015; Vermetten, Burback, et al., 2025b; Wiederhold & Wiederhold, 2025).

Conclusion

PTSD traps people in a self-reinforcing cycle of avoidance that blocks the adaptive processing trauma memories need to resolve (see: Understanding PTSD and emotions). Standard trauma-focused therapies require patients to confront exactly what this cycle causes them to avoid, which contributes to high, non-response and dropout rates (see Why treatment can be difficult).

Immersive therapies such as VRET and 3MDR address this by using presence, embodied cognition, prediction error and memory reconsolidation to help patients safely approach trauma cues rather than avoid them (see: What does the research evidence show). The technology itself is only a delivery mechanism, it is the psychological processes that drive change.

The evidence to date shows meaningful reductions in PTSD symptoms and comparatively low drop-out rates, alongside broader gains in emotional regulation. However, small samples, methodological variation, and a lack of long-term data mean the evidence base is still developing, and cost and infrastructure barriers remain significant (see costs and limitations).

Nuvola apps kuser Take-home message: Immersive therapies do not heal PTSD trauma through technological novelty or digital feedback. Instead, they create a safe, dynamic space that lets individuals confront trauma and reprocess memories into something they can live with. In doing so, people’s lives may once again shift toward value, optimism, and wellness.

See also

Wikiversity

• Anxiety book chapter
• Evidence-based PTSD assessment
• Phobias book chapter

• Sense hacking book chapter

Wikipedia

• Affective labelling
• Augmented reality
• Brain-derived neurotrophic factor
• Broaden-and-build theory
• Clinician-Administered PTSD Scale
• Cognitive processing therapy
• Cyber sickness
• DSM-5
• Emotional dysregulation
• Extended reality
• Malleability of intelligence
• Memory reconsolidation
• Mixed reality
• Post-traumatic stress disorder
• Prolonged exposure therapy
• Transdiagnostic emotion dysregulation
• United States Department of Veterans Affairs
• University of Canberra
• Virtual reality exposure therapy

References

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Wiederhold, B. K., & Wiederhold, M. D. (2025). Virtual reality therapy combined with physiological monitoring provides effective treatment, with objective metrics, for post-traumatic stress disorder. Expert Review of Medical Devices, 22(2), 117-119. https://doi.org/10.1080/17434440.2025.2454930

External links

• Web: Post traumatic stress disorder (Australian Government)
• Web: National Center for PTSD information home page (US Government)
• Web: US Veterans Affairs Immersive Programs Innovation (US Government)
• Web: Australian Royal Commission into Defence and Veteran Suicide - Final Report (Australian Government)
• Podcast: PTSD Podcast (Peace of Mind: Mental Health and Psychiatry, ACAST, 43 min)
• Video: 3MDR: Virtual reality treatment for veterans (National Centre for Mental Health,Youtube, 2:46 min)
• Video: VR exposure for combat PTSD (PsyTech VR, Youtube, 2:20 min)
• Final Report: 3MDR randomised control trial - Final-Report (Cardiff University)