This study focuses on the provision of supportive care services and programmes for cancer survivors post-treatment in Aotearoa New Zealand (NZ). It aims to aid our understanding of an often challenging and fragmented phase of cancer survivorship, and lay the groundwork for future research into the development of survivorship care in NZ.n = 47) involved in service provision for cancer survivors post active treatment, including supportive care providers; clinical and allied health providers; primary health providers; and Māori health providers. Data were analysed using thematic analysis.This study employed a qualitative design using semi-structured interviews with a range of healthcare providers  of care; and the use of survivorship care plans; all of which could help improve referral pathways, and clarify clinical responsibility for post-treatment survivorship care. In cancer, survivorship gives emphasis to the health and wellbeing of a person with cancer from the point of diagnosis, until the end of life, and includes specific assessments, programmes and services focused on living with, through and beyond cancer . Within One issue emerging from the international survivorship literature is that, despite advances in cancer care, survivors still report unmet needs after completing active treatment , 5. BurgWhile these recommendations have been implemented, there is considerable variation in design and implementation , 14, andSimilarly, many models of care for cancer survivorship have been researched and developed in the past decade, but there is little evidence of their efficacy , 22–24. New Zealand Cancer Plan 2015–2018 emphasised the role of survivorship care post active treatment, stating that “follow-up care, involving monitoring and surveillance as well as physical, psychological and social support to help people manage the short and long-term effects of their cancer, can improve a person’s quality of life”  get to the end of treatment, and family and friends are celebrating, and ‘isn’t it great, you got through this’. In terms of support, relationships often go back to how they were pre-cancer. Most people don’t understand that life has changed, they just think you are clear of cancer, get on with it” .It was also noted by many participants that the support of family and friends often begins to subside during the transition from active-treatment to follow-up care, as there is a tacit expectation that life ‘returns to normal’:“Once you’ve had a cancer diagnosis, it never actually leaves you, it’s always in the back of your mind. That fear of recurrence and information around that, is something that I think most people struggle with post-treatment, I would say it’s universal. It’s not that well-addressed during treatment and is something people are left with – I mean they’re given the stats, at 5 years blah, blah, but how do you negotiate that information about a way of actually getting through that fear of recurrence…you know, what do I do if I suddenly have a pain here? I know when I was in treatment, I could ring the ward, or whatever. Whereas now it’s like, oh, I’ve got a pain here, who do I talk to about that? What do I do if I’m worried about something? And often it’s, I’m going to have a scan in 6 months, but what happens if it’s growing now? Right now?”A specific anxiety stemming from the sense of abandonment outlined above, was described by participants as a ‘fear of recurrence’. They noted that while in treatment, cancer survivors often find some comfort in the regular monitoring and contact from health professionals described above. But there is a fear that changes to their health may be missed once monitoring becomes less frequent post-treatment. This point is highlighted by Participant 16 (Supportive Care Provider), who states:“When you have to go back and have another scan, and you know, if you check every year, are you going to find out that this is the year it comes back? You talk to anyone that goes through that, it makes people incredibly anxious…there’s very little support for that.” Somewhat paradoxically, participants also described a heightened fear of recurrence in the context of follow-up surveillance as being a major source of anxiety for cancer survivors post-treatment. A number of participants used the term ‘scanxiety’ to embody feelings of anxiety and fear felt by cancer survivors leading up to, and awaiting the results of, scans and medical tests conducted routinely post-treatment:Thus, fear of recurrence was not only considered a consequence of reduced contact with health professionals, but also potentially triggered by contact with health professionals, post-treatment.“often people are just on autopilot, hunkering down to get through the diagnosis and get the treatment done, and its not until they finish treatment and are out the other side, that they have an opportunity to process it, and it all comes crashing in on an emotional level.” A number of participants talked about post-treatment being the first opportunity for many cancer survivors to process the emotional and psychological toll cancer had on them. As Participant 37 describes, survivors are often so focused on getting through the treatment, that they do not have the capacity to process the emotional and psychological impacts of a cancer diagnosis:“It’s often working through the grief process of what has happened, because it almost seems that when going through treatment, the focus is on getting to the end of treatment. And that’s where it is ‘I’m going to beat this’, ‘I’m going to live’, then they get there and all of a sudden, the reality of what life looks like post-treatment hits them. And it’s a very different place to what life was like pre-diagnosis” .This emotional and psychological processing post-treatment was described by participants as a ‘grieving process’ and ‘existential crisis’, where cancer survivors are faced with the fact that their life had changed irrevocably:“The physical part of treatment, be it chemo, or radiation, or whatever, is just so physically demanding that the emotional processing hasn’t had time to catch up. And it’s when they’ve got to the end, and all the support has disappeared, because they’re not seeing, you know, their doctor regularly, they’re not back every 3 weeks for chemo, they’re not having radiation. So those relationships that they’ve built up during treatment suddenly disappear at about the point that their emotional processing of what’s actually going on starts.” Participants also suggested that the anxiety induced by this period of emotional and psychological processing is heightened because it tends to occur in conjunction with the ‘sense of abandonment’ outlined above:“I hear it all the time – ‘I’m living, and I should be grateful, but I just want to cry. I’m anxious, I’m overwhelmed and really emotional. What’s wrong with me?”A sense of abnormality, driven by both internal and external expectations, was also raised by participants as a common issue facing cancer survivors post-treatment. Feelings associated with the sense of abandonment, fear of recurrence, and emotional and psychological processing, described above, are often internalised as abnormal by cancer survivors who have finished treatment, a point exemplified by Participant 13 (Supportive Care Provider):“[Survivors] will get an offhand comment from somebody about, often just one comment, you know, why aren’t you back at work? Why do you need an afternoon nap? And they start feeling really embarrassed and conscious of why, and think something is wrong with them. They are often reluctant to seek help because they feel ungrateful for bringing those kinds of things up when there are people who are going through cancer and still have that uncertainty about what the final outcomes are going to be. It’s not until they get into a support group setting with other survivors, where it’s [post-treatment issues] actually talked about, that they realise they’re actually quite, for want of a better word, normal, and that society’s expectation on them is unrealistic.” .These feelings of abnormality are often amplified by external expectations, and can be a significant barrier to cancer survivors seeking support post-treatment, as Participant 36 articulates:“The physical part of treatment, be it chemo or radiation or surgery or whatever, is just so physically demanding. Be it losing a body part, or losing general strength, most people end up on this low, physiologically, post-treatment, that requires time and rehabilitation before they even vaguely feel normal again.” .There were no clear sub-themes around the specific physical needs of cancer survivors post-treatment, possibly because the physical impact of cancer varies so widely between different cancer types, and different treatment types. However, there was a general consensus among participants that all cancer survivors face some form of physical rehabilitation following treatment for cancer, as participant 15 neatly articulates:“There can be high expectations on the person to get back to work ASAP, within themselves and from their employer, but the actual reality of returning to work often hits them like a tonne of bricks” Participants largely referred to social issues faced by cancer survivors post-treatment in relatively general terms, for example “…and there are a number of social issues survivors face following treatment” . But some specific commonalities were evident, most notably returning to work:Other social issues raised by participants included dealing with relationship problems that emerge, or compound, during the cancer journey; and financial concerns caused by loss of income, cost of treatment, or expenses relating to accessing treatment .