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ONRAMP-AI-VRAR: an operational protocol for ethics and governance of AI-enabled
immersive psychotherapy
#MMPMID41382074
Rahangdale A
; Schildkraut J
; Wadsworth C
BMC Psychiatry
2025[Dec]; 25
(1
): 1145
PMID41382074
show ga
BACKGROUND: Artificial intelligence (AI)?powered virtual reality (VR) and
augmented reality (AR) therapies offer promising tools for treating mental health
conditions. However, their immersive and data-intensive nature introduces novel
ethical, legal, and cultural risks not adequately addressed by existing
frameworks. OBJECTIVE: To introduce a structured ethical framework?Operational
Neuroethical Risk Assessment and Mitigation Protocol for AI in Virtual and
Augmented Reality (ONRAMP-AI-VRAR)?for identifying, mitigating, and governing
risks specific to immersive AI-driven psychotherapy. METHODS: We conducted a
targeted literature review across PubMed, Scopus, PsycINFO, and the Cochrane
Library using Boolean combinations of XR, mental health, ethics/risk, and AI
terms. From an initial pool of 913 records, 15 studies met inclusion criteria
(ethical principles, governance, or mitigation strategies relevant to XR
psychotherapy). Following peer review, 3 additional conceptually relevant works
were incorporated (e.g., Beg and Verma) into the narrative synthesis (total
n?=?18). Findings were coded to research questions (ethical, governance,
implementation) and mapped to ONRAMP-AI-VRAR?s steps/tools. RESULTS:
ONRAMP-AI-VRAR translates recurrent risks into practical processes and artifacts:
(1) a Biometric Bias Audit Checklist, (2) a Cultural Sensitivity Rubric for
immersive content, (3) a Risk Prioritization Matrix, and (4) a VR/AR Data Flow
Mapping Template for transparency and compliance. The protocol embeds
human-in-the-loop oversight through a Multidisciplinary Oversight Board and
proposes a tiered implementation model (Full, Integrated, Practitioner-level) to
enhance feasibility across settings. It aligns with international guidance,
including the EU AI Act, GDPR, WHO/UNESCO ethics recommendations, OECD AI
Principles, and the NIST AI RMF. CONCLUSIONS: ONRAMP-AI-VRAR offers an actionable
pathway to ethically deploy AI-enhanced immersive psychotherapy by integrating
upfront audits, culturally aware design, layered consent, and continuous
governance. The included tools are conceptual prototypes requiring psychometric
validation. Future work should evaluate reliability, validity, and clinical
impact across diverse populations and platforms. CLINICAL TRIAL NUMBER: Not
applicable. SUPPLEMENTARY INFORMATION: The online version contains supplementary
material available at 10.1186/s12888-025-07557-x.
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