A qualitative pilot study examining the feasibility and acceptability of a virtual reality delivered intervention for opioid use disorder

Abstract

Introduction

This qualitative pilot study examined the acceptability of a virtual reality (VR) delivered intervention combining motivational interviewing and cognitive behavioral therapy for individuals with opioid use disorder (OUD).

Method

Six participants (ages 23-48) with diagnosed OUD completed semi-structured exit interviews following an 8-week VR-based therapeutic intervention. Interviews were analysed using Colaizzi's seven-step descriptive phenomenological method and thematic inductive analysis.

Results

Five overarching themes emerged: (1) utilization of technology (with sub-themes of instrumentation challenges, tolerability concerns, and ease of use), (2) mode of delivery (including psychological safety, and concentration benefits and preference for VR versus in-person delivery), (3) mental health improvement, (4) therapist satisfaction (characterized by non-judgmental support and individualization), and (5) program satisfaction (highlighting convenience, flexibility, and one-on-one therapeutic engagement). All participants reported improvements in mental health, including better stress management, enhanced relationships, and overall well-being. Participants demonstrated high therapeutic engagement and felt psychologically safer sharing personal concerns through VR compared to traditional face-to-face therapy.

Conclusions

VR-delivered interventions show promise as a feasible and acceptable treatment modality for OUD, offering unique advantages in therapeutic engagement and psychological safety. However, physical comfort issues (headset heat, motion sickness) and individual preferences must be addressed in future implementations. The findings support the potential for VR technology to transcend generational boundaries and provide effective therapeutic outcomes across age groups.

Keywords

Virtual reality opioid use disorder substance use disorder telehealth motivational interviewing cognitive behavioral therapy qualitative research therapeutic alliance

Introduction

The integration of virtual reality (VR) technology into mental health and substance use disorder (SUD) treatment has emerged as a promising innovation, offering immersive, interactive environments that traditional therapies struggle to replicate.^1,2 By simulating real-life situations in a controlled, customizable setting, VR facilitates the delivery of therapeutic strategies that can directly target SUD's psychological and behavioral components. This study critically examines the acceptability of a VR-based intervention in treating mental health disorders and SUDs, emphasizing both the promising outcomes and the practical challenges that must be addressed for widespread adoption. The immersive nature of VR technology creates engaging therapeutic environments that enhance patient participation and adherence to treatment protocols.³ This dynamic engagement is critical in addressing complex mental health conditions where traditional therapy may fail to fully engage patients. Research highlights the effectiveness of VR across a spectrum of mental health disorders, including anxiety, PTSD, substance-related disorders, and psychosis.^4,5 Emmelkamp et al.⁶ explored VR's therapeutic potential and underscored its ability to offer safe, controlled exposure therapy while enhancing treatment adherence. This adaptability allows for tailored interventions that meet the specific needs of diverse patient populations, making VR a versatile therapeutic tool.

Beyond its capacity to replicate real-world scenarios, VR technology introduces new possibilities for cognitive and emotional training, offering patients opportunities to build resilience and coping strategies in a safe environment.⁷ The capacity to customize exposure to specific stimuli enables clinicians to tailor interventions, improving their relevance and effectiveness. Gregg et al.⁸ demonstrated that VR therapy delivers outcomes comparable to traditional in vivo exposure therapies, particularly for anxiety disorders. The ability to create controlled, customizable environments and immediate feedback fosters a heightened sense of presence that can significantly improve therapeutic engagement and outcomes. Moreover, VR has been successfully integrated into cognitive-behavioral therapy (CBT) for conditions such as social phobia and persecutory ideation, leading to reductions in anxiety symptoms and improvements in subjective well-being.^9,10 The adaptability of VR extends to populations with SUDs, as evidenced by Man,¹¹ who reported improvements in attention, memory, vocational skills, and self-efficacy among young ketamine users undergoing VR-based cognitive training. Patient satisfaction and tolerability of VR therapy remain consistent, further supporting its viability as a therapeutic intervention.⁸

