=Paper=
{{Paper
|id=Vol-3147/paper7
|storemode=property
|title=Virtual reality in emotion regulation: A scoping review
|pdfUrl=https://ceur-ws.org/Vol-3147/paper7.pdf
|volume=Vol-3147
|authors=Anna-Leena Macey,Joseph Macey,Juho Hamari
|dblpUrl=https://dblp.org/rec/conf/gamifin/MaceyMH22
}}
==Virtual reality in emotion regulation: A scoping review==
https://ceur-ws.org/Vol-3147/paper7.pdf
Virtual reality in emotion regulation: A scoping review
Anna-Leena Macey 1, Joseph Macey 1,2 and Juho Hamari 1
1
Gamification Group, Tampere University, Finland.
2
Centre of Excellence in Game Culture Studies, University of Turku, Finland
Abstract
Academic research investigating virtual reality (VR) is growing rapidly; as a result of VR
becoming more easily accessible, it has become a more viable tool for helping individuals
regulate their emotions. This research aims to provide an overview of the field and the contexts
in which VR has been implemented to facilitate emotion regulation. Results indicate that
although VR has been used to facilitate ER for over two decades, empirical research in the field
has remained somewhat static until 2018. Furthermore, the contexts in which it has been
employed have remained narrow with more than half of all included publications utilising VR
to administer exposure therapy. While the recent increase of published works in the field,
combined with more varied uses of VR, indicate a broadening of the field this work highlights
several gaps in the extant literature, identifying a series of potential avenues for future research.
Keywords 1
Immersive VR, emotion regulation, technological affordances, human-computer interaction,
scoping review
1. Introduction adapted to individual user needs4. Furthermore, it
provides opportunities beyond simple simulation
or replication; by exploiting the technological and
Virtual Reality (VR) is an immersive,
gameful affordances of VR, novel and innovative
multisensory medium which provides the user
techniques can be developed to provide more
with the experience of being in, and interacting
meaningful and affective experiences5.
with, an environment other than that in which they
Recent years have seen an increasing degree of
are physically present1. As affordable VR
academic attention paid to the topic of emotional
hardware has become more widely available, the
regulation (ER); indeed, it has become one of the
number of studies investigating VR, spanning
most studied concepts within the field of
fields from psychology to human-computer
psychology during the past two decades6. ER is
interaction, is growing rapidly. As such, there is
defined as “processes by which individuals
an increasing need to understand and study the
influence which emotions they have, when they
technology and its affordances.
have them, and how they experience and express
Since the early days of VR, it has been utilised
these emotions”7. These processes or regulatory
in simulation training and therapeutical contexts
strategies can be conscious or subconscious, and
to help people deal with challenging, stressful,
be used to increase, decrease, or maintain one or
and anxiety-inducing situations in safe and
more components in emotion generation.
controlled environments2. Reviews and meta-
While interest in both VR and ER has grown
analyses have provided evidence of VR’s
in parallel with one another, it is only relatively
usefulness in treating diverse clinical conditions3.
recently that they have begun to coalesce. As a
VR holds much promise as a tool to deliver
result of technological developments VR headsets
both therapy and training; in addition to offering
are becoming both easier to use and more
safe and predictable environments, it can be
affordable, as such the use of VR technology and
6th International GamiFIN Conference 2022 (GamiFIN 2022),
April 26-29 2022, Finland. EMAIL: anna-leena.macey@tuni.fi
(A.1); jrmace@utu.fi (A2); juho.hamari@tuni.fi (A. 3)
ORCID: 0000-0002-9325-4522 (A. 1); 0000-0002-9770-739X (A.
2); 0000-0002-6573-588X (A. 3)
©️ 2022 Copyright for this paper by its authors. Use permitted under Creative
Commons License Attribution 4.0 International (CC BY 4.0).
