Substance use disorders (SUDs) are highly prevalent and complex psychiatric conditions with a high disease burden [1]. Individuals with mild to borderline intellectual disabilities (MBID) are at an increased risk for developing SUDs [2,3]. MBID covers both persons with mild intellectual disability (MID) and borderline intellectual functioning (BIF) [4], and in the Dutch clinical context, it is defined by an IQ between 50 and 85, accompanied by limitations in adaptive functioning with onset during the developmental period. Individuals with MBID often experience cognitive limitations that affect comprehension, memory, and problem-solving abilities, as well as difficulties in understanding the consequences of substance use, which can increase their susceptibility to SUDs and reduce the efficacy of treatment as usual [2]. Additionally, the prevalence of SUDs among persons with MBID is exacerbated by social vulnerabilities, such as problems with social skills [5], as well as social isolation, trauma, and substance use as a form of self-medication against negative life events [6].

Despite the availability of various psychotherapeutic and pharmacological treatments, maintaining long-term recovery in individuals with MBID can be challenging. As reported by the National Institute on Drug Abuse (2020), relapse rates in the general population who were treated for SUDs vary between 40 and 60 percent. Although specific relapse data for individuals with MBID are limited, relapse rates in this group might be even higher, given the challenges in assessment and standard treatment they may encounter [7,8]. For instance, most individuals with MBID experience communication barriers as they struggle to verbalize their thoughts, emotions, behaviors, and everyday risk situations. Moreover, barriers in skill application are present, as they often experience difficulties with applying newly learned skills from treatment in real-world risky situations [8]. These barriers in communication and skill application can make it more difficult to engage in therapeutic processes such as cognitive behavioral therapy (CBT) that rely on reflective, language-based approaches, which require cognitive and adaptive skills. Although tailored CBT protocols for the dual diagnosis of MBID and SUDs are available in the Netherlands [8,9], they still require patients to remember and reflect on their own behavior within treatment when discussing high-risk situations. Furthermore, generalizing and applying the newly learned coping skills in the real world remains difficult [8]. Consequently, there is a need for experiential, context-rich treatment approaches that reduce the reliance on abstract verbal processing and support in-context rehearsal of coping responses.

Immersive virtual reality (IVR) offers a promising approach to address the cognitive barriers that people with MBID experience within standard treatments that are based on the principles of CBT. IVR can be described as a computer-generated simulation of a 3D setting by using special electronic equipment [10]. Typically, head-mounted displays (HMDs) are used to immerse the user into a virtual environment (VE). Previous research suggests that IVR might lower learning obstacles by making experiences and training abstract concepts and interrelationships more explicit, understandable, and trainable, thereby improving comprehension for people who struggle with abstract thinking, such as those with MBID [11-13]. This approach eliminates the requirement for disembedded thinking, which refers to the capacity to grasp concepts outside of immediate and physical contexts. This is a skill that individuals with MBID find challenging [14]. Moreover, IVR can facilitate active learning rather than passively receiving information, thus reducing the reliance on abstract reasoning and verbal instructions while fostering skill acquisition [14]. This implies that learning becomes an engaging experience that does not solely rely on a language-based experience. Instead, IVR facilitates skill development through experiential learning, allowing individuals to learn by doing in a safe, controlled setting and acquire new skills without solely relying on language-based instructions [15,16].

Various studies have shown that VEs can elicit realistic (physical) reactions and behaviors in patients with SUD [10,17,18], including tension and substance cravings [13]. Virtual reality exposure therapies (VRET) have been developed based on these “natural” reactions to stimuli in IVR, for example, within the domain of anxiety disorders [19]. Following this initial success, research has also explored possible uses of VRET for SUDs, drawn by its ecological validity in realistically eliciting cue reactivity, such as drug craving and psychophysiological reactions (eg, increased heart rate and sweating) to stimuli associated with substance use [20].