Despite these encouraging findings, the practical implementation of VR therapy in clinical practice presents notable challenges. Skeva et al.¹² investigated practitioners’ perspectives regarding integrating VR therapy in SUD treatment. Practitioners, including psychologists, psychotherapists, counselors, and social workers, recognized VR's potential to enrich therapy by offering realistic, immersive experiences conducive to developing coping strategies. However, they identified significant obstacles, such as technical limitations, accessibility issues, and cost concerns, which could hinder widespread adoption. Additionally, practitioners strongly preferred VR applications that focused on high-risk situations and social environments, emphasizing the importance of personalized scenarios that align with individual treatment goals. This feedback highlights the necessity for targeted VR interventions that are both clinically effective and practically feasible. The broader adoption of VR therapies is further complicated by systemic barriers within healthcare settings. Wray et al.¹³ examined the reluctance of therapists to adopt VR exposure therapy (VRET) for anxiety disorders, attributing this hesitation to factors like financial constraints, the need for specialized training, and the challenges of integrating VR into existing clinical workflows. To mitigate these concerns, they advocated for comprehensive studies assessing VRET's real-world effectiveness alongside efforts to streamline treatment protocols and improve platform compatibility with clinical practices. These recommendations underscore the importance of addressing systemic barriers to facilitate the broader integration of VR therapies into mental health and SUD treatment frameworks.

In the context of addiction treatment, VR offers unique advantages by providing controlled simulations of real-life triggers, enabling researchers and clinicians to gain insights into the psychological and neurobiological mechanisms underlying addiction. Mazza et al.¹⁴ highlighted how VR's capacity to elicit cravings and measure cue reactivity allows for a more nuanced understanding of addiction-related behaviors. By delivering personalized exposure therapy and cognitive-behavioral interventions, VR enables targeted strategies to manage triggers and reduce relapse risk. This approach holds promise across various forms of addiction, including alcohol, tobacco, opioids, and gambling, illustrating VR's broad applicability in addiction treatment.¹⁵

Complementing these findings, Taubin et al.¹⁶ evaluated the impact of VR-based interventions on secondary outcomes associated with SUD treatment, including mood regulation, anxiety reduction, emotional stability, and treatment retention. While VR interventions consistently reduced substance use and craving, findings related to mood improvement and treatment retention were mixed, underscoring the need for further investigation into these secondary effects. For example, one study included in this systematic review examined whether postretrieval extinction (PRE) delivered via VR could disrupt the reconsolidation of smoking-related memories among smokers. In this randomized design, participants were assigned to one of three groups: G1, which received VR-based PRE immediately following a brief (15 s) smoking-memory retrieval within the reconsolidation window; G2, which received VR-based extinction without prior smoking-memory retrieval; and G3, which received PRE following memory retrieval but outside the reconsolidation vulnerability window. Although all participants demonstrated a significant increase in cigarette craving following smoking-related VR exposure on Day 1 (p < .01), by Day 3 only participants in G1 showed successful disruption of memory reconsolidation and reduced craving. In contrast, PRE was ineffective in G2 and G3, highlighting the importance of both memory retrieval and precise timing of extinction within the reconsolidation window. Collectively, these findings suggest that VR-based PRE following targeted memory retrieval may be more effective than standard extinction procedures and those VR interventions may have greater therapeutic impact when designed to engage specific learning and memory mechanisms relevant to SUD treatment.

Moreover, the neural mechanisms engaged by VR interventions may further support recovery in individuals with SUDs. Worley¹⁷ explored VR's capacity to manage cravings, mitigate stress and anxiety, address pain, and teach essential life skills. Notably, VR activates brain regions similar to those affected by addictive substances, suggesting its potential to influence the neural pathways associated with addiction. This neural engagement may explain VR's effectiveness in reducing cravings and supporting long-term recovery efforts. By offering immersive environments that simulate real-life stressors and triggers, VR provides a safe platform for patients to develop and practice coping strategies essential for sustained recovery. While existing literature highlights VR's promising potential in treating mental health and SUDs, critical challenges remain in translating these findings into routine clinical practice. Addressing these challenges requires ongoing research into VR's efficacy across diverse populations and conditions. Furthermore, interdisciplinary collaboration between clinicians, researchers, and technology developers is essential to design scalable and cost-effective VR solutions that align with clinical workflows. Continued innovation and targeted studies will be crucial in realizing VR's full potential as a transformative therapeutic tool.

Methodology and procedures

Design

This study employed a qualitative research design to explore the experiences and perceptions of individuals with opioid use disorder (OUD) who participated in a VR-delivered intervention integrating motivational interviewing (MI) and cognitive behavioral therapy (CBT), with particular focus on assessing the acceptability of this delivery modality. A qualitative phenomenological approach was chosen to capture participants lived experiences and the nuanced meanings they ascribed to the VR-based sessions, which served as the primary data source for evaluating acceptability.

