Immersive Virtual Reality–Supported Cognitive-Behavioral Therapy for Patients With Mild to Borderline Intellectual Disabilities and Substance Use Disorders: Two Exploratory Studies

Abstract Background Substance use disorders (SUDs) are prevalent and characterized by high relapse rates. Individuals with mild to borderline intellectual disability (MBID) are more likely to develop SUDs and face barriers within treatment related to difficulties they experience with abstract thinking, verbal skills, and generalizing learned strategies to real-world contexts. Therefore, experiential, context-rich approaches are needed that reduce reliance on retrospective verbal reflection, support in-context identification of triggers, and allow the rehearsal of coping responses. Immersive virtual reality (IVR) may provide realistic, safe environments where patients with SUD and MBID can practice cognitive and behavioral skills with visual and practice-oriented materials. Objective This study aimed to generate design input for the development and clinical integration of IVR-supported therapy for individuals with MBID and SUD. Specifically, Study 1 explored alcohol-related triggers in patients with alcohol use disorder, whereas Study 2 examined the feasibility and acceptability of practicing nicotine-related coping strategies in patients with nicotine dependence (ND). Methods Two explorative studies were conducted at an inpatient clinic for patients with MBID and SUD in the Netherlands. Study 1 included 10 adults with alcohol use disorder and MBID who participated in interviews to determine relevant risk situations, triggers, and therapeutic goals for IVR-cognitive behavioral therapy (CBT). Study 2 included 10 adults with MBID and nicotine dependence who practiced coping strategies within an existing IVR featuring craving-inducing and craving-reduction scenarios. A multiple-method approach was used to gather input for IVR-CBT development and to explore feasibility and acceptability (user evaluation interviews, the Questionnaire of Smoking Urges, and Visual Analog Scale ratings). Results In study 1, we identified high-risk situations, including at-home routines (eg, sitting on the couch watching football), supermarkets (eg, confrontation with alcohol and advertisements), social gatherings (eg, invitations and peer pressure), and being outside or traveling (eg, public transport or passing alcohol-related places). Triggers clustered into multisensory cues (eg, seeing or smelling alcohol), social influences (peer pressure and interpersonal conflict), affective states (tension, distress, boredom, or euphoria), and personal habits (eg, rewarding oneself or associations with money). Participants expressed interest in using IVR to identify triggers, discuss affective states, and train refusal skills. In study 2, IVR elicited nicotine craving, which increased during cue exposure and decreased during tutorial and coping phases. The coping elements embedded in IVR included relaxation (eg, mindfulness or breathing exercises), distraction (eg, virtual pets and interactive games), and physical activity (eg, walking or sports). Conclusions IVR-CBT elements appear feasible and acceptable in inpatient MBID care with appropriate support. Findings provide patient-derived design insights for integrating trigger identification and coping rehearsal within IVR. Future work should use an iterative, user-centered design approach based on validated CBT-related techniques (eg, functional analysis or coping, or skills training) and compare IVR-CBT with CBT as usual to understand benefits and risks for patients and therapists.