For people interested in psychological counseling, opening up to a stranger face-to-face can feel daunting. Using an anonymous avatar during therapy offers a potential solution, lowering emotional barriers by hiding a patient's physical appearance while still allowing them to communicate nonverbally.
A joint research team led by Professor Cho Chul-hyun of the Department of Psychiatry at Korea University Anam Hospital, Professor Heo Jeong-yoon of the Department of Smart Experience Design at Kookmin University, and researchers from the University of Southern California (USC) explored this approach. Their findings were published on Aug. 6 in the Journal of Medical Internet Research.
The four-week program evaluated 60 adults aged 19 to 70 who reported needing mental health support. Participants engaged in 50-minute weekly one-on-one sessions with a designated counselor using a computer, smartphone, or tablet—without requiring separate virtual reality (VR) headsets.
While cameras were enabled, counselors could not see participants' actual faces. Instead, the system captured facial expressions, eye movements, head turns, and gestures in real time, projecting them onto an anonymous avatar. This setup concealed personal appearance while preserving the nonverbal cues crucial for therapeutic communication. To analyze the experience, the research team conducted in-depth interviews with a representative subset of 30 participants (16 women and 14 men).
Behavioral Realism Outweighs Physical Resemblance
Participants noted that hiding their physical appearance reduced the emotional pressure of opening up, making it easier to discuss sensitive thoughts and feelings.
Crucially, users reported that physical resemblance was unnecessary. Participants felt connected to their avatar not when it looked like them, but when it naturally mirrored their real-time behaviors—such as blinking, smiling, or moving their head. The researchers termed this "behavioral realism," distinguishing it from mere visual similarity.
The counselor’s avatar responsiveness was equally vital. Some participants felt disconnected or doubted whether the counselor was actively listening if the counselor's avatar failed to clearly reflect attentive behaviors, such as nodding or directing their gaze. However, researchers noted that more animated movement was not universally better; while some users immersed themselves in detailed expressions, others felt distracted by exaggerated motions.
Lowering Barriers Without Replacing In-Person Care
For individuals who hesitate to seek care due to anxiety over showing their face, avatar-mediated therapy offers a promising alternative. However, the researchers emphasized that the study focused on user experience rather than clinical efficacy. It did not measure reductions in depression or anxiety symptoms, nor did it compare treatment outcomes directly to traditional in-person or video therapy.
Furthermore, excessive reliance on anonymity presents potential clinical risks. For patients with severe social anxiety, relying on an avatar could become a "safety behavior"—an avoidance mechanism that reinforces real-world isolation if a patient comes to believe they can only communicate when hidden.
Consequently, the research team suggested positioning avatar-based therapy as a complementary entry point alongside in-person and traditional video counseling, rather than a full replacement for face-to-face care.
“The key takeaway is that anonymity and emotional connection are not mutually exclusive,” said Professor Cho Chul-hyun. “From a user experience standpoint, we confirmed that a design hiding physical appearance while faithfully conveying facial expressions and gestures can significantly lower the threshold for self-disclosure.”