CEUR Workshop Proceedings (CEUR-WS.org)
64
virtual environments to help users regulate their The search string used in the query was
emotions is a more viable prospect4. composed of three sections: one describing virtual
Two main approaches exist to promote reality, the second describing emotion, and the
relaxation, stress reduction and ER in virtual third describing the management. These sections
environments: the first uses content derived from were built using multiple related terms and
classical relaxation techniques as a means to employing wild cards for a comprehensive search
enhance users’ well-being at a specific moment, where appropriate. All results were assessed using
while the second engages the user in emotional the inclusion and exclusion criteria presented in
and behavioural learning processes through more Table 1. These criteria were developed to address
customisable virtual environments. While the the aims of the research, as such only studies
majority of studies utilise one or the other, greater which specifically promoted long-term ER for
potential is offered if they considered in users were included. Additionally, given that this
conjunction with one another, thereby providing work is concerned with the use of VR to evoke
more effective approaches. See, e.g., Pizzoli et al.8 and assess ER, publications presenting conceptual
Whilst the evidence of the usefulness of VR in or theoretical research were excluded. Similarly,
treating diverse clinical conditions have been given the potential for confounding issues to
provided by reviews and meta-analyses3, the affect small samples, any study with less than 10
purpose of this scoping review is to identify how participants was excluded. Finally, to ensure
VR technology and its particular affordances have consistency, only one type of VR hardware was
been used to facilitate and promote ER strategies. included: immersive, Head-mounted Displays.
Indeed, the use of VR to elicit changes in the
emotional state of users has often focused on the Table 1
short-term effects, for example as an analgesic 9, Inclusion and Exclusion Criteria
or its potential to alter individual moods10. Such Inclusion criteria Exclusion criteria
approaches cannot be considered as constituting Considers VR as Considers VR as mobile VR,
ER as they do not engage users in emotional and immersive VR (HMD) CAVE, or other
Promotes user emotion User is not active in emotional
behavioural learning processes which promote regulation regulation
long-term change. Therefore, such works are not Promotes long-term skill
within the scope of this review. Focuses on short-term effects
development
The focus of this work is on experimental and Reports on manipulation Presents only a design for a
empirical research investigating both the VR outcomes future study
Includes 10 or more Includes less than 10
manipulations employed in treatment and their
participants participants
context of use. The review aims to provide an Published on pre-print server
overview of the field and to identify any gaps Peer-reviewed or other non peer-reviewed
which currently exist in the field and the possible forum
future research avenues in this increasingly Written in English Written in any other language
significant field of research. Legend: VR = Virtual Reality; HMD = Head-mounted
display; CAVE = Cave Automatic Virtual Environment
2. Method The initial search produced 1074 hits, after
exclusion of review papers, conference reviews,
This research used the PRISMA checklist editorials, books and letters 909 results remained.
adapted for scoping reviews11 to guide the process Further screening excluded all non-English
of data collection, and reporting. The initial search publications, leaving 883 publications.
was conducted in February 2021 in the Scopus Subsequent screening removed all duplicate
database, one of the largest, multidisciplinary publications; abstracts of remaining publications
databases. Conducting the searches in as few were screened to identify publications addressing
comprehensive databases as possible instead of the main research question. All publications were
several different ones is preferable for purposes of first screened by one author, then reviewed by a
rigor and clarity12. To achieve the objectives the second author; any conflicting or unclear
literature search in the Scopus database was interpretations were marked for review, discussed
conducted using the following search query: and reconciled by the authors to ensure
consistency and conceptual clarity. Of the initial
TITLE-ABS-KEY ((VR OR "virtual reality") AND
(emotion*) AND (train* OR regulation OR management OR results, 16 were retained. Backwards and
treatment)) forwards searches were conducted on the
65
remaining publications. A further 183 potential expanded to incorporate both primary and
publications were identified, these were screened secondary elements (see Table 2.).
to ensure they met the same inclusion criteria as
in the initial round, leaving 20 publications. A 3.1. Publications
second search on Scopus database was conducted
in December 2021 using the identical search
Recent years have seen a marked upturn in
query as before. This was done to ensure that all
published works, with the number of publications
the relevant papers published since the initial
rapidly increasing from 2019 onwards. It is
search were included. This search produced 149
worthy of note that the first publication included
(additional) hits, after exclusion of review papers,
in this review was published in 1995, yet none
conference reviews, editorials, errata and letters
were published from 1996 to 1999, or in either
118 results remained. All non-English
2004 or 2013, see fig. 2. Of these publications, the
publications were also excluded from the search
overwhelming majority, 47 of 49, were journal
results, leaving 113 publications, of these five
articles with the remaining two publications being
publications met the inclusion criteria. Backwards
a book chapter and an article published in
and forwards searches were conducted on the five
additional publications, providing a further eight conference proceedings.