“It’s very client centred. What they bring is what we work on” .As noted above, cancer survivors face a wide variation of issues post-treatment, resulting in a wide range of needs as they transition from active treatment to long-term follow-up care. Consequently, where it is accessible, current post-treatment supportive care provision is guided by the individual needs of each survivor, with participants across the range of supportive care provision interviewed typically describing their role with post-treatment survivors as ‘meeting them where they are at’, ‘problem solving’, or ‘finding solutions’:“I nurse the system as much as I nurse the patient, because it’s that care coordination and problem solving when there’s complexity in the disease, but there’s also complexity in the person or their social context that requires different solutions to the standard.” This commonly involves identifying issues the survivor and/or their whānau require support with, and either providing that support themselves, or identifying services within their organisation, the wider health system, or the community, that can provide the necessary support:“It’s [post-treatment supportive care] pretty disjointed. We sort of make it up as we go along, based on clinical experience, and patient needs at the time.” .While the above quote highlights the value in the patient-centred nature of this approach, participants also commonly referred to the current post-treatment supportive care landscape as ‘fragmented’, ‘disjointed’, and ‘ad hoc’, as a consequence of it:“There are patients that I pick up who are a long way down their survivorship journey, with all sorts of problems, and you ask them if they’ve been referred to, you know, whatever support care service, and no-one has ever offered them that. They don’t know what they don’t know” .Many also acknowledged that it is patient-driven, placing the onus on cancer survivors to seek supportive care at the end of treatment, which can result in unmet needs post-treatment:Participants described a range of services that they either offer themselves, or refer cancer survivors to, to meet their post-treatment needs, including psychological, counselling and social work services; DHB support services; Cancer NGOs; and community organisations. Support provided was generally in the form of one-on-one sessions, support or exercise groups, home visits, webinars, and written resources. Innovation in peer-to-peer support through online platforms such as Support Crew  and Ripp“We don’t have a lot of places to refer people to. We use the Cancer Society a lot.” “the main one is the Cancer Society, because everybody knows who they are, and what they do.” .“Pinc and Steel physiotherapists are kind of scattered all over New Zealand, the world actually, it’s international. And anyone from diagnosis to 10 years post-diagnosis can access funding, so it’s a really great network for people to access.” While overall a wide range of services were discussed, there was little consistency between participants in terms of specific organisations that they would refer patients to for post-treatment supportive care. The Cancer Society and ‘Pinc and Steel’ (an initiative focused on physiotherapy for cancer survivors), were the only two organisations that were mentioned frequently by participants, when discussing the organisations they refer cancer survivors to for post-treatment care:“Survivorship care is one big gap.”Broadly speaking, there was an underlying sentiment that post-treatment supportive care was a gap, in and of itself, within the gamut of cancer treatment and supportive care, as Participant 15 (Supportive Care Provider) so succinctly surmised:“I think we could do some more work around the survivorship specific support groups, and webinars and education and stuff. I think a lot of it is disease specific and treatment specific, but I don’t think we do as much around post-treatment, sort of, survivorship stuff.” .This sentiment, while extreme, aligns with comments of others which indicate few services, if any, exclusively target the post-treatment needs of cancer survivors. Participants generally work with cancer survivors across the cancer continuum, but the front of pathway tends to be prioritised:“I guess the thing about survivorship, if you bring those post-treatment people together, as a group, they then become support for each other, and can build each other’s skillset and resilience. That’s probably you know, what we’re lacking. We will have pockets of that in our support groups, but we have nothing established specifically for post-treatment.” .Consequently, the post-treatment supportive care needs of cancer survivors tend to be met within the existing framework of supportive care services, rather than services and programmes specifically designed to meet their needs:“We really would love exercise physiologists, we’d love a dietitian. We’d love more psychological support to send people to you know, we’d love budgeting advice, social workers to talk about financial problems.” .“sexual dysfunction [is a gap], we do that really, really poorly. And I think it’s skipped a lot of the time. And I think there’s various reasons because there’s nothing available. So what can you do? And then, you know, the classic, it’s just a bit awkward, or making some assumptions that maybe that persons no longer sexually active.” .More specifically, participants perceived psychological and emotional support to be a major gap in service provision, which aligns with their identification of psychological and emotional wellbeing as a key issue for cancer survivors post-treatment, as outlined above. Participants also flagged sexuality and fertility services; budgeting and financial services; and dietary and nutrition services, as significant gaps in the current post-treatment supportive care landscape.“I think that there’s a real gap in terms of no-one actually claiming that survivorship space…so in the post-treatment phase, there is a real focus on the clinical follow-up, but it’s really, really clear that there is a huge gap in meeting the psychosocial needs, and that’s just not mentioned enough and not talked about, and no-one has really taken ownership of that space.”One of the broad reasons articulated for the fragmented nature of post-treatment supportive care was that no single body or organisation has taken ownership of the survivorship space. This point is clearly explicated by Participant 28 (Supportive Care Provider) who states:“It isn’t clear who is ultimately responsible for post-treatment support. And I think as we move more and more to pushing longer term follow-up care back into the community and primary care, and emphasise self-management, this becomes more challenging for people.”Consequently, a range of different organisations and roles currently contribute to post-treatment supportive care, without any overarching framework or leadership to guide them, as Participant 7  illustrates:“There aren’t really the kind of outpatients’ services, with the knowledge of other services, or the ease of access to other services, that would be really helpful. There’s no pathway where we say, right, you have finished treatment, we will continue to monitor the cancer through ongoing surveillance, but all your other needs will be managed by these guys over here” .Stemming from the lack of ownership of the survivorship space outlined above, many participants suggested that there were no clear referral pathways from front of pathway to post-treatment supportive care:“There are lots of services that can be drawn on, but it depends largely whether the person referring knows about those services. Sometimes clinicians don’t ask [patients] because they don’t know what the solution to what’s presented to them might be.” Some participants indicated this lack of clarity around referral pathways can lead to a reluctance to ask questions around cancer survivors’ post-treatment needs:“Because of capacity, unless you get a bounce back saying the referral is declined, you probably wouldn’t follow-up…which is a place that gaps can occur.” .Participants also often acknowledged that they would not generally follow-up on referrals that they made, which can lead to cancer survivors falling through the cracks once they have finished treatment:“we should be planning for post-treatment from diagnosis. Obviously getting the biomedical stuff right is crucial, but we should also be thinking about and planning for survivorship from the beginning, rather than leaving them to work it out for themselves when things to begin to unravel.” There was the spectrum of attitudes toward post-treatment supportive care evident among the participants interviewed. While there was a general consensus that post-treatment supportive care is important, attitudes varied on how it should be prioritised within the cancer continuum. Some felt that post-treatment supportive care was vital, and should be incorporated into survivorship planning at the point of diagnosis:“As health professionals, we know that there’s obviously going to be that survivorship pathway after treatment, and I think it’s gaining momentum and traction and acceptance, but it seems a bit of a plus, you know, the icing on the cake, rather than vital. It’s not a priority focus. If we don’t get the treatment pathway right, there is no survivorship.”While participants at the other end of the spectrum acknowledged the value of post-treatment supportive care, but felt that given the resources and capacity currently available, it should not be prioritised, as Participant 10  exemplifies:In addition to the lack of ownership or leadership in the survivorship space, there also appeared to be limited implementation of survivorship models of care in the provision of post-treatment supportive care. While a small number of participants did refer tangentially to a survivorship model of care, for example “our model of care is very survivorship focussed” , there was no reference to any specific survivorship models, nor any articulation of how they are being operationalised within the provision of supportive care for post-treatment cancer survivors.“We haven’t got a survivorship plan for people. There’s been lots of discussion in the past that there should be survivorship plans, but we don’t use them” .Survivorship care plans are also markedly absent in the provision of post-treatment supportive care in NZ, with the comments of Participant 1 typifying the majority of responses:“Survivorship care plans are considered the gold standard in Australia, and I think we should be doing that here” .While the quote above hints at an acknowledgement that survivorship care plans should be adopted as best practice, Participant 28 makes the point more explicitly:“So the biggest barrier is funding, there is little public money for post-treatment services. You know, I can talk to a patient, give them some basic advice, but there’s really nothing else I can offer them unless they can afford to pay for it.” .Participants consistently cited a lack of financial resources and/or capacity as a significant barrier to the provision of post-treatment supportive care. Participant 5 highlights the limited public funding for services in NZ:“I also think, health professionals, we think we do a good job most of the time. But we don’t always actually do what we say we’re going to do. When you have people, at the very breaking point of just being able to do the basics of their job, and keep people well and safe, physically. It’s really, really hard to do those additional layers of best practice care.” “Please don’t make that [survivorship care plans] one of your recommendations, we are stretched so thin as it is.” .Whereas Participant 7 describes how the provision of post-treatment supportive care is severely restricted by a chronic lack of capacity in the healthcare workforce, a point embodied by Participant 1.