Avatar Customization and Embodiment in Virtual Reality Self-Compassion Therapy for Depressive Symptoms: Three-Part Mixed Methods Study
Background: As VR technologies become more accessible, understanding how design features influence user experience and psychological benefit is critical, particularly for emotionally sensitive interventions. Thus, while prior studies support the use of self-compassion paradigms in immersive 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 user experience (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 (iVR) therapy protocol based on a two-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 (UEQ), the Self-Compassion Scale (SCS), and the Patient Health Questionnaire (PHQ-8). In Study 3, presence was also assessed using the Slater-Usoh-Steed (SUS) 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 (SCS: baseline M = 3.05, follow-up M = 3.55, 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 = .30) and UX across four UEQ categories, including Attractiveness and Dependability. However, self-compassion did not significantly change in Study 3 (M = 3.88 → 4.09, t₆₃ = 0.71, P = .47, d = .18). Presence scores (SUS) in Study 3 (M = 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 user experience and therapeutic benefit in VR self-compassion therapy. These findings challenge the assumption that hyper-realistic 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. Clinical Trial: Not applicable; this study was not a registered randomized controlled trial.