However, the effectiveness of VRET for SUDs remains questionable. While pilot studies using VRET for SUDs led to cue reactivity and participant satisfaction, as well as expectations of clinical benefit, a 2021 review indicates that this has not yet been demonstrated in research on clinical effectiveness [21]. This is supported by an earlier review from Segawa et al [22], who stated that although IVR is effective at eliciting craving, VRET treatment outcomes vary. One hypothesis is that exposure in the context of addiction does not lead to extinction but rather reactivates a pathologically disturbed reward system, unlike anxiety disorders. As a result, VRET might even increase the risk of relapse [23], which is consistent with the lack of effectiveness of regular exposure therapies for SUDs [24]. Taken together, the evidence at the time of this writing indicates that VRET is insufficient for lasting change and that it may be essential to integrate, for example, CBT techniques in IVR interventions to actively understand triggers and train coping behaviors. This approach aligns with a literature review by Taubin et al [25], who found that IVR protocols integrating mindfulness practice, cognitive reappraisal, or other emotion-regulation tasks alongside IVR were more likely to achieve clinically meaningful effects on substance-use outcomes. Experimental data support this conclusion; in a randomized study, smokers who actively crushed virtual cigarettes, an IVR task that requires users to enact an immediate coping response, achieved significantly higher abstinence rates than smokers who performed a neutral control task [26]. These findings indicate that active rehearsal of coping strategies rather than exposure alone is essential for therapeutic benefits. Accordingly, an IVR protocol used in an active learning format that engages patients in practicing coping responses to trigger-related craving may positively influence internal biases and promote behavior change.

Building on these insights, embedding active learning tasks into an IVR can lead to interactive, user-centered interventions that are more compatible with the needs of individuals with MBID and SUDs. IVR-CBT for SUDs allows patients to safely confront triggers by exploring maladaptive thought patterns and gradually exposing them to drug-craving-provoking situations while practicing coping strategies in a secure, controlled VE. Moreover, IVR-CBT provides a supportive learning environment that allows users to experiment with alternative behaviors in a step-by-step manner, thereby enabling cognitive restructuring and learning of suitable behavioral responses to SUD-related symptoms. This aligns with the core objectives for SUDs in standard addiction care treatments that are based on CBT principles [27], including psychoeducation, skill development for coping strategies, developing more adaptive thinking patterns, strengthening problem-solving skills in a practical manner, and relapse prevention through self-control and reinforcement of positive behaviors [28]. However, research in interdisciplinary teams is needed to understand design requirements to develop IVR-CBT interventions, as well as implementation into treatment as usual.

This study reports on 2 explorative studies conducted with patients in a specialized addiction clinic for individuals with MBID and SUD. Study 1 aimed to identify patient-reported high-risk situations and craving triggers relevant to alcohol use during preparation for temporary clinical leave. Study 2 aimed to explore the feasibility and acceptability of engaging patients with MBID in an IVR protocol that induces nicotine craving while embedding coping components in virtual reality (VR; eg, distraction, relaxation, and physical activity). Feasibility was defined as completion of IVR phases and tolerability (eg, need for support/breaks, discontinuation), and acceptability was defined as perceived realism and perceived usefulness. Given the substance-specific focus of each study, findings are interpreted as exploratory and design-oriented, without assuming transferability of identified triggers or coping preferences across substances. Across both studies, our overarching goal was to generate initial design requirements and clinical integration considerations for future IVR-CBT modules for MBID and SUD populations.

This study reported 2 exploratory, design-oriented studies that were conducted in an inpatient MBID setting, examining high-risk situations, triggers, and coping strategies to inform the development and clinical integration of IVR-supported elements for substance-use treatment.