publications which met the inclusion criteria. In 10
total, 49 publications were included, see fig. 1. 8
6
4
2
0
1997
2019
1995
1999
2001
2003
2005
2007
2009
2011
2013
2015
2017
2021
Figure 2: Publications by Year
The use of VR as a tool for teaching emotional
management is an inherently multidisciplinary
topic. With this in mind, the field of study was
extracted from the publication venue rather than
from the publications themselves. In order to
ensure consistency of approach the disciplinary
fields of each venue were extracted from the
MinEdu database established and maintained by
the Finnish Ministry of Education and Culture.
Figure 1: Publications Included in Review MinEdu defines scientific fields by combing
classifications used by the Scopus and Web of
3. Results Science databases, Norwegian and Danish rating
systems, and those of the European Reference
A concept matrix13 was used to conduct the Index for the Humanities (ERIH). While some
analysis and all publications meeting the inclusion publication venues have a single classification,
criteria (N=49) were individually coded according others can have upto four separate classifications,
to the following pre-defined concept matrix: as such the cumulative figures below exceed the
1. publication type, field & year total number of papers included in this review.
Given that this work is concerned with the
2. context of use & target behaviour
subject of VR and emotional management, it is
3. study design
unsurprising that the most referenced fields are
4. virtual reality utilisation Psychology (32 hits), Neurology and Psychiatry
The concept matrix above was developed prior (16 hits), and Computer and Information Science
to the review in order to capture the information (13 hits). There is great diversity evident in the
required to achieve the aims of the research11. publication venues, however, with referenced
During the review process it was adapted in order fields including Nursing (7 hits), Sociology (6
to fully reflect the nature of the included hits), and Educational Sciences (1 hit). Table 2
publications. For example, context of use was
66
provides a full list of scientific fields served by the VR equivalents. VR-CBT was utilised in treating
publications included in this review. gambling disorder (P3), morbid obesity (P22) and
paranoid symptoms in psychotic patients (P11).
Table 2
Scientific fields represented Table 3
# of Use contexts and fields of application
MinEdu Classification
hits Primary Target
Secondary UC Publication
UC Behaviour/Condition
Psychology 32
P4, P7,
Neurology and psychiatry 16 P18, P27,
PTSD P28, P29,
Computer and information sciences 13 P34, P35,
P36, P37
Nursing 7
P30, P38,
Aviophobia
Media and communications 6 P40, P41
P6, P10,
Sociology 6 Arachnophobia
Exposure P14
Biomedicine 5 Therapy Panic Disorder w/wo
P1, P33
Agoraphobia
Public health care science, environmental and
4 P8, P25,
occupational health Acrophobia
P39
Agronomy 2 Exam Anxiety P5
P13, P20,
Biochemistry, cell and molecular biology 2 PSA
P46
Therapy
Gynaecology and paediatrics 2 P17, P19,
SAD
P49
Health care science 2 Gambling Disorder P3
Others 2 Morbid obesity P22
CBT Paranoia P11
Educational sciences 1 PSA P43, P48
Medical and health sciences 1 SAD P2
Psychodynamic
Depression & anxiety P45
Neurosciences 1 therapy
Body Exposure
Other engineering and technologies 1 Anorexia Nervosa P32
Therapy
Philosophy 1 Mindfulness
GAD P31
Skills
Statistics and probability 1
Relaxation P15, P16,
Depression & anxiety
Visual arts and design 1 Therapy P42
Legend: MinEdu = Finnish Ministry of Education and CBT Stress P9
Culture Database Obesity P23, P24
Stress Relaxation
Manage- Mood Disorder P44
Training
ment Stress P47
3.2. Context of use and targeted Stress-coping
Stress P21
skills
behaviours/conditions ER skills Adolescent risk
P12
Psycho- building behaviour
education Cognitive Borderline
The majority of studies included in the review P26
reappraisal Personality Disorder
utilized VR in therapeutic contexts (41 Legend: CBT = Cognitive Behavioural Therapy; ER = Emotional
publications), exposure therapy (ET) being by far Regulation; GAD = Generalised Anxeity Disorder; PSA = Public
the most common field (29 publications). VR was Speaking Anxiety; PTSD = Post-Traumatic Stress Disorder; SAD
= Social Anxiety Disorder; UC = Use Context; w/wo = with or
used extensively as part of the treatment for post- without
traumatic stress disorder (PTSD) (e.g. P4, P28,
P34), but also for several phobia: aviophobia In addition to exposure therapy and CBT, VR
(P30, P40), arachnophobia (P6), acrophobia (P25) was used to create environments for Ericksonian
and panic disorder with or without agoraphobia psychotherapy and relaxation therapy targeting
(P33). VR was also applied in exposure therapies depression and anxiety of the elderly (P16),
targeting social anxiety disorder (SAD) (P17), patients with cardiovascular disease (P15) and
public speaking anxiety (P46) and exam anxiety chronic obstructive pulmonary disorder (P42).