Acceptability assessment

Acceptability was operationalized as participants’ subjective appraisals of the appropriateness, comfort, satisfaction, and perceived utility of the VR-delivered intervention. Consistent with qualitative acceptability research, we assessed acceptability through participants expressed willingness to engage with the technology, perceived therapeutic value, and overall satisfaction with the program, all captured through semi-structured exit interviews.

Ethical approval

Ethical approval for this study was obtained from the University of Alabama Institutional Review Board (Protocol #19-06-2419). All participants provided informed consent prior to participation.

Description of the VR intervention

The VR component was delivered using a secure REDCap-integrated VR platform hosted at the University of Alabama. Each session combined elements of MI and CBT to promote motivation for change, self-efficacy, and adaptive coping skills. Sessions were facilitated by a graduate research assistant (GRA) with a master's degree in counseling. The facilitator guided participants through real-time counseling sessions within the VR environment, focusing on self-reflection, emotional regulation, and coping strategies related to recovery. The program followed a standardized session flow to ensure consistency while allowing flexibility for the facilitator to tailor prompts and discussions to individual participants’ needs and progress, making it adaptive. Each session lasted approximately 30–60 min. The sessions were held on a weekly basis.

Overview of MI and CBT approaches

MI is a person-centered, collaborative communication approach designed to strengthen an individual's own motivation and commitment to change by exploring and resolving ambivalence.¹⁸ CBT operates on the premise that thoughts, emotions, and behaviors are interconnected, and that identifying and modifying maladaptive patterns can support lasting behavioral change.¹⁹ In this protocol, MI and CBT were used in an integrated fashion: MI principles including reflective listening, open-ended questioning, and eliciting change talk were embedded throughout all sessions to sustain engagement and therapeutic alliance, while CBT provided the structured skill-building framework that participants applied to their recovery goals.

Session structure

The 8-week intervention followed a general progression across three phases. Early sessions (sessions 1–2) focused on establishing rapport, exploring participants’ motivations for change, and introducing the cognitive-behavioral framework as it related to opioid use and recovery. Mid-treatment sessions (sessions 3–6) addressed core CBT skill areas, including identifying triggers and high-risk situations, cognitive restructuring, and developing personalized coping strategies, with MI techniques used to navigate ambivalence and reinforce self-efficacy throughout. Final sessions (sessions 7–8) focused on consolidating gains, reviewing progress toward individual treatment goals, and preparing participants for sustained recovery beyond the intervention.

Data collection and analysis

The exit interviews were collected by a trained GRA utilizing a semi-structured interview guide. The interviews lasted on average for 30 min. All audio recordings were transcribed verbatim and imported into NVivo software for qualitative analysis. A thematic inductive analytic approach was utilized, enabling the data to be summarized while preserving its depth and richness. The analysis adhered to Colaizzi's²⁰ seven-step descriptive phenomenological method: (1) identifying the phenomenon of interest, (2) transcribing participants’ detailed descriptions, (3) extracting significant statements, (4) formulating the meanings of these statements, (5) grouping related meanings into thematic clusters, (6) constructing a comprehensive description of the phenomenon, and (7) validating the findings with participants to ensure accuracy. This process entailed a meticulous examination of the participants’ narratives to explore their perceptions of the challenges and benefits associated with VR-based interventions. The researchers carefully reviewed all transcripts to gain a deep understanding of the data. Initial codes were developed and organized into a codebook, which served as the foundation for identifying themes and subthemes. These codes and themes were iteratively reviewed and discussed with the research team, with adjustments made to ensure they accurately reflected the participants’ perspectives as conveyed in the data. The data analysis was completed by three team members, and all codes were revised until there was concordance among the researchers.

Participant recruitment and eligibility

A total of 10 participants were recruited from local community-based substance use treatment facilities. Inclusion criteria required participants to be 19 years or older, have a clinical diagnosis of OUD, be able to provide informed consent, and be willing to complete individual therapy with a counselor via VR.

Sample size & data saturation

Although the final qualitative sample consisted of six participants, this size is methodologically appropriate for a focused phenomenological pilot study examining feasibility and acceptability rather than theory generation. Consistent with Colaizzi's descriptive phenomenological approach, the analytic goal was to capture shared meanings and core experiential structures rather than exhaustive narrative accounts. Data saturation was assessed iteratively during analysis and was determined when no new themes, subthemes, or conceptual insights emerged across successive interviews. Despite the relatively brief interview duration (approximately 30 min), participants provided dense, focused accounts centered on a common intervention experience (an 8-week VR-delivered MI + CBT program), resulting in substantial overlap and redundancy in experiential content. By the fifth and sixth interviews, participants reiterated previously identified themes related to psychological safety, engagement, therapist support, and perceived mental health benefits, with no novel codes emerging. This convergence of themes across participants, combined with the narrow study aim and homogeneity of the intervention context, supports the conclusion that thematic saturation was achieved within the present sample.

