Agency over engagement in virtual reality mental health interventions: neurodivergent experiences

Digital technologies are increasingly central to the future of mental health care. Among them, Virtual Reality (VR) has moved rapidly from experimental settings into real-world clinical settings offering immersive and scalable approaches to supporting wellbeing.

At the same time, demand for mental health support among individuals with attention deficit hyperactivity disorder (ADHD) and autism spectrum condition (ASC) continues to grow (1). Across the NHS, long waiting times for both diagnosis and post-diagnostic support for these populations highlights the need for new approaches that can provide timely, personalised and accessible care (2).

Responding to growing demand via innovative models of mental health support aligns closely with the NHS’s current strategic direction, including the shift towards delivering more care in community settings, focusing on preventative support and making greater use of digital technologies to improve access and efficiency (3). As these trends converge, immersive technologies such as VR are increasingly positioned as part of the solution, with a view that they can deliver flexible, engaging interventions at scale (4).

Early signals from practice support this view. TendVR, an organisation supported by Health Innovation East, delivers mindfulness-based cognitive interventions through VR Meta Quest headsets. Through routine service use, the TendVR team observed that a notable proportion of individuals engaging with their platform identified as neurodivergent.

Such data prompts a deeper line of enquiry. If neurodivergent individuals are engaging disproportionately with immersive technologies, what is it about these environments that resonates with this population? Further, what might this tell us about how mental health support can be better designed for neurodivergent populations?

Searching for evidence

To explore these questions, Health Innovation East undertook a structured literature review, drawing on the organisation’s evaluation expertise to examine how neurodivergent people experience mental health interventions delivered through virtual reality.

Search terms and inclusion criteria were carefully developed and five major academic databases were searched, followed by a robust screening process including title and abstract review followed by full-text assessment.

Given the rapid growth of digital mental health products and immersive technologies, we expected to uncover a body of qualitative evidence offering insight into how neurodivergent individuals experience VR-based mental health interventions.

We found one paper (5)

While qualitative research on VR and neurodiversity is growing, much of it focuses on educational applications, skills training or simulated social interactions, such as practising everyday conversations or preparing for job interviews. Other studies focused on the pre-emptive design of the VR environments or co-production, with limited follow-up on real-world user experience.

These approaches have merit but do not capture how individuals experience VR-based mental health interventions, nor do they explain the mechanisms through which they may support engagement, emotional regulation or therapeutic benefit. Without this understanding, it becomes difficult to refine existing approaches or design interventions better tailored to neurodivergent populations.

Despite the limited evidence base we uncovered, several useful themes emerged (6,7).

Useful themes from limited evidence

VR enables low-demand emotional regulation

• Participants described VR as a calming and controllable space that supported emotional regulation without the cognitive, social or verbal demands often associated with traditional therapies. Low-pressure activities such as guided breathing and drawing enabled gentle self-soothing, suggesting VR may offer an alternative pathway to regulation that does not rely on interpersonal interaction.

Control of sensory environment appears central to VR’s value

• A defining feature was the ability to actively shape sensory input. Adjustable lighting, sound and environment allowed individuals to create spaces aligned to their needs – from low-stimulation “empty” environments to immersive natural settings. Preferences varied significantly between individuals, reinforcing the importance of adaptability rather than standardisation.

Agency and autonomy may drive engagement

• Participants consistently valued the ability to control pace, interaction and intensity. A sense of agency, combined with privacy and reduced social expectation, enabled engagement in the intervention without pressure to mask aspects of their neurodivergence or adapt their behaviour to meet perceived neurotypical expectations. This may be particularly significant given that such factors are frequently reported as barriers to neurodivergent individuals accessing traditional mental health settings (8).

Therapeutic impact appears closely tied to design

• Across findings, the effectiveness of VR was inseparable from its design. Features such as sensory modulation, environmental stability and optional interactivity directly shaped user experience, suggesting that in immersive interventions design decisions may function as mechanisms of change.

Overall, the findings suggest that VR may be effective not because it delivers therapy differently, but because it changes the conditions under which individuals are able to engage with it. However, while these insights are valuable, they are drawn from an extremely limited evidence base and point to a critical gap in the research that needs to be addressed.

Bridging the gap

The evidence gap has not emerged by accident, but as a product of how research in this space is currently structured.

Much of the existing evidence is shaped by academic systems, where studies are often conducted by research students operating within fixed timelines. These constraints make it difficult to design, deliver and evaluate VR-based mental health interventions, while also capturing rich qualitative follow-up data. Such data typically require a longer and more resource-intensive analysis phase than quantitative approaches.

Ethical requirements, particularly when working with neurodivergent populations in clinical contexts, are essential. However, they can further constrain recruitment, study duration and the depth of data collected in academic settings.

A broader preference for quantitative evidence has also shaped the field. Outcome measures and effect sizes are often prioritised for their perceived generalisability, while qualitative approaches, which are typically more resource-intensive and complex to analyse, remain comparatively underutilised. However, this has long been recognised as a systemic limitation within healthcare research. Whilst quantitative approaches are invaluable for establishing efficacy and measurable outcomes, they may offer an inherently reductive account of intervention impact when used in isolation. Scholars have argued that overreliance on quantitative metrics can obscure the contextual, experiential, and process-driven insights afforded by qualitative enquiry, despite these factors often being central to understanding how and why interventions succeed in real-world settings (9,10,11).

At the same time, research funding and design have tended to prioritise paediatric populations and measurable clinical outcomes. This has led to a reliance on proxy accounts, such as parental reporting and a focus on evidencing symptom reduction rather than lived experience. While valuable, these approaches offer only a partial view, particularly when exploring how individuals engage with and make meaning from clinical content delivered through experiential environments.

Finally, much VR research has focused on skills training or behaviour change, often oriented towards social performance or adaptation. This emphasis risks overlooking the value of VR as a space for autonomy, regulation and authentic engagement with clinical content for neurodivergent individuals. As a result, we gain insight into whether interventions have an effect, but far less understanding of how or why they work, which is essential for refining interventions and improving outcomes over time.

Action: qualitative insight must be embedded

If VR and other digital technologies are to play a meaningful role in the future of mental health care, we must move beyond asking whether they work and start understanding how and why they work, for whom and in what contexts.

Quantitative measures of clinical effectiveness will remain essential. However, without first-hand qualitative insight into how neurodivergent individuals experience these interventions, we risk scaling solutions without fully understanding the mechanisms that drive engagement, trust, and meaningful change. Addressing this systemic gap in research practice will be critical to designing and implementing interventions capable of delivering meaningful impact at scale.

A step change in qualitative insight requires a shift in how immersive VR mental health interventions are evaluated. Qualitative insight must be embedded alongside clinical outcomes, with greater emphasis on lived experience, co-design and longitudinal follow-up. Each are factors that are particularly critical for adult populations, whose perspectives remain underrepresented.

No single organisation can address this. Innovators, health systems, and research partners must work together to bridge the gap between development and real-world understanding. Partnerships with organisations equipped to deliver robust, experience-led evaluation will be essential.

VR holds significant promise as a scalable, preventative tool. Realising that promise depends on our ability to understand, and not just measure, its impact.

To contribute to the conversation and understand more about Health Innovation East’s work contact evaluation@healthinnovationeast.co.uk