of university students (P5). VR was also employed in body exposure therapy
VR was also used as part of cognitive treating anorexia nervosa (P32) and in a form of
behavioural therapy (CBT) by replacing the in therapy promoting mindfulness skills in patients
vivo exposures and behavioural experiments with with generalized anxiety disorder (P31).
67
Other than therapy, VR applications were controls and affected individuals were each
employed in studies implementing stress assigned to one of three treatment conditions
management protocols and psychoeducation. VR (wait-list control, standard treatment, and VR-
offered environments for relaxation training for enhanced treatment) (P14). The most common
subjects suffering from obesity (P23), mood approaches, however, used either a two-group or
disorder (P44) and psychological stress (P47). A three-group design where VR-enhanced
VR game promoting stress-coping skills, aiming approaches were compared to either a control
at altering a negative stress mindset of a patient group (wait-list, standard treatment, or healthy
population was also investigated (P21). individuals) or a combination of control and
In the area of psychoeducation, a VR game standard treatment. The prevalence of studies
was also utilized to help young patients with utilising control groups in preference to an AB
borderline personality disorder (P26). Another design ensure more robust conclusions can be
interactive VR platform was also used for role- drawn from the work.
play, supporting adolescents’ ER skills building in The overwhelming majority of works (21 of
situations potentially leading towards risk 49) incorporated two measurement points,
behaviours (P12). Table 3 provides a full list of baseline (pre-experiment) and post-experiment, a
primary and secondary use contexts (UC) and the further 16 incorporated three measurement points,
specific behaviours and conditions which were baseline, post-experiment and follow-up (ranging
targeted with the use of VR. from one week to one year). While within-
subjects analysis exceeded between-subjects
3.3. Study design analysis, 18 and 11 respectively, the majority of
works, 20, used both approaches in order to
measure individual changes as a result of
The focus on empirical works, rather than treatment and changes between treatment groups.
theoretical or conceptual pieces, resulted in a
Approaches to measurement were evenly
situation in which every single publication distributed between the studies: 13 employed both
featured in this review took the form of self-reports and physiological measures, 14
quantitative, experimental research. However, employed self-reports only, and 15 employed both
there was notable diversity in the design of the self-report measures and clinical assessments.
experimental approaches. First, recruitment Only five studies employed clinical assessments,
ranged from convenience-samples among the physiological measures and self-reports; two
general population (P17), university students studies used clinical assessments only.
(P19), or in-patients (P44), to targeted recruitment
of individuals who were thought to benefit from
new approaches to the management of emotions 3.4. Virtual reality utilization
(P27). The nature of the studies, their application
and context of use (section 3.2), largely defined Virtual reality was predominantly used to
the recruitment of participants, for example create practice environments promoting ER which
requiring active service members diagnosed with were safer, more controllable (whether by the
combat-related PTSD (P34) or individuals therapist or the users themselves), and recently,
affected by anorexia nervosa (P32). Given the more cost-effective. VR was utilised in the
specific nature of both conditions, it is majority of the studies included in this review as
unsurprising that the samples were dominated by part of existing therapeutic protocols, e.g. ET and
males and females, respectively. However, in CBT, functioning as an alternative to in vivo
many other studies investigating more generalised exposure. With the rise of low-cost consumer
disorders, such as Public Speaking Anxiety, hardware, the possibility of also using VR for self-
females dominated the samples, with only four guided exposure has emerged (P49). For this
non-PTSD studies using samples where the reason, most VR applications used in the studies
number of males exceeded females (P8, 45.45% aimed to simulate real-life scenarios, either to
female; P11, 31%; P39, 40%; P46, 48%). expose and desensitize users or to allow certain
Second, a number of studies used only a single skills could be practiced via role-play. In several
condition, adopting an AB design in order to cases VR was featured as an alternative to
assess differences between baseline and post- visualisation (P17, P18), an aid for concentration
experiment measures (P44), while another study (P24) or an addition to more traditional treatment
adopted a 2x3 design in which a group of healthy protocols for relaxation training (P24, P36).