In the first study, qualitative interviews were used to identify alcohol-related high-risk situations, triggers, and patient-defined treatment goals in preparation for temporary clinical leave. Participants identified a range of high-risk situations for AUD, including being at home, in supermarkets, at social gatherings, in public spaces, or while traveling. Alcohol craving in these contexts was associated with multiple types of triggers, including multisensory cues, social influences, affective states, and personal habits. Participants described these alcohol-related high-risk situations as challenging and expressed interest in using IVR to identify personal triggers in context, discuss emotional responses while being immersed, and repeatedly rehearse refusal skills or alternative actions for temporary clinical leave.

In the second study, an existing IVR cue reactivity environment was used to explore the feasibility and acceptability of practicing coping strategies for nicotine craving, alongside descriptive craving assessments. All participants reported that the IVR elicited nicotine craving, and most were able to complete the procedure. This suggests that the use of IVR was feasible in an inpatient MBID setting, when therapist support was available. Participants perceived several coping strategies as helpful, which were related to distraction (eg, games and virtual pets), relaxation (eg, mindfulness and breathing exercises), and physical activity (eg, sport and walking the dog). Descriptively, nicotine craving tended to increase during cue exposure and decrease during the tutorial and coping phases. Notably, participants differed in how they experienced the specific IVR scenarios, and some required additional support due to anxiety or unfamiliarity with IVR. For example, one participant described a virtual riverside environment as triggering for nicotine craving due to personal associations with alcohol use (“I live close to the IJssel [Dutch river] myself and that was a very triggering place for me last summer, because automatically people sit there to drink alcohol” [S04]), whereas other participants experienced similar scenarios as craving reducing. This illustrates that the subjective meaning of IVR scenarios can vary substantially between individuals and that certain environments may evoke unintended craving responses depending on personal history.

Taken together, these findings suggest that IVR may provide a structured and experiential format for identifying high-risk situations and rehearsing coping responses in context for individuals with MBID. This is particularly relevant given the barriers in MBID treatment, including difficulties with abstract reflection and transfer of coping skills to everyday environments [2,8].

Participants in Study 1 identified different high-risk alcohol situations such as supermarkets, home settings, social gatherings, and public spaces. These findings are consistent with previous research on triggers in AUD, which has highlighted the role of environmental cues such as bars and stores in eliciting cravings [21,33]. However, participants in the present study frequently described these environments in combination with social influences (eg, peer pressure and interpersonal conflict) and affective states (eg, tension, negative affect, and distress) as triggers for alcohol craving. For example, in supermarkets, alcohol exposure was described as stressful and confrontational due to advertisements and visibility of alcohol products. Social gatherings were linked to invitations and pressure to drink. In the home setting, alcohol use seemed to be described as embedded in a habitual sequence of actions, such as coming home, sitting on the couch, watching football, and then drinking.

These findings indicate that alcohol craving in this MBID sample was experienced as embedded in daily routines and interpersonal situations, rather than triggered by exposure to environmental stimuli alone. This aligns with broader conceptualizations of craving as context-dependent while being influenced by affective and social processes [33]. In this study, participants described complex situations in which contextual cues, emotions, and social interactions were closely intertwined. For individuals with MBID, who often find it difficult to analyze and describe their everyday risk situations [2,8], addressing such interconnected triggers in a traditional CBT session can be challenging. CBT typically relies on retrospective discussion and functional analysis of high-risk situations. This requires patients to reconstruct the situation, identify the links between context, emotion, and behavior and consider alternative responses. Within this context, IVR may offer a complementary way to examine and rehearse high-risk situations in a more concrete and structured way.

While most IVR cue reactivity research operationalizes craving through predefined substance-use environments, such as bars or public venues [10,17,18], the present study identified high-risk situations and triggers for alcohol craving in patients with MBID through a bottom-up approach derived directly via interviews with patients. The situations described by participants were often routine and home-based and embedded in everyday activities rather than limited to prototypical drinking locations. Using these patient-derived situations as a starting point when developing IVR scenarios may increase the practical relevance of IVR within MBID inpatient treatment.

