Avatar Customization and Embodiment in Virtual Reality Self-Compassion Therapy for Depressive Symptoms: Three-Part Mixed Methods Study.

Abstract

Background: As virtual reality technologies become more accessible, understanding how design features influence user experience (UX) and psychological benefit is critical, particularly for emotionally sensitive interventions. Thus, while prior studies support the use of self-compassion paradigms in immersive virtual reality (VR) environments, the effects of avatar stylization, customization, and mirrored self-representation on therapeutic outcomes are not well understood. For instance, while it is often assumed that increasingly realistic avatars are preferable to less realistic ones, this basic premise remains largely untested.

Objective: This study aimed to evaluate whether avatar appearance, customization features, and virtual mirrors affect UX and therapeutic outcomes in VR self-compassion therapy. Specifically, we examined whether stylized avatars, avatar customization, and virtual mirror feedback influenced user-rated self-compassion and depression symptoms.

Methods: Across three between-subjects studies (N=107 neurotypical adults), participants engaged in an immersive individualized VR therapy protocol based on a 2-phase compassion task. The conditions were (1) stylized avatars (n=20), (2) stylized customizable avatars (n=49), and (3) stylized customizable avatars with a virtual mirror (n=38). Participants completed the User Experience Questionnaire, the Self-Compassion Scale, and the 8-item Patient Health Questionnaire (PHQ-8). In study 3, presence was also assessed using the Slater-Usoh-Steed scale. Qualitative feedback was analyzed thematically. Between- and within-study comparisons used t tests and Mann-Whitney U tests.

Results: Avatar customization (study 2) led to a significant increase in self-compassion (Self-Compassion Scale: baseline mean 3.05, SD 0.98; follow-up mean 3.55, SD 1.16; t89=2.22; P=.03; d=-0.47), though PHQ-8 scores remained unchanged. The virtual mirror condition (study 3) significantly improved depression scores (PHQ-8: U=477.5; z=2.53; P=.01; r=0.30) and UX across four User Experience Questionnaire categories, including attractiveness and dependability. However, self-compassion did not significantly change in study 3 (mean 3.88, SD 1.33 → mean 4.09, SD 1.05; t63=0.71; P=.47; d=0.18). Presence scores in study 3 (mean 4.56, SD 1.58) were also comparable to real-world benchmarks. Qualitative feedback highlighted strong engagement with avatars and mirrors, and participants reported emotional safety and personalization benefits.

Conclusions: Stylized avatars, when paired with customization and mirrored embodiment, can support UX and therapeutic benefit in VR self-compassion therapy. These findings challenge the assumption that hyperrealistic avatars are superior and highlight the importance of emotionally congruent design choices. The combination of stylization, individualization, and visual feedback may offer a low-barrier, user-aligned strategy for future therapeutic VR applications.