Participants reported a wide range of opioid use histories, with self-described durations of struggle spanning approximately 3 to nearly 30 years, most commonly falling between 7 and 25 years, reflecting varied trajectories of opioid use and recovery. Detailed substance use characteristics and treatment status (e.g., abstinence, medication-assisted treatment) were not systematically collected as part of this qualitative feasibility study. With respect to substance use characteristics that were voluntarily disclosed, two of the six participants reported heroin or other opioid use, with some stimulant use (e.g., cocaine or amphetamines); the remaining participants did not specify a primary substance during data collection.

Results

Participant flow and completion

Of the 10 participants who began the study, six completed both the 8-week VR intervention and the exit interview, while four did not complete the interview phase due to relapse (n = 2), loss of contact (n = 1), or scheduling conflicts (n = 1). These reasons for attrition have been noted to contextualize the completion rate and inform feasibility assessments.

Sample characteristics

The final sample consisted of six participants who completed both the VR intervention and exit interviews, with ages ranging from 23 to 48 years (M = 39.0, SD = 8.77). The sample was equally distributed by gender, with three females (50%) and three males (50%). All participants (100%, n = 6) reported their race or ethnicity as white. Regarding relationship status, two participants (33%) were separated, two (33%) were married or in a relationship, one (17%) had never married, and one (17%) did not report their status. Educational backgrounds varied and included upper secondary education, vocational or trade school training, with one participant holding a bachelor's degree. Employment status comprised part-time employment (n = 3, 50%), retired (n = 1, 17%), not employed and not seeking work (n = 1, 17%), and one unreported (17%). Annual household income ranged from $10,000 to $34,999, with four participants (67%) reporting income between $10,000 and $24,999.

Study themes

Five overarching themes emerged: (1) utilization of technology with sub-themes of instrumentation, tolerability concerns, and ease of use, (2) mode of delivery with sub-themes of psychological safety, concentration, preference for VR versus in-person delivery (3) Mental health improvement, (4) Therapist satisfaction with sub-themes of non-judgmental and individualization, and (5) Satisfaction with the program with sub-themes of convenience, flexibility and one-on-one.

An overview of the identified themes and subthemes is provided in Table 1 to enhance clarity and readability.

Table 1.

Summary of themes and subthemes identified from exit interviews.

Theme	Subthemes	Description
1. Utilization of Technology	Instrumentation	Physical experiences using VR hardware, including comfort, heat, and motion-related issues.
	Tolerability Concerns	Physical side effects (motion sickness, disorientation) that affected comfort and satisfaction ratings.
	Ease of use	Perceived ease of operating the VR system, including the role of basic technology literacy.
2. Mode of Delivery	Psychological safety	Increased comfort, openness, and reduced fear of judgment when engaging with the therapist in VR.
	Concentration	Ability to focus during sessions due to reduced distractions and immersive environment.
	preference for VR versus in-person delivery	Individual preferences regarding VR-based versus face-to-face therapy delivery.
3. Mental Health Improvement		Perceived improvements in emotional regulation, stress management, relationships, and coping skills.
4. Therapist Satisfaction	Non-judgmental	Perceptions of therapist empathy, acceptance, and absence of criticism.
4. Therapist Satisfaction	Individualization	Feeling that therapy was personalized to participants’ specific needs and goals.
5. Program Satisfaction	Convenience	Ease of participation, minimal burden, and accessibility of the program.
	Flexibility	Accommodation of schedules and reduced logistical barriers.
	One-on-one	Value placed on individualized sessions with a single therapist.

In addition to the qualitative themes, participants who were asked to provide numeric ratings during their semi-structured interviews reported consistently high ratings for both ease of use (median 9, range 7.5–10, n = 5) and ease of concentration (median 10, n = 4) (see Table 2 below). These ratings align with the qualitative findings described in sub-themes 1.3 and 2.2.

Table 2.

Participant ratings of VR experience.