In the second study, participants explored several coping strategies to reduce nicotine craving in IVR. All patients reported that the IVR environment induced nicotine craving, confirming its ecological validity, consistent with earlier findings [13]. Interestingly, nicotine craving decreased during the tutorial phase, which contrasts with previous results that showed increased nicotine craving during immersion [13]. One possible explanation for this difference is that the gamified tutorial required sustained attention and functioned as a distraction, thereby reducing nicotine craving. This observation suggests that the structure and content of the tutorial phase may influence craving responses and should therefore be considered carefully when designing IVR protocols.

Participants perceived coping strategies that were embedded within IVR as helpful, particularly those that involved concrete actions such as interacting with virtual animals or engaging in games. This suggests that including active coping components within IVR may be important, rather than relying on cue exposure alone [22,26]. However, participants differed in how they experienced certain environments, which highlights the need for careful scenario selection and therapist guidance. The riverside example illustrates that environments intended to be calming may evoke craving if they are associated with prior substance use experiences. This underscores the importance of assessing personal associations and monitoring tolerability when integrating IVR into clinical care.

The findings from both studies provide practical starting points for the development of IVR-supported CBT elements within MBID SUD treatment. The present studies identified high-risk situations and coping strategies that patients themselves considered as relevant within inpatient MBID treatment and demonstrated that practicing coping skills within IVR was feasible and acceptable when therapist support was available. Participants also described treatment-related goals, such as discussing feelings with therapists during IVR sessions, practicing refusal skills, and learning to manage craving-related distress. These goals align with CBT mechanisms such as functional analysis and coping skills training [34], as well as with MBID-adapted CBT protocols that are used within Dutch inpatient treatment settings at the time of this writing [9].

Although clinical effectiveness was not evaluated, the descriptive reductions in craving during the coping phases suggest that CBT-based coping strategies, including self-control techniques tailored to the needs of patients with MBID, can be operationalized within IVR environments. The possibility to simulate socially and emotionally complex situations in a structured and controlled setting may allow for repeated rehearsal, which can be difficult to stimulate in traditional therapy but can be practiced safely and repeatedly in IVR. Prior studies have shown that IVR is effective at establishing cue reactivity by simulating real-life scenarios related to substance use. However, many applications focused primarily on exposure to SUD-related cues, without embedding active coping skill training or other therapeutic elements that are essential for behavioral change [35]. Integrating coping rehearsal directly within IVR may help to address this limitation by combining immersive exposure with the immediate practice of coping strategies.

Based on the findings from both studies, several design and implementation considerations for developing IVR-CBT interventions (ie, trigger-coping scenarios) can be identified. First, IVR environments may be useful for supporting two fundamental CBT objectives: (1) identification of high-risk situations and triggers (CBT: stimulus control) and (2) coping with trigger-induced craving (CBT: stimulus response prevention) [36]. IVR may function as a complementary modality within existing CBT protocols by enabling in-context rehearsal of skills that are otherwise discussed retrospectively. In doing so, a structured IVR-CBT framework may be developed that systematically links CBT objectives to certain IVR training modules with risk-coping scenarios, grounded in both CBT theory and immersive learning design. Stimulus control could be addressed through specific IVR trigger-assessment modules, in which patients, for instance, identify, label, and rate high-risk situations or triggers via simplified interfaces and real-time feedback tools via either the IVR or the therapist. Once patients can recognize and assess their high-risk situations and triggers, the next step would involve training them to actively manage their responses, thereby moving from stimulus control to stimulus-response prevention. The transition from stimulus control to stimulus-response prevention can be supported by an IVR-CBT framework with a staged approach that aligns technological affordances with a pedagogical learning design, as recommended by [37], by sequencing skill acquisition through concrete, repetitive, and context-specific activities.

