Transcending Self Therapy Virtual Reality Expansion: Effect on Engagement, Completion and Temporal Usage Patterns

Transcending Self Therapy (TST) is an integrative cognitive behavioral therapy for substance use disorders (SUDs) that was adapted into an immersive virtual reality (VR) platform (TST-VR) featuring psychoeducation modules, mindfulness exercises, and interactive activities that reinforce TST principles. Utilizing an evidence-informed framework and incorporating feedback from a feasibility study, Transcending Self Therapy Virtual Reality (TST-VR) was expanded from a 4-Module version to a 10-Module version. Each of these modules contains four to six distinct lessons or interactive activities presented in a virtual environment. The aim of this study was to examine the effect of this expanded content on engagement with TST-VR. We hypothesized that the expanded content and feedback-informed changes incorporated into the 10-Module version would increase engagement in terms of total time (minutes) in the program and program completion. Fifty-eight military veterans receiving or being considered for SUD treatment (N = 34 in the 4-Module group; N = 24 in the 10-Module group) received access to TST-VR headsets. Usage metrics, including total time in headset, time of day usage, and module completion, were tracked to assess adherence and patterns of engagement. Contrary to concerns that more modules could increase attrition, veterans assigned the 10-Module program not only spent a higher average total time in headset but also showed a greater likelihood of completing all assigned modules. In an exploratory analysis, temporal analyses further revealed that overnight usage (midnight to 6 AM) was observed in a sizable minority in both groups (14% of users in 4-Module, 29% of users in 10-Module), suggesting that VR can function as an on-demand therapeutic resource beyond typical clinical hours. Additional insights were indicated, such as the counterintuitive finding that, in a population that may not be digitally literate with gaming devices, the amount of time spent in the early tutorial section (learning how to use the device controls) did not indicate whether a user would complete all Modules. These data imply that following user-centered design principles and expanding VR content (creating a larger, more fulfilling world) not only sustains but may increase patient engagement, warranting further study into how a larger virtual world can foster adherence and SUD treatment engagement.