VR for Complicated Grief: An Emerging Therapeutic Frontier

What we mean by complicated grief, and why VR is relevant

Complicated grief, captured in the DSM-5-TR as prolonged grief disorder, describes a grief response that persists beyond culturally expected timeframes (at least twelve months in adults, per the DSM-5-TR), marked by intense yearning, difficulty accepting the loss, avoidance of reminders, or disruption of life goals. It is not simply prolonged sadness: it involves significant functional impairment and usually requires specialized intervention.

The treatment with the strongest empirical support is Shear and colleagues' complicated grief therapy, which combines elements of interpersonal therapy, exposure to avoided memories, and imaginal revisiting work with the deceased. It is precisely this imaginal component—the guided conversation with the person who is no longer there—that has led several European teams to ask whether virtual reality could offer richer sensory support for that work.

The question is not whether VR replaces grief psychotherapy. It never does. The question is whether, within a well-structured protocol, certain components of grief work benefit from an immersive setting that lets the patient look, listen, and say goodbye under controlled conditions.

What we know: the research line from Slater and colleagues

Mel Slater, professor at the University of Barcelona and a world reference in virtual presence research, has published several studies exploring how VR avatars can be used therapeutically. His line of work with virtual bodies and self-compassion dialogues (in which the patient alternates between their own perspective and that of a significant avatar) has shown consistent effects on self-criticism, self-compassion, and emotional processing.

Applied to grief, several groups have adapted this paradigm so the patient can hold a guided conversation with an avatar representing the deceased. The available studies are mostly pilot studies, with small samples and no active control group, and should be read as proof of concept. They do not constitute sufficient evidence to speak of an effective treatment.

Even so, qualitative findings point to relevant phenomena: patients who report having said what was left unsaid, a transient drop in acute yearning, a sense of partial closure. Adverse effects also appear when documented: reactivation of acute pain, a sense of unreality, or later distress. The general rule we draw from the emerging literature is that the effect is not neutral and depends on the psychotherapeutic frame surrounding the session.

Specific clinical risks of avatar-based grief work

Three risks underlie the clinical precautions found in the emerging literature and in professional guidelines about evocative techniques in grief. Virtual reality for burnout and compassion fatigue in healthcare professionals

First, the risk of idealization: an avatar is necessarily a construction, and the construction the patient accepts will tend to take on the traits that best match their yearning. If the avatar ends up as an idealized version of the deceased, the therapeutic work may consolidate—rather than process—the difficulty in accepting the loss.

Second, the risk of covert avoidance: patients with complicated grief often avoid real-world reminders (cemetery visits, photo albums, family conversations). If VR becomes the only place where they meet their person, it can substitute for contact with the reality of the loss instead of preparing them for it.

Third, the risk of retraumatization in grief linked to traumatic death: accidents, suicide, violence. Here the literature is unequivocal: no evocative exposure without prior stabilization, without a differential diagnosis ruling out PTSD, and without a frame that allows the session to be stopped immediately.

Where VR fits within a grief psychotherapy protocol

The conservative reading—and the one the VRET clinical team adopts—is that VR, if used at all, belongs in a mid-to-late phase of therapy, once the patient has worked through the narrative of the loss with their therapist, identified what was left unsaid, and has basic emotional regulation skills to tolerate intense evocation. It is not a first-line technique or a shortcut to processing.

Avatar-based grief work is not among our available scenarios. Current VRET scenarios (immersive mindfulness, exposure to specific phobias, interoceptive exposure) do not include avatars of deceased people, and that decision is deliberate: the clinical, ethical, and technical investment required to deploy such a scenario with sufficient safety exceeds what a commercial product can responsibly offer today without an associated clinical research program.

What we do offer the clinician interested in grief work is the immersive mindfulness ecosystem and exposure to concrete reminders when phobic avoidance is present (for example, fear of driving after an accident that took a family member's life). Both components fit within the stabilization phase and the behavioral work on avoidance, not within the imaginal component involving the deceased.

Ethical questions any clinician should answer before using VR in grief work

Before considering VR use with a grieving patient, the clinician should be able to answer five questions in writing. What concrete therapeutic goal does VR add to what you are already doing? Have you ruled out contraindications (active PTSD, suicidal ideation, unstabilized traumatic grief, psychosis)? What is the plan if the patient's pain reactivates intensely during or after the session? How will you document informed consent, making clear that this is an off-label application within a psychotherapeutic protocol and not a standardized treatment? How will you evaluate the effect—positive or negative—at the next session?

If any of these questions lacks a clear answer, the responsible clinical decision is not to use VR with that patient. Immersion adds emotional intensity; it does not add clinical justification if the indication is weak.

VRET is a support tool for psychotherapy, not a CE-marked medical device or a standalone treatment. In complicated grief, this distinction is especially relevant: the therapeutic work is always carried by the licensed psychologist, within their usual scope of practice.

Where the research is heading

The next few years will be decisive. Clinical trials are underway in Europe evaluating VR protocols for complicated grief with larger samples, active control groups, and validated measures (complicated grief inventories, functioning scales). Until these results are available and replicated, the accurate language is emerging evidence, not effective treatment.

The VRET clinical team follows this line of work closely and will publish specific reviews when trials of sufficient methodological quality appear. In the meantime, the place of grief work in VRET clinical practice remains the conservative one: stabilization, immersive mindfulness, addressing associated phobic avoidance. The imaginal component involving the deceased remains experimental territory, not a product.

This article is for informational purposes for psychology professionals. It is not clinical advice for any individual case and does not replace the judgment of the licensed psychologist in charge. VRET is professional clinical-support software, not a CE-marked medical device.