Is emotion regulation a mechanism of change in virtual reality-assisted therapy for auditory hallucinations? Secondary analyses of the CHALLENGE randomized clinical trial

Virtual reality (VR)–assisted avatar therapy has shown promising effects for reducing voice-related distress and overall severity of persistent auditory verbal hallucinations (AVH) in psychosis, yet the mechanisms underlying these improvements remain unclear. Emotional processes may play a role during therapeutic encounters with simulated voices, but it is unknown whether treatment effects involve broader changes in emotion regulation. We conducted secondary analyses of the CHALLENGE randomized clinical trial ( N = 270), comparing a seven-session immersive VR-based avatar therapy with enhanced treatment as usual (standard care plus additional supportive counseling). Mediation models tested whether changes in cognitive reappraisal or expressive suppression, assessed using the Emotion Regulation Questionnaire (ERQ), mediated treatment effects on AVH severity and frequency at treatment end. Randomization to VR-assisted therapy did not significantly change ERQ reappraisal or suppression. Although higher reappraisal at follow-up was associated with lower AVH severity, no significant indirect effects were observed. These findings suggest that improvements following VR-assisted avatar therapy are unlikely to be explained by changes in self-reported trait emotion regulation strategies and may instead reflect more context-specific processes during voice confrontation.