68
A limited number of implementations went Multisensory experiences with auditory,
beyond the “real” and utilised the affordance of olfactory, tactile and vibrotactile cues were often
VR technology in order to create more fantastical utilised in exposure settings to augment the
and gameful environments. For treating immersive qualities of VR. By increasing the felt
depression and anxiety in patient populations, the presence of participants, and by creating more
Virtual Therapeutic Garden offered an interactive, authentic environments, treatment efficacy was
multisensory (visual, auditory and kinesthetic) improved. Simple props were already utilised in
environment, where users could bring a grey, the early studies alongside VR, e.g. a furry toy
untidy garden back to life by tending it through spider or real railing used to create tactile
completing therapeutic tasks. In this way, the experiences for arachnophobes (P10) and
gradually increasing colour palette and growth of acrophobes (P39), or real aeroplane seats with
plants both served as a reminder of their progress vibrating sensations for patients dealing with
and symbolised their own recovery (P15, P42). aviophobia (P40). The more current platforms,
These more playful and, indeed, more gameful such as “Virtual Iraq” employed in multitude of
approaches are also reflected in the emergence of studies (e.g., P18, P27, P34) targeting combat-
environments which have been created to alter a) related PTSD in active-duty military personnel,
stressful mindsets, and b) cognitions about the are highly adjustable with combat-related features
flexibility of emotions. In “Stressjam” heart rate and can be customised to suit user needs.
variability (HRV) biofeedback was used to Biofeedback (BF) was used to communicate
provide participants (both healthy controls and with the VR environment in only one study
patient population) information about their included in this review. As discussed previously,
capacity to cope with stress, i.e. their the “Stressjam” game environment used HRV
“superpower” in the game. They used this skill to biofeedback to provide participants in-game
advance in the game: exploring, finding and information about their stress-coping capacity
applying effective mechanisms in their bodies to during an interactive VR experience (P21).
generate stress or to remain calm. (P21). The
educational game “InMind” was employed by 4. Discussion
researchers to enable adolescents diagnosed with
Borderline Personality Disorder to modify beliefs
To our knowledge, this scoping review is the
about their ability to affect their own emotions.
first attempt to outline how immersive VR
During the game participants took charge of
technology and its affordances have been utilised
changing emotions within the brain by “firing”
to facilitate ER. Immersive VR and ER have seen
red neurons and transforming them to green, in
academic attention grow in parallel, yet this
this way they were able to reduce the intensity of
review reveals a notable increase in published
an emotion, this process being analogous to
studies combining both areas only recently. ER
reducing the intensity of an emotional experience
has been one of the most studied topics in
by adopting an alternative approach. Adopting an
psychology over the past two decades, as such it
active role in game encouraged the participants to
is unsurprising that studies investigating VR’s
believe that self-directed emotional change was a
potential in this area are largely from this field.
realistic and achievable goal (P26).
Employed as a means of delivering Body This review highlights many benefits afforded
by VR in the promotion of ER. The most obvious
Exposure Therapy for patients with anorexia
advantage of VR relates to its customisability;
nervosa, a VR environment was used to
many publications utilising platforms which could
manipulate the body image of the study
be adapted to the specific needs of individual
participants. They were first exposed to a virtual
users. Second, it is a safe, stable, and predictable
body with their real-size silhouette and body mass
environment, a particular asset when used to
index (BMI) which was gradually manipulated by
address phobias or traumatic experiences. Finally,
applying small BMI increases to the body over
VR was also often found to be a useful alternative
successive sessions. This continued until the
for subjects having difficulties engaging in the
healthy BMI target was reached. The aim of each
visualization-based practices often required when
session was also to reduce the participant’s initial
using different therapeutic techniques.