Measure	Scale	Ratings (n = 6)	Median
Ease of use	0 (very difficult) to 10 (very easy)	7.5, 8, 9, 10, 10, (n = 5)	9
Ease of concentration during sessions	0 (very difficult) to 10 (very easy)	10, 10, 10, 10 (n = 4)	10

Note: Not all participants provided numeric ratings for all measures during the semi-structured interviews. Ease of use ratings were obtained from 5 of 6 participants, and ease of concentration ratings from 4 of 6 participants.

Theme 1: Utilization of Technology. Our objective was to investigate the participants’ level of satisfaction with the utilization of VR technology. We also aimed to discern any reservations or concerns they might have had if they did not find VR technology enjoyable. To systematically address these concerns and reservations, we employed sub-themes for a more comprehensive analysis.

Sub-theme 1.1: Instrumentation: This sub-theme dove exclusively into the participants’ experiences related to the physical aspects of using VR headsets. We sought to identify any challenges or issues encountered while interacting with the hardware components of VR technology. Participants described both positive and negative aspects of headset use. Some noted physical discomfort such “get too hot” or that “have a facial piercing” causing some discomfort in using the headsets during longer sessions, while others found the setup easy to navigate. Despite these challenges, most participants were open to using VR again, provided future versions address physical comfort.

Sub-theme 1.2: Tolerability Concerns: Several participants experienced physical side effects that affected their comfort during VR sessions, most notably motion sickness and disorientation. When asked about their experience with the technology, participants who experienced motion sickness expressed that physical discomfort impacted their experience, though this reflected tolerability concerns rather than dissatisfaction with the therapeutic content itself. One participant stated using VR

“I mean it wasn't that bad, it was just, I mean, after so long it was unbearable. It was just, after so long, with the headset on, I feel like I was floating like I was seasick.”

Another participant expressed similar sentiments that they

“I had some motion sickness, but after that was fixed, it's simple, easy to use.”

These findings highlight that while VR was therapeutically engaging for participants, physical tolerability particularly motion sickness remains a barrier that must be addressed through improved hardware design, gradual acclimation protocols, or screening for motion sensitivity.

Sub-themes 1.3: Ease of Use: When asked to rate ease of use, participants consistently provided high ratings (median 9 out of 10, range 7.5–10). Participants cited clear instructions and intuitive controls. One participant said,

“It was easy because I just wore it” and “It was really easy. So, for anybody that can, you know, knows how to work any kind of electronics”.

It is important to note that proper use of VR technology entailed a level of technology literacy to fully engage with the study. Participants were provided with an orientation at the beginning of the study on how to use the equipment and what symptoms to report to the study team members. Study participants were also informed that they were free to stop the session at any time if they became too uncomfortable. Although most participants completed VR sessions as planned, one participant elected to stop a VR session midway due to feeling unwell, although it was unclear whether this was attributable to the VR experience or to unrelated factors.

These Theme 1 insights combined underscore that while VR technology is generally seen as easy to use, comfort and potential motion sickness may be issues for some users, especially during prolonged use. Participants had mixed feelings about their overall VR experiences, with some finding the use of VR to be beneficial and others having reservations. These observations highlight the need to address physical comfort, motion sickness, and individual preferences when implementing VR in various contexts, such as SUD therapy and education.

Theme 2: Mode of delivery. The second theme focused on the mode of delivery of the VR sessions, where participants reflected whether they found the VR sessions useful compared with other modes of SUD therapy delivery they have engaged in. Three sub-themes emerged: psychological safety, concentration, and preference for VR versus in-person delivery.

Sub-theme 2.1: Psychological safety: The sub-theme of psychological safety emerged from our inquiry related to how safe participants felt while participating in the VR sessions. We wanted to know how safe participants felt to share their concerns, ideas, and problems related to their OUD without any fear of humiliation or judgment from the counselor. Participants reported that they felt safe while talking to the therapist as reported by one participant that;

“[therapist] got to know more about me probably than my sponsor here because it was a lot easier to talk to [therapist]. I would have never talked that much face-to-face with somebody. I mean, because you really don't, if you see them, but you know they're not in the same room and they can't, your guard ain't up, so you don't have to be cautious.”

A second participant mentioned that,

“Well, I personally, face to face, I can tell you I'm more shocked when I'm face to face with people. And when I first meet you, I don't even like talking on the phone. But I was willing to talk [to the therapist] more than I would have in person… I guess it helped.”

These statements indicated a positive impact of VR on psychological safety during therapeutic sessions. Participants expressed a notable increase in comfort and openness when engaging in VR sessions compared to face-to-face sessions, attributing this to the absence of physical presence in the same room, which might reduce the need to be cautious or guarded.