“This is what keeps me awake at night. What’s happening with Māori, Pacific and Asian folk who are going through a cancer experience, and how do they connect in to get the support services they need. And I just don’t see an adequate plan in place for those folk. I think they are hugely vulnerable, and if you look at the statistics, they don’t do well following treatment, but there doesn’t seem to be a plan in place.” .As outlined earlier, few supportive care services and programmes specifically target the post-treatment needs of cancer survivors, so it is unsurprising that services and programmes specifically targeting the post-treatment needs of under-served populations are almost non-existent:When discussing services for under-served populations, participants tended to refer to broader health system services that provide cultural support, language translation, and transport. For example, services mentioned included: DHB-based Māori and Pacific support services, or cancer specific services situated in both DHBs and the community, such as Māori and Pacific cancer navigators, rather than services specifically targeting post-treatment needs.“We certainly need more Māori and Pacific cancer co-ordinators, because they are just invaluable. I cannot tell you how many patients that would not have engaged with us, had it not been for the Māori and Pacific cancer co-ordinators that we do have. They quite literally save lives.”Equity in cancer care was considered important across the spectrum of participants, but largely framed in deficit discourse, as evident in the comments of Participant 4 :“We are such a hospital-based system. We are a very hospitalised, very white service, traditionally” .“Our Māori whānau, I think a lot of them like to be connected with other Māori. And when you consider that actually most Māori go through the cancer journey and they don’t see one Māori face, you know, it can be terrifying. Imagine being a Pākehā going through treatment, and you never saw another Pākehā face – that’s kind of scary, eh.” Despite acknowledging the importance of equity in cancer care in NZ, participants generally felt that it is not currently prioritised. The comments below of Participant 1  and Participant 2  illustrate this point, describing a mono-cultural system, ill-equipped to deal with the diverse ethnic population it serves:“Equity factors around ethnicity, distance to treatment centre, health literacy, personal resources, economic factors still hugely impact cancer outcomes. But an expression that I use frequently is lack of capacity will always knock over equity.” “We have a very mono-cultural service, that deals with some people really well, but not everybody, and we see the outcomes of it…We’ve got a whole lot of people in the healthcare workforce, who all have cultural competencies, or Te Tiriti o Waitangi competencies, but year in, year out, just seem to get signed off, with nothing tangible or accountable put in place.” “Systemic racism is definitely a barrier, and then there is that whole clinical versus non-clinical thing. Health is a very hierarchical system, you know, and we’re  right at the bottom.” Barriers to equity being prioritised in cancer care commonly noted by participants included a lack of capacity; lack of accountability for failing to meet cultural competencies; and systemic racism, as the following comments elucidate:“There is definitely a postcode lottery. What services you can connect into depends on where you live.” Participants also indicated that large geographical variation exists in the provision of post-treatment supportive care:“[our service] is just not out there, unless they are coming to us specifically. I mean, there is one other place here in Auckland, but that is it. So if you don’t live in Auckland, or can’t travel to Auckland, then you just can’t access [our service]” .This geographical disparity generally manifests in two distinct ways. First, as Participant 34 highlights, some specialised services are only available in certain parts of the country:“We have several regions, and our national office, and a lot of expertise, but it’s kind of not all together, so everyone is often doing different things. That is something we could do better.” And second, the range of services are prioritised differently in different parts of the country, even within the same organisation, as participant 24 explicates:“There will always be nuances…we have a big rural population, so we really need to make sure the needs of rural people are met, but Auckland has a huge Māori/Pacifica population. So you have to say hey, we are not the same, there will be nuances that fit that geographical population disparity, but everyone can expect a base model of care. This is where I think, hopefully, this New Zealand Health reform is going to be better.” While the comments of Participant 24, above, frames this disparity negatively, many participants argued that some regional autonomy needs to be retained in order to meet the needs of specific populations, within a national base standard of care:In line with international literature, the findings of this study of 47 healthcare providers involved in the treatment and supportive care of cancer survivors indicate that cancer survivors in NZ face a wide-range of psychosocial and physical issues following treatment. Psychosocial issues include a sense of abandonment; fear of recurrence; emotional and psychological processing; a sense of abnormality; returning to the workforce; and financial implications; while physical issues range from loss of strength through to loss of a body part. In 2006, the American Institute of Medicine published a seminal report entitled ‘From Cancer Patient to Cancer Survivor”, which outlined 10 recommendations aimed at improving the provision of care for cancer survivors to help address these unmet needs. One of the key high-level recommendations from this report was that healthcare providers, patient advocates, and other stakeholders should work to establish cancer survivorship as a distinct phase of cancer care, raise awareness of the needs of cancer survivors, and act to ensure the delivery of appropriate survivorship care . There hOne of the key barriers to the establishment of cancer survivorship as a distinct phase of cancer care in NZ, identified by this study, was the lack of ownership of the post-treatment survivorship space. The provision of post-treatment supportive care currently sits between treatment providers, primary care providers, and a suite of cancer NGOs and allied health providers in the community, with no overarching leadership or framework to guide the co-ordination of care for cancer survivors. International literature clearly highlights the benefits that each category of healthcare provider outlined above individually brings to survivorship care –39, but Te Aho o Te Kahu (the Cancer Control Agency) in NZ, is perhaps best positioned to fill the leadership vacuum in survivorship care, given its wide-ranging purview to work with partners across the cancer continuum to improve cancer care outcomes for all New Zealanders [The recently established alanders . At an oalanders , 37, 48.The other high-level barrier to more structured post-treatment survivorship care evident in this study was the lack of development and/or implementation of a model, or model(s), of care. Many models of care for cancer survivorship have been researched and developed in the past decade, for example risk stratification models, chronic care models, and transition models , 23, butSurvivorship care plans are also notably absent from the post-treatment supportive care landscape in NZ. A survivorship care plan is a written record of a cancer survivor’s diagnosis, treatment, and recommended follow-up care, advice on maintaining their health and well-being and monitoring for recurrence, and information about the availability of psychological and social support –51. ProvThere is also a growing literature describing the barriers to the provision of survivorship care plans to cancer survivors. Key barriers to survivorship care plan use include the time needed for preparation of the plans; the lack clarity around who is responsible for preparing the plan and lack of reimbursement for this role; poor communication and collaboration between providers; and the lack of data on the association between the use of survivorship care plans and patient outcomes noted above , 18, 19.There are some limitations to our findings. First, participants were drawn from across the country which, while providing a good overview of the post-treatment supportive care landscape in NZ, made it difficult to capture the nuances of service provision at the local level, or make meaningful comparisons between different areas. Second, the sample was imbalanced between the different categories of healthcare providers, with fewer participants coming from primary health providers and Māori health providers than planned. As noted above, international literature indicates that different categories of healthcare providers bring different strengths and biases to post-treatment survivorship care, so this imbalance in the sample may have skewed our findings. Moreover, while the sample included participants working in both tumour-specific and cross-tumour settings, not all tumour-specific streams were represented. As different tumour types require different treatments, there is wide variation in the post-treatment needs of cancer survivors, and support services required to meet them, which may not have been exhaustively captured here. Third, participants were almost exclusively female and predominantly Pākehā. While this is, in some ways, reflective of the supportive care and cancer nurse workforce in NZ , the lacIn summary, cancer survivors in NZ face a range of psycho-social and physical issues post-treatment that require supportive care. At present, the provision of supportive care to meet these needs is fragmented and inequitable. In order to raise awareness of the issues faced by cancer survivors, and improve the provision of post-treatment supportive care in NZ, cancer survivorship needs to be established as a distinct phase of cancer care, in line with the recommendation of the American Institute of Medicine. Measures to help achieve this could include greater leadership in the survivorship space; the development and/or implementation of a survivorship model(s) of care; and the use of survivorship care plans; all of which could help improve referral pathways, and clarify clinical responsibility for survivorship care. The key barriers to implementing such measures include a lack of capacity and resources within the existing cancer care framework; divergent attitudes to survivorship care within the cancer care workforce; and a lack of clarity around whose responsibility post-treatment survivorship care is. Future research could include kaupapa Māori approaches, the development, implementation and evaluation of model(s) of care, survivorship care plans, and/or programmes and services specifically targeting the post-treatment needs of cancer survivors. Future research could also explore ways in which the contributions of different types of healthcare providers could be guided in a more structured way to help improve referral pathways, and clarify clinical responsibility for survivorship care.


