Expert panel to identify applications of virtual reality (VR) in cognitive behavioral therapy for alcohol use disorder: A Delphi study

Background. Cognitive behavior therapy (CBT) is efficacious for alcohol use disorder (AUD). Virtual reality could augment CBT by immersing patients in relevant situations, scenarios, or exercises. We sought expert consensus on the most promising applications of VR and how, when, and where it might best be used. Methods. We conducted a Delphi study with 10 experts in CBT for AUD. Round 1's open-ended questions across 10 topics generated 89 items. In later rounds, panelists rated each item's benefit/importance from 1 to 5. Consensus required at least 70% agreement. Items not achieving consensus were re-assessed in three subsequent survey rounds. Results. The panel reached consensus on 84 of 89 (94%) items after three rounds. Panelists endorsed VR for practicing high-risk situations, drink refusal and assertiveness skills, and trigger identification, with therapists coaching in real time. They agreed on recommendations for introducing and debriefing and agreed VR was suitable for all levels of care. Top implementation barriers were therapist reluctance, low technology confidence, training time, cost, technical support, and reimbursement. Conclusions. Findings offer a blueprint for using VR in CBT for AUD, including applications, delivery, timing, and setting, and a path to evaluating whether it improves outcomes beyond CBT alone.