Sub-theme 2.2: Concentration: All participants reported that it was easy for them to concentrate on their sessions. For some, more adjustment time was needed to combat motion sickness, but once acclimated, concentration was easy. Participants who provided numeric ratings all gave the highest rating (10 out of 10). As reported by one participant

“It was the easiest, I would say.”

Another one reported,

“It was very easy. I can concentrate because you was looking there at it and there were no outside distractions to that and that was a good thing about it.”

Sub-theme 2.3: Preference for VR versus in-person delivery: While most participants responded positively to the VR format, individual attitudes toward the medium itself varied. Some participants found VR to be more beneficial than prior counseling experiences, with one stating,

“I think this one [program] was a lot more helpful than the others that I have done”. This participant was referring to other counseling programs they have previously participated in.

Another reported that “I don't like the virtual” but “think that it was a good growing experience for the people that are here doing the program [study team] and the ones that are doing the therapy [study participants].”

These varied perspectives highlight that while VR was broadly acceptable, individual preferences for delivery format should be considered when implementing VR-based interventions in clinical settings.

Theme 3: Mental Health Improvement. In this sub-theme, we identified that participants saw improvement in their overall mental health such as better relationships, alleviating stress, or working on improving themselves by taking VR Sessions each week with the counselor. When asked the questions, “So do you feel like your overall mental health has improved since you started this session?” all participants regardless of preference for in-person or VR sessions reported an improvement in their mental health. As stated by one participant,

“Yes, it [the therapy sessions] definitely has helped. It has definitely helped with like the restoration of relationships with my children, just how to manage my life now. The way I cope with problems, the way you know, because I'm having to relearn how to, you know, actually deal with problems and with stress without, you know, willing to fall back to numb myself or, you know, feeling guilty about stuff from when I was in active addiction that comes back to haunt me. You know, it's just stuff like that that was, you know, easy to talk, not easy to talk about, but helped me talk about it to kind of fix those areas.”

Another participant reported that

“Having a support network and someone to vent to [the study therapists] has helped me manage situations that would have otherwise probably driven me to relapse. It's helped me slow down, take a second thought, and, you know, at the very worst, if I needed someone to, cause I was on the verge of breaking down or even just someone to send an email to, to try to convey the emotions that I was feeling. You know, it's been very helpful in keeping my mental health going in a positive direction”.

Theme 4: Therapist satisfaction. This theme explored how the participants viewed the therapist they were working with. We wanted to explore this code as well since therapist and client rapport is a stronger indicator of successful completion and overall improvement in therapy.

Sub-theme 4.1: Non-judgmental: The participants felt safe and comfortable to talk with the therapist as reported by one participant that,

“It was nice to be able to sit there and talk to somebody and they didn't judge you or criticize you about what you said. You just kind of, and they helped you understand yourself. The discussion was awesome because even though if I tell them something and didn't quite have the answer, I said it out loud, which also helped me understand.”

Another participant reported, “[the counselor] got to know more about me probably than my sponsor here because it was a lot easier to talk to [the counselor].”

Sub-theme 4.2: Individualization: Most participants reported that they felt their therapist was supportive, cared about their concerns, and wanted to work on their goals. As reported by one participant,

“Well, I had a problem with therapists and things in the past where It seemed like they was very generic about their questions and how they responded and, and so it helped me to see that therapy is not bad, it's a good thing if you get the right therapist.”

Another one reported, “How much it was really felt like he really cared about what was going on with me in particular.”

Theme 5: Satisfaction with the program. Lastly, we explored whether the participants felt the program was good and if they were satisfied.

Sub-themes 5.1: Convenience: Participants felt the program was easy to complete, which added to their ease of comfort and support. One participant reported,

“It's been very helpful, the program over the course of eight weeks. I've had a continued support network established more so than I had before, and I had access to a bunch of different resources granted to me that I didn't even know existed beforehand. And the continued support of my counselor and those involved in the program has been very beneficial in almost every aspect of my life, whether it's been gaining employment or remaining sober, it's been very helpful.”

Sub-theme 5.2: Flexibility: Participants felt the program was accommodating to the participant's schedule, it was free, and it did not take a lot of time from their day. All of the participants reported that they were satisfied with the program and felt the program accommodated them where needed. As reported by one participant,

“Yeah, it worked with my schedule real good, and didn't last too long, they also very good on working around my schedule. If I was late due to a doctor's appointment or something, they were very helpful with securing the [counselor] back. For us, having you to handle things is very good.”