(body related) anxiety level by 40%. To induce
As a result of this scoping review several gaps
full body illusion (FBI) over the virtual body,
in the existing literature have been identified. This
visuomotor and visuo-tactile stimulation was
is to be expected as, although publications
conducted in the beginning of each session. (P32).
69
included in this work span 25 years, until 2018 adolescent risk behaviours, those treating combat-
publications averaged 1.1 per year before jumping related PTSD observed the opposite. Both context
to 6 per year between 2019 and 2021. Those issues of use and target population, therefore, are
and areas felt to be fruitful avenues for further particularly important and it cannot be assumed
research are discussed below. that the benefits of VR can be equally applied to
The use of VR as a means of delivering all. More research is needed featuring participants
exposure therapy dominated the reviewed drawn from representative, non-clinical samples.
literature, appearing in over 50% of publications, The latest research, and the rapid growth of
albeit the range of specific phobias or disorders work in the area, utilising VR technology in the
addressed via exposure therapy was reasonably facilitation of user ER indicate the broadening of
broad. However, this situation indicates that the the field and the emergence of new systems and
potential of VR is far from being realized. It is the designs. In addition to more fruitful exploitation
context of psychoeducation which offers the most of the affordances of the technology, the future of
scope for growth with only two identified works VR as a tool for ER lies in highly personalised,
in that area being published in the previous two customisable and adaptive implementations3 21.
years. Indeed, the use of VR for psychoeducation- Standard limitations apply to any review, and
based training is not limited to clinical settings; this work is no exception. The most notable being
research integrating ER and psychoeducation into that when investigating a multidisciplinary field,
other forms of workplace training, for example, particularly one associated with a developing
affords many possibilities. Such an approach technology, it is unlikely that all relevant
would build on work which is beginning to utilise publications will be identified despite all best
VR when, e.g., training emergency personnel.14 15 efforts when constructing the search. This issue is
Closely connected to the above point, the somewhat mitigated by the fact that backwards
majority of research featured virtual environments and forwards searches were conducted on all
which were designed simply as a direct replication included hits, indeed these searches returned more
of in vivo treatments, or as simulations of the real- relevant results than the initial searches. Second,
world. While the environments featured degrees the pre-defined inclusion criteria necessarily
of customization and user-centred adaptability shaped the publications selected for inclusion,
unavailable in vivo, they did not exploit the while this is not a limitation in itself, the need to
affordances of the technology. Further work is focus on a specific type of publication, in this case
needed to expand upon pilot studies which use VR empirical studies, meant that conceptual or
to tailor scenarios according to individual theoretical works are not featured in this work.
responses, such as with anxiety disorders16.
Interestingly, studies utilizing VR technology’s 5. Conclusion
affordances more widely, of going beyond the
“real”, have all been published since 2019. The
This work provides an overview of the field
emergence of research which highlights gameful
and contexts in which VR has been implemented
affordances of VR in facilitating ER provides an
to facilitate ER. Results indicate that until
example of a promising avenue for future research
recently, empirical research in the field has
combining VR, psychoeducation, emotional
management, and gamification17. remained somewhat static with a relatively
narrow scope, although the recent increase of
Interestingly, despite the widespread use of
published works, combined with more varied uses
physiological measures our search results featured
of VR and its’ affordances, suggest a broadening
very few studies utilizing biofeedback (BF)
of the field.
technology alongside VR. No doubt, this is
associated with the available technologies given
that several early studies incorporated a range of 6. Acknowledgements
multisensory aids to augment VR. Indeed, BF in
VR has increasingly been studied in relation to, This work was supported by the Foundation of
for example, relaxation18, mindfulness19, and as a Economic Education (Grant 190111), the
game mechanic20. Academy of Finland (Grant 312396), and the
A particular issue of interest is that regarding Academy of Finland Flagship (Grant 337653).
drop-outs or non-completers; while some studies
found that VR encouraged participation, for
example when using psychoeducation to address
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