Synaesthesia is a condition where people experience unusual sensory or cognitive sensations in response to apparently unrelated stimuli. This paper presents two experiments which aimed to examine whether Virtual Reality (VR) technology can be used to recreate the synaesthetic experience. There is a lack of research in this area, with most studies focussing primarily on synaesthetic colors. Experiment 1 aimed to build on previous research by using not only a traditional color-picker but also VR to capture a more nuanced picture of synaesthetic perception. A multiple case study design was used to examine the experiences of six participants in detail. Data gathering took place via Zoom. During the initial data-gathering session, participants used a color-picker to provide grapheme-color associations. After this session, some of the participants’ synaesthetic experiences were recreated using a VR-by-proxy approach. Results indicated that VR is capable of capturing elements of synaesthetic perception that other methods have been unable to, such as texture, small degrees of movement, and 3D structure. Experiment 2 expanded upon these findings by moving beyond the VR-by-proxy approach and asking three participants to recreate their own audiovisual synaesthetic associations in the VR environment. Inductive Thematic Analysis was used to analyze the results of this experiment. The potential of expanding this technique to other forms of perceptual diversity is discussed. Synaesthesia is a condition where people experience unusual sensory or cognitive sensations in response to apparently unrelated stimuli . For exaStimuli giving rise to synaesthetic experiences are known as “inducers,” and the resultant perceptual or cognitive experiences are known as “concurrents” . InducerSynaesthesia can be developmental, acquired, or induced. This study will focus on developmental synaesthesia only, which is synaesthesia that has been present from a young age, and accounts for most known cases of synaesthesia .Over 100 variants of synaesthesia have been reported to date . SynaestGrapheme-color synaesthesia is the most commonly studied variant, accounting for around 45% of synaesthetes, or 1.4% of the total population . In grapheme-color synaesthesia, letters are perceived as being inherently colored. Colors will be individual to each synaesthete, although certain graphemes have a higher-than-average chance of being a particular color—for example, A is red and D is brown more often than would be expected by chance .In auditory-visual synaesthesia, additional visual content is triggered by hearing sounds . ThroughMany studies have depicted synaesthetes’ grapheme-color associations using color pickers. However, these are generally used as a method of assessing the genuineness of grapheme-color synaesthesia , rather Sonata of the Stars (1908) and Fuga (Fugue) (1914), respectively, which both expressly aimed to translate music into paintings (https://web.archive.org/web/20190403020359/billieeilishexperience.com/).More broadly, many artists have created works based upon synaesthetic associations. Artists such as Mikalojus Konstantinas Čiurlionis and Wassily Kandinsky created the pieces aintings . More reaintings . Relatedaintings . Steen eaintings . More reaintings  (see htt. Openbrush (2016) allows users to paint in an immersive 3D environment with a range of brushes including dynamic and textured effects. As a medium, VR is more accessible in terms of the time and skill required to create sketches compared to animation packages. Furthermore, VR is a highly authentic and realistic tool with strong ecological validity  in 3D space, corresponding to how they experience these sequences . This waThis paper presents two experiments. The first experiment is a pilot study discussing the cases of six synaesthetes who report various combinations of grapheme-color and auditory-visual synaesthesia. We decided to carry this research out with a small group of participants in the form of multiple case studies in order to garner in-depth, detailed accounts and representations of their experiences, which is a benefit of qualitative research .Due to COVID-19, in Experiment 1, the researcher acted as an intermediary (“VR-by-proxy”). To this end, individual Zoom interviews were conducted with each participant, where we gathered detailed descriptions of their synaesthetic experiences in response to a range of stimuli. We used Google Slides to present stimuli, collect data, and recreate color associations via a color-picker. In cases where shape, movement, textural or three-dimensional qualities were present in the concurrent, we attempted to recreate the participant's experience in OpenBrush (2016). In this way, we aimed to provide recreations of synaesthetic experiences using both a traditional color-picker and OpenBrush (2016), and to ascertain whether OpenBrush (2016) can capture some elements of the synaesthetic experience in a way that traditional methods cannot—and by extension, whether it is worthwhile pursuing VR further as a means of exploring synaesthesia.In Experiment 2, we followed a similar procedure to Experiment 1, but this time (post-pandemic) participants attended experimental sessions in person and were able to draw their experiences in OpenBrush (2016). Again, a multiple case study design was used to explore a small number of participants’ experiences in detail. Inductive Thematic Analysis (ITA) was used for the analysis of participants’ descriptions of their experiences.Six participants were recruited for the study through university channels, personal connections, and the UK Synaesthesia Association's mailing list. Inclusion criteria were a history of developmental synaesthesia and proficiency in English. Three of the participants were men and three were women, with ages ranging from 20–59.OpenBrush (2016) was accessed via PlayStation VR on a Playstation 4 slim, CUH-ZVR2 model. This is a fully immersive, head-mounted display  with sixhttps://www.syntoolkit.org/studies/syn-database-volunteer/start). Questions 9, 11, 15, 16, and 17 were retained from the original survey. Participants were first asked to complete a grid that allowed them to match a range of triggering stimuli with potential synaesthetic experiences. Next, they were asked whether they experience letters, numbers, days, or months as having genders or personalities. The next two questions asked whether they had experienced these types of synaesthesia for as long as they can remember and whether their associations ever change. Finally, the last question asked whether there was anything else that the participants would like to say about their synaesthesia.A short screening questionnaire was used to establish which types of synaesthesia participants experienced. This questionnaire was a condensed version of one previously available on the University of Sussex's website , a selection of short piano melodies, and various voices, celebrity, and noncelebrity, saying single words or short phrases. All participants were played an equal ratio of male and female voices. Piano melodies ranged in duration from 3–13 s and were unfamiliar to the participants. Music and noises were obtained from the website Freesound (https://freesound.org/). Voice clips were primarily sourced from sound files provided by https://www.youtube.com/). Celebrity voice clips used were of Queen Elizabeth II and Barack Obama available under Creative Commons licenses.Stimuli were tailored to each participant based on their answers to the questionnaire. Stimuli  included letters of the alphabet, numbers 0–9, days of the week, and months of the year, all presented in Arial font. Auditory stimuli included a selection of everyday sounds and musical notes  call with the researcher. During this call, participants were presented with stimuli that had been prepared in advance based on their responses to the questionnaire. As we were interested in gathering as much detail as possible about participants’ phenomenological experiences, the viewing time of stimuli was not limited. These stimuli were presented in a Google Slides  presentation, which was shared at the beginning of the meeting. Both the researcher and the participant had access to this and could edit it by adding descriptions or colors. Where complex shapes were described, sketches were made using pen and paper. At the end of the interview, the researcher showed participants a short video introducing them to OpenBrush (2016). This video is available in the supplementary materials. The purpose of this was to familiarize the participants with OpenBrush (2016) and ascertain whether they thought this medium could be used to display their synaesthetic experiences.Participants who experienced grapheme-color synaesthesia changed the colors of stimuli themselves using the color-picker on the shared Google Slides presentation and provided ratings for how well this matched their synaesthetic experiences during this initial session. Color data were stored as hexadecimal color codes (HEX). Ratings were measured on a continuous scale from 0–5, with 0 indicating “no match” and 5 indicating “perfect match.”After the meeting, the researcher identified which stimuli had been sufficiently captured on slides and which would benefit from further exploration in OpenBrush (2016). For example, if an individual experienced the letter A as brick red and had changed the color of the A in the slideshow to reflect this, it would suffice to leave it at that. However, if a participant viewed a sound as a shimmering of colors around their periphery, the researcher would attempt