Another one reported that,

“I was excited about it. I've enjoyed it. While it's free accounts for one thing, but it was neat to see how I've never used one of those before. That was interesting.”

Another participant reported,

“It was probably the fact that it was very non-invasive. It was just an hour out of my day each week, but I still established, you know, I got a lot of goals done in that short amount of time. It's been you know, there are many things that have been positive.”

Sub-theme 5.3: One-on-one: Participants reported that they were satisfied with the program due to the fact that it was one-on-one with the counselor, which helped them greatly improve their mental health. One participant reported that

“it was nice to have. Like, I mean, you had somebody one on one to talk to. It helped me learn about myself. It encouraged me to keep going because I knew that I wasn't alone.”

Discussion

SUDs remain a persistent public health challenge, requiring innovative treatment modalities that enhance engagement, accessibility, and client comfort. This qualitative pilot study explored the acceptability of a VR delivered intervention integrating MI and CBT for individuals with OUD. The findings indicate that VR-delivered therapy is both acceptable and engaging, supporting the potential of technology-assisted counseling to complement traditional treatment approaches. This study utilized a phenomenological approach. This design allowed for a rich, contextual understanding of participants’ interactions with the technology and the therapeutic process. The focus on participant perspectives illuminated the unique advantages and potential limitations of VR therapy, offering valuable insights into its clinical adoption and applicability as an alternative or complementary therapeutic modality.

Acceptability of VR-delivered MI + CBT

Participants reported that the immersive VR format promoted focus, emotional openness, and reflection, core mechanisms of MI and CBT. The sense of psychological safety cultivated through the virtual environment enabled participants to discuss personal experiences without fear of judgment, mirroring the empathy and non-confrontational stance central to MI.^12,14,16 Similarly, CBT-based elements such as stress-management and cognitive-reframing exercises were reinforced through realistic, interactive settings that helped participants connect abstract coping concepts with lived experiences.^6,8,15 These qualitative insights align with recent work demonstrating that VR can facilitate behavior change and emotional regulation across diverse clinical populations.^4,7,14–16^,21 The strong engagement and high satisfaction reported by participants suggest that VR can reduce barriers to participation, particularly for individuals who may feel stigmatized or uncomfortable in face-to-face therapy settings, which is consistent with current literature.^13,22 Importantly, these findings reflect perceived feasibility and acceptability of the mode of delivery rather than clinical efficacy; thus, effectiveness in reducing substance use behaviors remains an avenue for future research.¹⁷

Therapeutic alliance and counselor role

A consistent theme throughout the data was the value participants placed on the counselor's empathy, flexibility, and individualized support. Even in a virtual format, participants described feeling heard and understood, an essential condition for successful MI/CBT interventions^.^23,24 The therapist facilitating sessions fostered a collaborative, client-centered dynamic, demonstrating that strong therapeutic alliances can develop even through digital platforms. These findings echo prior literature emphasizing that the quality of the therapeutic relationship, rather than the delivery medium, is often the key determinant of client satisfaction and engagement in technology-based therapy.^20,22–24

Engagement across age and technology comfort levels

Contrary to earlier studies suggesting that older adults may struggle with VR interfaces,²⁵ participants in this study across the age range represented in the sample (23-48 years) expressed comparable satisfaction and comfort with the VR intervention. This is a unique finding as evidence suggests generational differences in technology adoption preference, and usability.²⁶ Our sample spanned three generations: Gen X, Gen Y, and Gen Z. Several factors may explain this: one-on-one counselor support during sessions, simplified instructions, and gradual acclimation to the technology. The novelty of the VR experience may also have fostered curiosity and motivation to engage. However, it remains important to recognize potential disparities in technology readiness across age groups, underscoring the need for brief orientation or technical assistance as was provided in the present study.

Clarifying effectiveness and outcome scope

Although participants reported improved emotional regulation, motivation, and coping, this qualitative design did not measure substance-use outcomes directly. The term effectiveness here refers to perceived psychological and behavioral benefits, including increased self-awareness, reduced stress, and stronger interpersonal functioning. These self-reported improvements provide an early indication that VR-delivered MI/CBT may enhance intermediate mechanisms of recovery such as self-efficacy and emotion regulation that are predictive of sustained behavioral change.^14,15,17 Future mixed-methods or randomized controlled studies should examine these relationships quantitatively.²²

Relevance of just-in-time adaptive interventions (JITAIs)

The study's integration of VR technology conceptually aligns with the principles of JITAIs, which aim to provide timely, personalized support in response to an individual's real-time needs.²⁵ While this pilot did not incorporate JITAI algorithms, the capacity of VR to simulate high-risk or emotionally salient scenarios suggests an opportunity for future interventions to adapt dynamically based on user behavior and affective state. Embedding MI/CBT content within adaptive VR environments could strengthen engagement and ensure the therapeutic experience evolves with the client's progress.

