JMIR Publications

ABSTRACT

Background:

Face-to-face psychotherapy remains the gold standard for mental health treatment; however, it faces accessibility barriers, including geographical constraints, costs, and stigma. Although videoconferencing psychotherapy addresses some limitations, challenges with engagement and therapeutic alliance persist. Metaverse psychotherapy is a promising evolution, combining digital accessibility with enhanced presence through anonymous avatar-mediated communication.

Objective:

To explore the design requirements for metaverse psychotherapy services that provide therapeutic effects comparable to face-to-face therapy by examining user experiences with avatar-based communication and space utilization.

Methods:

We conducted a qualitative study using a minimum viable product platform among adults aged 19-70 years with psychological health management needs, recruited from Korea University Anam Hospital and Korea University (n=60). The participants attended four weekly sessions (50 minutes each) using anonymous avatars reflecting real-time facial expressions and nonverbal cues. After completion, 30 participants (16 women, 14 men; 15 hospital employees, 15 university students) were purposively selected for semi-structured interviews (30-50 minutes). Data were analyzed using thematic analysis with ATLAS.ti software.

Results:

From 508 initial codes, four main themes emerged through iterative analysis performed by five researchers: (1) Balancing Anonymity and Self-Disclosure Through Avatars—anonymous avatars facilitated greater self-expression while maintaining emotional connection through synchronized nonverbal expressions; (2) Holistic Role of Metaverse Spaces—pre-therapy spaces served as preparation areas, during-therapy spaces required focused design, and post-therapy spaces enabled reflection and community support; (3) Meta-Connection—cyclic feedback systems were essential for translating virtual experiences into real-world behavioral changes, requiring specialized therapist training; (4) Space Design Considerations—technical stability, cross-platform accessibility, and user guidance were crucial for sustainable delivery.

Conclusions:

Avatar-based metaverse psychotherapy is promising as a sustainable and scalable platform that extends beyond face-to-face therapy. Key design principles include anonymous avatars with behavioral realism rather than visual similarity, multi-stage spaces supporting the therapeutic journey, cyclic feedback mechanisms connecting virtual and real-world experiences, and integrated therapist competency development. These findings provide practical guidelines for developing effective services that balance therapeutic efficacy with accessibility and user engagement. Clinical Trial: Clinical Research Information Service KCT0009695; https://tinyurl.com/2a48s7dh