to implement this in OpenBrush (2016). OpenBrush (2016) illustrations were captured as videos which were edited in Adobe Premier Pro . UltimatFinally, a second meeting was arranged with three participants whose concurrents were further explored. In this meeting, the completed short videos, made by the experimenter using OpenBrush (2016), were shown. Participants were asked to give these an accuracy rating from 0–5 and were also asked to comment on whether VR had any merit in capturing their synaesthetic experiences. These comments were not formally recorded; instead, only the main points were extracted and paraphrased. The full details of the questions and comments are available in Supplementary Material.The questionnaire revealed that Participants 1, 2, 4, and 6 experience grapheme-color synaesthesia. Participants 3, 4, and 5 experience auditory-visual synaesthesia, with all three reporting that voices, music, and noises trigger colors and shapes. Participant 4 also reported texture associations for all inducing stimuli. Participants 1 and 2 also reported experiencing ordinal-linguistic personification. Participants 1, 4, and 5 reported that their synaesthetic associations never change, while Participants 2 and 6 reported that most associations never change. Only Participant 3 reported associations that frequently change. All six participants reported experiencing these types of synaesthesia for as long as they can remember.The full results tables detailing participants’ responses to all presented stimuli can be found in the supplementary online materials. In this section, only synaesthetic experiences which were visualized are reported. Using a color picker, Participants 2, 4, and 6 recreated their grapheme-color associations. Participant 1 also used a color picker, in addition to making formatting changes to best capture their experiences. As Participant 2 described some complex color interactions, as well as associated shapes, some of their grapheme-color associations were recreated in OpenBrush (2016). Participants 3 and 4 described complex visual experiences in response to a variety of stimuli. These descriptions were also recreated in OpenBrush (2016). Participant 5 also described visual experiences in response to a range of auditory stimuli, but as these were simple two-dimensional shapes with no movement it was deemed unnecessary to implement these in a three-dimensional environment. Participant 6 also described shapes associated with the days of the week and months of the year, but these were also simple two-dimensional shapes, so again it was decided that it was not necessary to implement these in OpenBrush (2016).For most participants, the digits 0–9 are colored and multiple-digit numbers become a combination of the digits within. For Participant 6, this is the case after the number 10, and for Participant 4, after the number 12. Therefore, Participants 4 and 6 experience the days of the week as one color. Participant 2 also experiences a dominant color, but occasionally the colors of some individual letters shine through. Participant 1 reported experiencing both individual color associations and overall dominant color. For clarity, these are displayed in separate columns .Participant 2 experiences the months of the year as combinations of the letters within, while Participants 4 and 6 experience one dominant color association . Again, The ratings that each participant gave the recreations documented above, out of 5, are reported below. Ratings are not intended for formal statistical analysis and are aimed at understanding how representative the drawings/recreations appear to the participants . Note thThis section concerns the synaesthetic experiences which were recreated in OpenBrush (2016). Participants’ ratings of each depiction are provided, as well as their general thoughts on each image and on OpenBrush (2016) as a medium. Example screenshots of OpenBrush (2016) videos generated by the researcher are presented in In addition to colors, Participant 2 reported associated shapes for the days of the week and months of the year. These shapes reflect the attention he gives to each part of the word as he scans it. When presented with the OpenBrush (2016) videos which depict these shapes in addition to colors, Participant 2 reported that they were good schematics, but in most cases did not accurately reflect how he truly sees them, but rather how much focus he gives each letter. These shapes would be better used as indicators of how bold the letters should be. Full ratings and descriptions are presented in Overall, he did not believe that VR was particularly effective at capturing his synaesthesia in a way that simply changing the colors of letters could not, with exceptions for the number 7 and June. For increased accuracy, he reported, the background should be darker; however, this was difficult to share with the participant, as when the VR environment was reduced to videos, dark colors did not show up well. The participant did express interest in VR if he could use it himself, as he believes it could replicate the feeling of being “alone in his head” better than videos. His biggest issue with any art-based medium was that it is impossible to separate his two types of synaesthesia—grapheme-color and ordinal-linguistic personification—therefore, it is not always possible to capture what feels most important about a word, as it may be related to gender or personality.Overall, the participant expressed surprise at how much of her experience was accurately recreated in VR. However, other aspects were impossible to capture, particularly with regard to certain types of motion. She also noted that her synaesthesia is very difficult to explain, so there would always be a loss in accuracy when another person attempts to reproduce it. Full ratings and descriptions are presented in Participant 4 reacted positively to the VR environment, stating that it looked promising and expressing interest in using it himself. Overall, he appreciated the 3D element and how it was possible to move around and interact within the environment. Full ratings and descriptions are presented in This study explored the concurrent visual experiences of six synaesthetes. Our aims were to provide recreations of grapheme-color and auditory-visual synaesthesia using both a traditional color picker and a VR package and to determine whether VR is capable of capturing elements of our participants’ synaesthesia that traditional methods cannot.M = 4.53, SD = 0.50). Generally, synaesthetic concurrents were limited to color, but occasionally, participants described accompanying textures or movement. For example, Participant 4 described “x” and “z” as having a metallic texture, and Participant 2 described “June” as a sunset shining through clouds and “7” as shadowy, smoky, and iridescent. Participant 2's associations for “7” and “June” were recreated in OpenBrush (2016). These recreations were described by the participant as the “most accurate” depictions of his experience he had seen and scored more highly than his ratings of numbers and months using a color picker. It appears that when grapheme-color synaesthesia is more complex than simply colors, OpenBrush (2016) is an advantageous method of portraying these additional qualities. However, when color is the only concurrent, color-pickers perform well, and most participants were relatively satisfied with their depictions. Indeed, for most of Participant 2's grapheme-color associations, he did not believe that OpenBrush (2016) was any more accurate than using a color picker.For participants with grapheme-color synaesthesia only, results indicated that color pickers are relatively good at capturing their synaesthetic experiences. Most participants consistently ranked their depictions as 4 or above on a scale of 0–5, indicating very good to perfect accuracy  showed considerable promise as a method of portraying complex elicited experiences. This was dependent on the nature of the concurrent experiences: for example, Participant 5 experienced two-dimensional colored shapes in response to a range of sounds. He expressed that these could easily be captured by Adobe Photoshop, similar to the methods employed by Regarding auditory-visual synaesthesia, general trends have pointed to higher-pitched sounds being lighter, brighter, and located higher in space than low-pitched sounds . Three oRegarding musical notes, Participant 4 experienced three-dimensional shapes in response to notes which were specific to the instrument being played. These shapes moved up or down in space depending on pitch. Participant 5 played short melodies rather than notes, as he expressed that his elicited experiences were related to timbres and tones rather than individual notes. Still, for most melodies, his concurrent visual experiences were a horizontal line of triangles, with the position of individual triangles moving up and down depending on the pitch of notes played within the melody. This was similar to how Participant 4 experienced melodies, except he experienced one three-dimensional shape which moved around in space depending on the pitch of each note. For Participant 3, no clear trend was observed relating to the pitch of notes she was played. Regarding synaesthetic color, Participant 5 stated that “bass sounds trigger dark colors” while high-pitched sounds, such as a “bright, high violin,” would be white. This trend was not observed in Participants 3 and 4; rather, each instrument tended to elicit its own unique color regardless of the pitch of the note it was playing.Although some common auditory-visual trends were observed, the overall impression from these data is the variety of concurrent experiences and the differences in content between individuals. For example, all three participants were played the same sound clip of cars passing each other on a road, and this elicited the following three experiences: a pink waterfall with shards or bubbles (depending on volume), a white mass moving underneath a yellow strip of color, and a slightly uneven, dull gray band. Although the results are interesting and in line with research showing commonalities between pitch, brightness of color, and location in space , it is tAs previously mentioned, due to the COVID-19 pandemic, our initial method which involved participants operating the VR equipment themselves was revised in favor of the “VR-by-proxy” method described in this report. Some drawbacks to this method were seen, with participants expressing difficulty in explaining their experiences accurately. Previous research has highlighted how challenging some synaesthetes find