Extended Reality (XR) applications hold promise for brain injury rehabilitation, but concerns persist about their impact on the patient-therapist relationship, known as the therapeutic alliance (TA). The TA is crucial for rehabilitative success, relying on agreement on tasks and goals, interpersonal bonds, and effective communication. This study investigated the use of immersive Virtual Reality (VR) in clinical settings for Acquired Brain Injury (ABI) rehabilitation, exploring its effects on the TA compared to traditional methods.

The methodology involved observing rehabilitation sessions with and without VR, alongside semi-structured interviews with patients and therapists. Thematic analysis of observations and interviews were employed. The findings revealed changes in patient-therapist interaction and communication with the introduction of VR. Informal conversation decreased, shared laughter increased, and therapists provided more verbal feedback. Despite patients not being able to see their therapists through their head-mounted displays, therapists maintained attempts at eye contact and used guiding gestures. Interviews emphasized the importance therapists placed on rapport-building and mutual reliance for expertise and reassurance.

This research offers insights into the impact of VR on the TA and suggests design considerations for XR applications in ABI rehabilitation. It indicates that VR alters interaction, posing challenges to the TA in immersive VR settings. These findings can inform the clinical use of VR and virtual environment design to support the essential TA, thereby enhancing rehabilitation outcomes. Future research could explore alternative XR technologies, diverse virtual environments, and methods to seamlessly integrate therapists into virtual environments to facilitate interaction.