Implications for digital and telehealth interventions

The findings contribute to the growing body of evidence supporting telehealth and digital platforms for behavioral health treatment.^2,22,27 Participants’ perceptions of increased comfort, convenience, and confidentiality echo trends observed in tele-counseling research, where virtual modalities reduce logistical barriers while preserving relational quality. Integrating VR into existing treatment programs could expand access for clients in rural or underserved areas, particularly when combined with hybrid or stepped-care models that blend digital and in-person sessions.^27,28

Limitations and future direction

The small sample, which was homogeneous with respect to diagnostic eligibility and exposure to the same VR-delivered intervention, limits the transferability of results and underscores the need for replication with larger and more diverse populations.²² Although data saturation was achieved, the brief study duration may not capture long-term engagement or sustained effects. The intervention period was limited to eight weeks, aligning with prior VR-based CBT and MI studies that typically range between six and ten weekly sessions^6,14,18; however, extending the duration could help assess long-term engagement and maintenance of therapeutic gains. Additionally, four participants did not complete the exit interview, and their experiences may differ from completers. Future studies should examine predictors of retention and comfort with VR across varying demographics and recovery stages.^15,17,29 Expanding the design to include quantitative outcomes and longer follow-up periods will help clarify the intervention's sustained impact.

Conclusion

This qualitative pilot study explored the use of VR to deliver counseling sessions grounded in MI and CBT for individuals with OUD. The findings indicate that participants found the VR-delivered intervention to be both feasible and acceptable, highlighting its potential to enhance engagement, psychological safety, and therapeutic connection within substance use counseling.

Participants reported that the immersive and interactive nature of VR helped them stay focused, reflect more deeply on their recovery goals, and apply coping skills introduced during sessions. They also valued the flexibility, convenience, and individualized support provided by the counselor, suggesting that therapeutic rapport and personalization can be effectively maintained in virtual settings.

Although the intervention showed promise, several implementation challenges were identified, including headset comfort and the need for technical orientation for some users. Addressing these issues and evaluating outcomes with larger, more diverse samples will be essential to strengthen evidence for the clinical integration of VR-based MI/CBT interventions.

Overall, the study supports VR as an innovative and client-centered platform for delivering evidence-based counseling, offering a safe and engaging environment that can complement traditional approaches to substance use treatment. Continued research and technological refinement will be vital to maximize accessibility, long-term engagement, and therapeutic effectiveness in digital mental health care.

Footnotes

Acknowledgements

None.

ORCID iDs

Fatima A Leghari

Jeremiah Matthews

Babatunde Owolabi

Olayemi Timothy Adekeye

Tongi G Mugoya

Ethical approval

We confirm that ethical approval for the study was sought and granted by the University of Alabama Institutional Review Board (Protocol; 19-06-2419).

Consent to participate

All participants voluntarily consented to participate in the study.

Consent for publication

We consent to the publication of this manuscript and that the manuscript has not previously been published nor is being considered for concurrent publication.

Contributorship

Mercy N. Mumba was involved in all aspects of the study from conceptualization, obtaining funding, data collection and analysis, and preparing manuscripts for dissemination.

Fatima A. Leghari was involved in intervention deployment, data collection and analysis, and preparing manuscripts for dissemination.

Jeremiah Mathews was involved in intervention deployment, data collection and analysis, and preparing manuscripts for dissemination.

Babatunde Owolabi was involved in data collection and analysis and preparing manuscripts for dissemination.

Evans Kyei was involved in data analysis, interpretation of findings, and preparing manuscripts for dissemination.

Olayemi Timothy Adekeye was involved in data analysis, interpretation of findings, and preparing manuscripts for dissemination.

George C.T. Mugoya was involved in all aspects of the study from conceptualization, obtaining funding, data collection and analysis, and preparing of manuscripts for dissemination.

Funding

The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This study was funded through a pilot award from the Capstone College of Nursing at the University of Alabama. There is no award number for this internal pilot grant.

Declaration of conflicting interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Data availability statement

The data that support the findings of this study are available from the corresponding author upon reasonable request.

Guarantor

Mercy N. Mumba and George C. T. Mugoya

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