verbalizing their experiences; comparing it, for example, to explaining the color red to someone who cannot see . AdditioIn this experiment, three audiovisual synaesthetes used the VR equipment themselves to recreate their visual experiences in response to five sounds. These sounds were played as the participants were in the VR environment for a fully immersive experience. The five sounds chosen were the “everyday sounds” from Experiment 1. This was because in Experiment 1, the everyday sounds section appeared to be appropriate for all audiovisual synaesthetes, while responses to musical and voice stimuli were more varied: in some cases, one word was not enough to elicit a concurrent response, while in other cases, a short phrase would produce a visual concurrent too complex to describe or recreate as it would require moving animations. Similarly, in some cases, one note would be too simple to warrant recreation in VR, while melodies would be too complex. We chose to focus on audiovisual synaesthesia only because Experiment 1 indicated that for grapheme-color synaesthesia, VR only very occasionally provided benefits compared to traditional methods such as color pickers.Three synaesthetes were recruited for the study . Mean age was 25.3. Full demographics information for each participant is presented in Participants were tested using an Nvidia GTX 1080 I Gaming PC (Windows 10) with HTC Vive Pro VR kit . The expEveryday sounds used in Experiment 1 were selected: cars passing, birds chirping, white noise, phone ringing, and rain . In order to adjust for the volume and allow participants to get used to the audio set up, simple acoustic music was selected for the onboarding —“Beat of Nature.mp3” .The procedure was significantly simplified from Experiment 1. In this instance, we were interested in audiovisual synaesthesia and wanted to allow participants to draw their perceptual experiences in VR themselves. Also, the primary focus was qualitative analysis, as in Experiment 1, the nuances of participants’ reports were missed without any formal qualitative procedure.. Participants were introduced to variable features of the tool, including environments they could draw in, adjustment of the size of the brush, and the brushes themselves. Some standard prompts were provided for participants to get comfortable in the environment and the teleporting tool was introduced to demonstrate how they can move easily in three-dimensional space. In the meantime, the experimenter was monitoring the physical space to ensure participants did not walk into objects in the VR lab.The current experiment was approved by the College of Science and Engineering, University of Glasgow Ethics committee. Participants read the information sheet and signed a consent form before arrival at the VR lab. Upon arrival, the experiment was explained to the participants, and the VR kit was demonstrated. Once participants were comfortable they were placed in the virtual environment. Open Brush was used for onboardingOnce participants were comfortable using Open Brush, an onboarding sound was introduced. The volume was adjusted to the participant's comfort and they attempted to draw the perceptual experiences the music elicited. At this point, a recording of the video screen  and participants’ comments were started. Participants were encouraged to describe their experiences and thought processes as they went along.When participants were comfortable with the virtual set-up, experimental sounds were played. Sounds were played in the same order, however, due to technical difficulties, the “White Noise” sound was played as the second stimulus for Participant 2, but the remaining order continued after. See Once again participants were encouraged to describe their experiences as much as possible. Each sound lasted approximately 30 s, therefore, the sound was replayed as many times as participants requested. After each stimulus, participants were asked to rank how accurately their drawing represented their perceptual experiences, from 0 to 5, where 0 is not representative at all and 5 is perfect.After all five stimuli were presented participants were asked general debriefing questions on their impressions of the VR and how well they thought the tool helped them represent their perceptual experiences.In order to get some idea of the consistency of responses, Participants 1 and 2 were retested on the same task approximately 19 weeks after their first session.Participants rated most of their drawings fairly highly as representative of the actual perceptual experiences. Due to the issues with VR controllers, the final rating for Participant 3 is not available. Participant 3 described their experience in this instance but was unable to produce a drawing. Thus, only qualitative data were collected in this instance. Full details of the ratings, their means and standard deviations are presented in Individual drawings made by the participants will be briefly discussed in this section before qualitative thematic analysis is explored. Participant 1 chose to produce drawings in the default gray environment. Bird song elicited clear colors and textures: yellow and sparkly. Cars passing had a bluer tone and animated, directional movement. Phone ringing, Rain, and White Noise stimuli were also represented mostly using animated brushes and colors which were elicited by the sound almost immediately . Full viParticipant 2 produced drawings in a dark environment. The majority of the drawings had defined shape and clear colors. Bird song elicited strong color and movement. The white noise drawing was produced using smoky and speckle brushes. Cars Passing and Rain sounds elicited a specific shape with movement in some parts of the drawings. The Phone Ringing drawing was made using several animated brushes . See onlFinally, Participant 3 initially chose to work in the dark environment for the first stimulus—Bird song, then changed environment color to default gray as it was hard to visualize certain colors and movements that they wished to use. Cars Passing and Phone Ringing stimuli elicited strong movement and texture with specific placements in space . Due to Audio recordings were transcribed verbatim and recordings themselves were deleted after transcription to comply with the Ethical procedures and GDPR guidelines. Thematic analysis was chosen as an analysis method for the qualitative data as this approach allows research on individual views, opinions, and experiences. ITA was used to analyze the transcripts , which mSix steps developed by Participants spoke in detailed terms about the specific features of their drawings. These have been broken down into more basic elements of the drawings, namely color, shape, and size, and more complex features, consisting of movement and texture.Participant 1: … there are different shades of blue because these, like electric bits. Here are a little bit lighter it's very yellow and orange, so I've done like a big yellow shape and then like a sort of orange line in the middle. But there's like other things coming through as well so. Like the little Guitar scratches are kind of silver, so…Shape was also important in the majority of the recreations. Participant 2 expressed most of their experiences via a shape first and then discussed influences of color and size:Participant 2: … Is very big to begin with and then it's sort of like get a little bit less… And shape that I get from it and then the little brown speckles are kind of almost like they are birds there's usually some kind of like sort of sideways eye shape in the middle…Overall, the Basic Features subtheme captured the very first descriptions of the experiences, as it often started with either specific color or shape. Then participants explained it in more detail and more nuanced experiences were explored. This is captured by the second subtheme—Movement + Texture.Basic features such as color, size, and shape were referenced often by participants and appeared to be captured well by VR. Color was an important feature in most recreations and in some cases, participants described how different elements of the drawing changed color.circular motion” that this brush provided was “quite important” in conveying their experience; however, the speed of the motion should have varied depending on its position within the drawing.Participant 1: …in the middle it's slower, but on the outside it moves a lot more, almost like a sort of gravitational vacuum.However, for other visual concurrents, the associated movements were not something that OpenBrush (2016) in its current form could accommodate.Participant 1: So basically from the center here everything is pulsating outwards as if it's churning round, yeah. But I can't obviously, draw that, so that would be sort of the reverb and it's not gonna work.Where movement could not be accurately expressed, participants found novel ways to suggest movement, such as collapsing varying-sized rings into one “mean ring” (Participant 2) or adding lines to depict swaying motions. Participant 2: Like floating away from the shape. And then obviously it starts strong and it gets quieter since doing that sort of like shape where it's like really big to really small and then this orange line is like the mean ring.Participant 1: and these move really slowly and with me waving them. That's just to show that they kind of move in a very solid wayMovement was a key element to many drawings for all participants. In some instances, this could partly be captured by VR. For example, Participant 1 chose one of the animated brushes to represent their experience in response to the sound of a phone ringing. The “Participant 1: Yeah, I mean this smoke will actually come in really helpful because a lot of my synaesthesia looks kind of like that.Texture was also important, and the textured brushes, particularly the smoke brush, allowed for this to be well captured.Participant 1: The embers would still be going over the top as well. You can see the embers through it. Yeah, and the bottom bit with smoke. Yeah, it's just a little bit fuzzy.Participant 2 also referred to the “smokiness” and “cloudiness” of her sensations, as well as describing “stony, rough” textures, while Participant 3 described the texture of one object as if it had been cut by a “serrated knife.”The Movement + Texture subtheme was of utmost importance, although somewhat limited by the brushes currently available. Each drawing produced by the participants had some type of movement, either accurately represented by the animated brushes or described by the participants themselves.Participant 1: Yeah, I mean this is the best I've ever