Moreover, given the variability in individual trigger experiences observed in this study, IVR systems may benefit from allowing flexibility in scenario selection and coping options. Personalization through therapist-patient goal setting [37] and the use of customized scenarios that are based on each patient’s individual triggers and coping needs [38] might enhance clinical relevance. For instance, patients presenting with predominantly social triggers can, for instance, engage in peer-pressure simulations involving assertive refusal training, while patients with predominantly environmental triggers (eg, being in a bar) may work within location-based scenarios that focus more on stimulus control and rehearsal of coping strategies (eg, going for a walk). However, it is still uncertain whether individualized tailoring improves outcomes when compared to standardized IVR modules, as this still requires empirical evaluation.

Furthermore, IVR content may benefit from alignment with individualized high-risk situations and trigger profiles systematically linked to personalized coping strategies, while keeping a balance between personalized IVRs and standardized treatments [39]. It is important that researchers distinguish therapeutic mechanisms from educational ones, as skill learning in IVR may occur even in the absence of immediate relief effects, which are typically associated with real-world coping. Therefore, future studies should not only evaluate whether patients can learn coping strategies in IVR but also how these strategies generalize to behavior outside of IVR. Finally, the development of IVR-CBT protocols may benefit from interdisciplinary collaboration to address clinical, technological, and implementation considerations, including questions related to intensity and dosage. Future research could contribute to the development and empirical evaluation of a CBT-informed framework for IVR interventions that links identified triggers to coping strategies across structured learning stages. In addition, further studies should examine personalization capabilities, implementation barriers, and acceptability of IVR-CBT across broader MBID populations and diverse treatment settings.

Several limitations should be considered. First, both studies included small convenience samples recruited from a single clinic; therefore, limiting the extent to which the results can be generalized to other settings or MBID populations. Our convenience sampling might have over-represented individuals with MBID who were comparatively stable, motivated, and comfortable with technology since participation in the studies was voluntary and patients with severe psychiatric instability were excluded, resulting in selection bias. As a result, our findings may not fully apply to the perspectives and needs of individuals with higher levels of psychiatric complexity or lower technological literacy. Second, the 2 studies focused on different substances and different therapeutic targets. While AUD and ND may share some features, they may also differ in contextual triggers, behavioral patterns, and treatment mechanisms; therefore, the findings should be interpreted within each specific substance context. While overlapping processes such as cue reactivity and coping rehearsal may be relevant across SUDs, the specific triggers and coping elements that were identified in this work are substance-specific and design-oriented. In addition, the studies were exploratory and design-oriented, thereby not assessing clinical effectiveness, long-term outcomes, or the generalization of learned coping strategies beyond the IVR context. Third, the data were collected verbally by nurses (in training to become specialists) to resemble a common treatment setting. However, this might have increased social desirability bias (eg, see contrary craving effects during the tutorial phase), though paper-based assessments appear too complex for our group. Fourth, the interactions within the IVR were limited and of short duration due to the explorative nature of our study. This might have restricted the patient’s opportunity to fully practice coping responses extensively and may have limited the extent to which craving reduction could be observed. Fifth, it is important to note that we demonstrated and explored coping skills by using a pre-existing IVR system. This may have caused confirmation bias because participants’ given responses may have been influenced by the available specific examples and functionalities that were presented, which may have limited the identification of additional coping strategies. Instead, our explorative research aimed to generate or understand how IVR can be integrated into current CBT treatment in patients with MBID and SUD. Finally, participants might have participated in prior studies by our group, which could influence the data collected.

IVR-supported CBT elements appear feasible and acceptable in an inpatient MBID setting when appropriate support is available. The present studies provide concrete, patient-derived design insights into alcohol-related high-risk situations and nicotine-related coping elements that can be embedded in IVR. The findings of these studies suggest that IVR may help to reduce barriers that are associated with abstract verbal reflection by enabling in-context identification of triggers and repeated rehearsal of coping responses within a controlled environment. However, IVR environments may activate personally learned substance-use associations that differ between individuals. Therefore, careful scenario selection, real-time craving monitoring, and therapist guidance seem to be necessary to prevent unintended increases in craving.