gotten to be honest. This is the best I've ever seen that can describe the sort of stars in your eyes. [in reference to the stars effect brush] …I never got to represent my experiences so clearly. I would like to show it to my family.Participant 2: There's so much more that I can convey and describe about it because I'm able to use like a 3D space rather than trying to draw something on a piece of paper. So yeah, a massive advantage.Participant 3: You need to just draw what I can see. Pen and paper are too small and doesn't get the same accurate representation so…The introduction of animated brushes, a three-dimensional environment, and additional ways to represent movement and texture of their experiences allowed participants to capture and describe their perceptual experiences better.Participants discussed how drawing their perceptual experiences in VR allowed for more accurate depictions of their synaesthesia than they had previously achieved in other media, for example, pen and paper.Participant 1: It's really quite difficult to describe that…Participant 2: It's hard, it's hard to describe so… It sounds really difficult… Yeah, it's it's really hard to describe.Participant 3: There's not as much…. I don't know how to sum up this pictureIn some cases, this difficulty extended into drawing as well. In some instances, this might have been due to limited drawing skills and artistic abilities.Participant 3: Yeah, definitely. It's mostly difficult to sometimes describe it, if I can't draw it.In other cases, it could have been due to the experiences themselves. Although, once again participants did not have an easy time articulating what specifically was difficult.Participant 1: ‘cause sometimes it's not so easy to draw what I see. Sometimes it will sort of feel a little bit like this and I don't really get much else.Participant 2: I think it is quite difficult to get this one. The general like hard shape. Is like definitely what I was thinking of..There can be several reasons for this difficulty. The most obvious ones are the artistic ability of the participant and the way the experiences are described alongside the drawings. However, in some cases, participants might not have had enough time to fully think about how they wished to represent their experiences, and the novelty of the tool added an additional layer of complexity.Participants spoke about how describing their experiences with words was difficult and the specific aspects of this difficulty were also hard to articulate.Being in the VR environment elicited a wide range of memories and past experiences that the participants discussed. Creative activities can often elicit these types of experiences and willingness to share and can be traced back to basic principles of art therapy, although this was not an intention of the current experiment .play several instruments,” and how different instruments elicit different experiences. The texture was also a dominant feature in their accounts.Participant 1: .. for example, I can sort of see a lot of the texture of the strings. I can see when they're getting plucked. And it's stimulating, but if I was hearing a much more grainy and overdriven guitar..Participant 1 also expressed they were “a big metal fan” and that the taste in music is linked to their synaesthetic experiences. They also shared that they are “trained in [culinary] knife skills” and the sounds and smells associated with the kitchen elicit strong memories and perceptual experiences. They also shared their love for cycling and “the feeling of … chain on the bike between . .. pedals” which made them think of “..like gray sort of rocks.. like sort of grinding against each.”Participant 1 described their love for music and how they can “Participant 2: like I do listen to quite a lot of rock music. So it depends on like the type of song.They also described how they perceive time and numbers and that they are represented spatially, as if on a map.Participant 2: I am on this map. Where I am at 31. And everybody else I know is like placed across the map.Participant 3 discussed how the sound of rain reminded them of everyday experiences living in Scotland and how colors and sounds clearly had a very strong association with memory. They also expressed how their music preferences are linked to their perceptual experiences.Participant 3: I don't like you know like skating music because I feel like it's really harsh.Whenever participants were placed in the virtual environment they were happy to discuss their immediate responses to the stimuli, but that also often connected to specific memories or daily experiences. Due to the qualitative nature of the study, these experiences can be captured and analyzed.Participant 2 also shared that their tastes in music were linked to their synaesthetic experiences.Participant 1: Yeah, I mean this smoke will actually come in really helpful because a lot of my synaesthesia looks kind of like that…Participant 1 also remarked on the animated sparkle brushes as very true to actual perceptual experiences.Participant 1: Oh my God… Yeah, this is. Pretty much. This is the best I've ever seen that can describe the sort of stars in your eyes.The ability to make three-dimensional shapes was admired by Participant 2 and Participant 3 found many brushes hyper-realistic.Participant 3: I feel like I could just touch them. They're very realistic.All participants engaged with various brushes and liked to experiment with texture. Alongside verbal descriptions of the process and the perceptual experiences themselves, the data collected had a rich qualitative account of synaesthetic perception.OpenBrush (2016) provides a variety of brushes and many of them are animated or unusual, often three-dimensional textures, which helped our participants express their perceptual experiences better. The smoke brush was certainly one of the most popular tools used.cool” (Participant 2) and “realistic” (Participant 3) it felt.Participant 1: I don't think it matters how long I would spend in here. It would never stop like amazing me.Enjoyment of the new tool has certainly been one of the key subthemes in the experiment, however, it did not deter from the task at hand. Participants completed their drawings without getting distracted by other available tools with guidance from the experimenter. However, the enjoyment should be explored further in any follow-up work.The novelty of the tool and the ability to engage with the three-dimensional world with a variety of tools was enjoyable for all of the participants. They often commented on how “Participant 3: This is going to sound strange. But I feel like I can taste this. So it's definitely a color. And yeah… but it tastes like, you know, you get those… Little tubs of pears”Participant 1 said that they could “see, smell, touch and [hear]” the stimuli, similar to how one might experience a memory. Participant 2, meanwhile, referenced physical sensations, such as feeling like her feet might get wet and experiencing the sound lower in her body as a result: “it feels very low down… thinking my feet are going to get wet.”All participants mentioned that the auditory stimuli elicited further cross-modal experiences, in addition to visual experiences. For Participant 3, these were primarily gustatory experiences:As a result, some of the visual perceptual experiences were fairly weak for some participants, which also depended on the stimuli. Participant 3 especially reported a lot of cross-modal experiences and some of the visual experiences were either weak or very hard to present as a three-dimensional drawing.Participant 1: I'm just in the corner of my eye. It's just a little bit of this here, and it's about that color.Participant 2 referred to “standing” on, “walking through” and “being inside” various objects, in addition to characterizing other items as “floating in space.” Similarly, Participant 3 mentioned being at first beside and then behind one construction:Participant 3: Seem to be at the side of both of my ears. Not only that… I wouldn't put it front of me. I would envision it to be beside…and then we're behind it.VR is a unique tool for representing the three dimensionality and movement of the perceptual experiences described by the participants. Although some aspects of the experiences were difficult to capture, the dimensionality and position in space subtheme reveals that there are three-dimensional aspects to synaesthetic experiences that should be explored further.The relevance of where the elicited visual experiences were in relation to participants’ bodies was mentioned by all participants and is something that VR is uniquely capable of capturing. Participant 1 talked about how he saw something at the periphery of his vision:Participants produced similar drawings in the retest. Although there were some differences seen in the brushes used or the intensity of colors chosen there are clear similarities in terms of the overall shapes, hues, and gist of the retest drawings which is striking given the number of degrees of freedom available see .Experiment 2 explored the perceptual experiences of three audiovisual synaesthetes. In contrast to Experiment 1, in Experiment 2 participants used the VR equipment themselves to recreate their additional perceptual experiences in response to five everyday sounds. We aimed to examine whether the VR environment can allow synaesthetes to create richer and more accurate depictions of audiovisual synaesthesia than two-dimensional media.M = 3.93, SD = 0.997)  see . These rQualitative analysis revealed the following themes: Features of drawings and perceptual experiences, The use of VR, and Diversity of synaesthetic experiences . FeatureThe diversity of synaesthetic experiences encompassed the dimensionality aspect of participants’ concurrent experiences, as well as any additional cross-modal experiences they reported, such as taste or physical sensations. Although additional cross-modal experiences cannot be captured within OpenBrush (2016), these details provide additional context to the participants’ visual recreations and a broader picture of the degree of multisensory integration within synaesthesia. In terms of position in space, participants clearly indicated where visual concurrents should be in relation to their own bodies in the VR space. Participant 1 described seeing things within his visual field, such as in his peripheral vision, whereas Participants 2 and 3 described being behind, beside, above, or within their synaesthetic experiences. This demonstrates the importance of three-dimensional media in attempting to recreate the experience of synaesthesia, as dimensionality cannot be adequately captured by other artistic media yet appears to be fundamental to participants’ synaesthetic experience.The use of VR contained the following subthemes: accuracy of representation of perceptual experiences, difficulty to describe experiences and drawings, eliciting memories and sharing experiences, engaging with tools and features, and enjoyment of using VR. Participants highlighted how, on some occasions, the VR medium allowed for the most accurate representation of the experiences that they had experienced so far. This was owing to several factors including the three-dimensional, immersive nature of VR and the availability of textured brushes such as the smoke and star brushes. Participants mentioned how difficult their synaesthesia could be to describe, and in some cases, the VR environment allowed them to express this. However, in other cases, this difficulty extended to drawing. Although VR requires less specialist skills than media such as animation, this can possibly be due to differing levels of artistic skill, as well as the short time participants had to become acquainted with the extensive features of OpenBrush (2016). A benefit of the case study approach and allowing participants time to explore and discuss their additional sensations was that memories and previous experiences were elicited. This allowed participants to share aspects of their synaesthesia that, although not directly relevant to the task, provide a broader picture of how their synaesthesia influences their daily lives. Participants also expressed enjoyment and a desire to spend more time in the VR environment .An important issue is to what extent synaesthetic experiences vary over time. The idea of consistency as the gold-standard test for synaesthesia has been questioned in recent years, and some studies have demonstrated lability in synaesthetic concurrents with age and mood (see This paper has presented two experiments investigating the use of VR to explore the phenomenology of grapheme-color (experiment 1 only) and audiovisual synaesthesia. Due to constraints presented by the COVID-19 pandemic, in Experiment 1 a VR-by-proxy method was used. In Experiment 2, participants were able to use the VR equipment themselves to create their own representations of their synaesthesia. In both experiments, participants responded very favorably to the VR environment, and in some cases stated that their VR drawings were the most accurate depictions of the synaesthesia they had ever managed to create.A clear benefit of using VR to recreate synaesthetic associations is the opportunity it affords to create drawings in an immersive, three-dimensional space. In both experiments, participants refer to where their concurrent experiences are positioned relative to their own bodies. For example, in Experiment 1, Participant 4 reported on viewing the researcher's recreation of the misty gray mass elicited by the sound of rain that rather than viewing it from a distance we should be very close up, almost among the mist. Similarly, for the speckles experienced in response to birdsong, two perspectives were shown, one from a distance and one from closer up. Although the far-away version was judged as very accurate, the participant said that he found the close-up version hard to judge as he did not experience it from such a close-up perspective. Participant 3 reported that the depiction of the researcher's voice should fade out into it the periphery, rather than hovering around a definitive edge. In both cases, the importance of positioning was something that participants mentioned only in meeting 2, but that they felt strongly about. This highlights the difficulty that participants had in verbalizing their additional perceptual experiences, a finding consistent with previous research . Additiobeside"(Participant 3), “behind” (Participant 3), “inside"(Participant 2) “standing on"(Participant 2), or “walking through"(Participant 2) their various synaesthetic experiences. These differences could reflect whether the participants were associators or projectors and exploring the differences in how associators and projectors choose to represent their perceptual experiences in a virtual environment could be an important avenue for future research.These findings were echoed by participants in Experiment 2, who all made repeated references to where objects should be relative to themselves see . For ParParticipants naturally drew these where they experienced them in space but tended to only describe this when prompted by the researcher. Clearly, where concurrent experiences are with respect to the synaesthetes themselves is an important element of audiovisual synaesthesia, and one which cannot be represented in traditional 2D media. VR allows for this form of expression and allows for nonsynaesthetes to step into the environment and experience a fuller, more immersive picture of another's synaesthesia.“the color is not quite right, but the movement is good” indicating that while this tool could accurately recreate her dynamic concurrent experience, the preset coloring resulted in reduced overall accuracy. Similarly, in Experiment 2, certain types of motion could not be captured, and participants resorted to a range of different measures to allude to motion—such as adding lines to indicate the direction of motion or drawing the “mean” (Participant 2) size of rings which should be moving and gradually getting smaller—rather than accurately depicting the motion as they experience it. These examples indicate that while OpenBrush (2016) is an advantageous tool for capturing some visual elements of synaesthesia, it is missing some features which would be necessary to fully capture other elements.Although showing promise, there were certain aspects of some participants’ elicited experiences that OpenBrush (2016) was not capable of capturing. Primarily, certain types of motion could not be captured. This was seen in both experiments. For example, in Experiment 1, Participant 3 described her reaction to the sound of birdsong as an orange color “jiggling” back and forth in the bottom right corner, which then darted across to halfway up the left-hand side and became a twisting peach octagon. Although the initial subtle “jiggling” motion was well captured, no tool allowed for that shape to then move across the screen, change color and shape, and then twist. Similarly, the sound of white noise elicited the experience of a white wave for Participant 3, similar to that of a heart rate monitor, moving across the screen and fading out as it did so. Again, no tool allowed for this movement to be captured. Furthermore, tools were preset, which reduced accuracy in some cases by subtly altering colors. For example, the brush which was chosen to recreate Participant 3's aforementioned pink waterfall turned white at the end of each brushstroke. Participant 3 remarked that Sensology (2010) and Punch-Drunk Love (2002) where they animated auditory-visual experiences in response to music  becoming an open-source platform, meaning that while Google will no longer update it, the code is now freely accessible and anyone can make changes to it . Althougto music . HoweverIn Experiment 1, a clear limitation was that participants were not drawing the concurrent stimuli themselves. This was rectified in Experiment 2. However, a strength of Experiment 1 was the full and detailed descriptions that participants provided of their experiences, and the specific feedback on how to improve the researcher's OpenBrush (2016) drawings. Additionally, the researcher had unlimited access to the VR system, allowing for a better grasp of the features available in OpenBrush (2016), and more time to consider how best to represent the descriptions provided by the participants. In Experiment 2, meanwhile, participants had a shorter time to become acquainted with the features of OpenBrush (2016) and provided commentary throughout their time in the VR environment, but in a more sporadic manner. Additionally, as VR can cause motion sickness , particiAcross two experiments, this study has examined the additional visual experiences of nine synaesthetes. Using the VR package OpenBrush (2016), we aimed to accurately capture the nuances of synaesthetic experiences, with positive results. This has led to a greater understanding and appreciation of synaesthesia for both the researchers and the participants. Furthermore, as an exploratory feasibility study, we aimed to determine whether it is worthwhile pursuing VR technologies as a medium for synaesthesia research.Participants generally expressed enthusiasm for using VR and stated that they saw potential in this line of research. Additionally, participants stated that participation was a good opportunity to consider details of their experiences that they previously had not noticed or considered in great depth. For example, in Experiment 1, after viewing the introductory OpenBrush (2016) video, Participant 6 remarked that the background should be light in color to match the images she sees, but that she had “never thought about that before.” Furthermore, in Experiment 2, Participant 1 stated that they would like to use the representation to show to their family, emphasizing the potential role of VR depictions as a communication tool.It is clear that, for some individuals with synaesthesia, both traditional color pickers and two-dimensional art-based software such as Adobe Photoshop are insufficient to represent the complexity of their concurrent experiences. This study demonstrates that VR can be used to depict more elements of a synaesthete's experience, including textural qualities, certain types of movement, and three-dimensional elements, than traditional methods, which therefore helps to promote a deeper understanding of synaesthetic individuals’ unique perceptual experiences.A final implication is that this novel technique could be used to explore other types of perceptual diversity, including perceptual experiences associated with known conditions such as autism or aphantasia as well as others that might be revealed by ongoing research .Click here for additional data file.Supplemental material, sj-zip-1-ipe-10.1177_20416695231166305 for Using immersive virtual reality to recreate the synaesthetic experience by Rebecca Taylor, Sarune Savickaite, Susanna Henderson, and David Simmons in i-PerceptionClick here for additional data file.Supplemental material, sj-zip-2-ipe-10.1177_20416695231166305 for Using immersive virtual reality to recreate the synaesthetic experience by Rebecca Taylor, Sarune Savickaite, Susanna Henderson, and David Simmons in i-Perception