Virtual reality in social skills training programs for people with schizophrenia: A systematic review and focus group

Abstract

Introduction

This study aims to determine the guidelines for the design of a social skills training programme for people with schizophrenia using virtual reality.

Methods

This article encompasses two studies: Study 1, a systematic review of five articles indexed in the databases B-on, PubMed, Clinical trials and Cochrane Library (2010–2020); Study 2, a focus group of occupational therapists trained in mental health and multimedia professionals, in which they discussed the outline of such a programme.

Results

A set of guidelines were identified as central and consensual which should be included in the programme. It must have multilevel logic and gradual learning, with simulations of everyday situations, in which it is possible to practise the skills of conversation and communication. Virtual reality provides people with schizophrenia with unlimited opportunities, enhancing a personalized intervention.

Conclusion

Social skills training could be part of the treatment for people with schizophrenia, and virtual reality is a promising tool to complement traditional training, although still little implemented in mental health services. Occupational therapists have a prominent role in the development and application of this because of their knowledge of activity analysis and their ability to facilitate the generalization of skills in different contexts.

Keywords

Schizophrenia social skills training virtual reality occupational therapy

Introduction

Around the world, about 20 million people have been diagnosed with schizophrenia (SZ), a serious chronic mental illness, which is characterized by distortions in thinking, perception, emotions, language, sense of self and behaviour (World Health Organization, 2019). According to the National Institute of Mental Health (2020), people with SZ seem to have lost touch with reality, which causes significant suffering to the individual, their family and friends. When left untreated, the symptoms of SZ are persistent and highly disabling, yet effective treatments are available. People with SZ have a reduced social network and few opportunities to interact socially. As social skills (SS) are developed and improved throughout life through social relationships and interactions, people with SZ, in addition to the difficulties caused by the disease, are also limited by the opportunities offered to them to practise their SS and, as such, they have problems with them (Limberger et al., 2018; Mueser et al., 2010).

SS and social competence are protective factors in the model of vulnerability–stress–protective factors of SZ. Social skills training (SST) allows for the mitigation of the negative symptoms of SZ, allowing patients to have a pleasant conversation and, consequently, has a salutary impact on the level of the emotional climate in the family. It also allows people with SZ to become active participants in controlling the disease, overcoming obstacles and mobilizing social support to reach their goals (Kopelowicz et al., 2006). Occupational therapists are core members of multi-professional teams that care for people with SZ (Morris et al., 2018). They have the education, skills and knowledge to provide evidence-based intervention to adults with SZ, helping them to engage in meaningful occupations, participate in the community and contribute to society (Lannigan and Noyes, 2019). Occupational therapy interventions aim to improve their quality of life and social participation, and this is achieved through the adaptation of activities and environments important to the individual to allow for the development of skills and of their confidence in the performance of daily tasks. This can include practical self-care, domestic skills, work skills, leisure activities, SST and family interventions (Bryant et al., 2014; Cook and Birrell, 2007). Occupational therapy emerges from occupational science and, as such, argues that involvement in important and satisfying occupations contributes to health and well-being, social inclusion and improves functioning and self-respect. Occupational therapists have an important role in the treatment and rehabilitation of people with SZ, providing different activities to improve the skills necessary for daily life (Foruzandeh and Parvin, 2012). Occupational therapy and SST are effective in the acquisition and recovery of useful activities and allow people with SZ to improve their performance and reduce withdrawal, isolation and passivity. It can be argued that both approaches can be assessed as valid rehabilitation resources as they emphasize the active role of participants in their treatment. Consequently, the burden of care on families is reduced (Foruzandeh and Parvin, 2012; Perilli et al., 2018). A review by Perilli et al. (2018) confirms the effectiveness of both occupational therapy and SST in the promotion of independence and self-determination in SZ patients. This review emphasized that the participants' performance increased during the intervention periods and that as their adaptive response improved, the psychotic characteristics were significantly reduced.

Observing and practising SS in a natural interaction can be useful, but equally time-consuming and probably highly intimidating for a person with SZ. Virtual reality (VR) for SST has emerged as a tool to overcome this limitation (Rus-Calafell et al., 2014).

During the experience with VR, the individual is exposed to multisensory information, surrounded by a three-dimensional representation, being able to move about in the virtual environment, observe it from different angles, participate in it, interact and, eventually, modify it (Buzio et al., 2017; Wallace et al., 2010). Users feel they can look around and move through the virtual environment (Malloy and Milling, 2010). The results for the person are psychological and physiological responses very similar to those in the real world (Moritz et al., 2014; Rus-Calafell et al., 2014; Veling et al., 2014). The fact that exposure to realistic environments, even if virtual, generates responses similar to those that would occur in reality, makes VR a very promising method for SST (Bordnick et al., 2012; Nijman et al., 2019).

Virtual reality(VR) is immersive, interactive and dynamic (Nijman et al., 2019), enabling interaction with a virtual character (Kozlov and Johansen, 2010; Park et al., 2011), which can be interrupted at any time and, therefore, individuals can practise without negative repercussions and without fear of constraints on their social lives (Nijman et al., 2019). Through VR, people with SZ can practise difficult or challenging social interactions in an environment where they are well protected because VR provides a favourable environment for making social mistakes, without the anxiety or fear of rejection commonly associated with face-to-face social interactions (Didehbani et al., 2016). Furthermore, VR can facilitate role playing as participants do not need to use their imagination to contextualize a given scenario (Mazurky and Gervautz, 1996).

Another prominent feature of VR is the sense of presence in the virtual world, which can be defined as the feeling of being there (Veling et al., 2014; Zacarin et al., 2017). During the experience with VR, the person feels that they belong in the virtual environment (Park et al., 2011), and the ability of the simulator to provoke this sense of presence in the person allows them to express emotions similar to those they would express in the real world (Zacarin et al., 2017).

On the other hand, VR equipment can be very expensive and is not always compatible with other existing systems (Mazurky and Gervautz, 1996; Park et al., 2011). There may also be cyber sickness, a temporary malaise, with the occurrence of nausea and dizziness, which can last for several hours or even days after exposure to VR (Mazurky and Gervautz, 2013).

Thus, reality, even though it is virtual, still represents the complexity of the real world and also offers the advantage of being able to be controlled by the therapist, providing a safe environment for people with SZ to practise SS and experience countless everyday situations (Didehbani et al., 2016). As VR technology advances, it can be applied more effectively in SST (Park et al., 2011).

This study aims to describe the guidelines for an SST programme for people with SZ using VR. To achieve the proposed objective, this study comprises two parts: Study 1, a systematic review of the use of VR in SST for people with SZ, and Study 2, a focus group to explore the design of an SST programme for people with SZ using VR.

Methods

Study 1

A systematic review was conducted to gather assumptions and requirements for the design of an SST programme using VR for people with SZ. The report of the systematic review follows the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement (Moher et al., 2015). The aim of systematic review is to summarize the impact of using VR to SST for people with SZ. Quantitative, qualitative and mixed-method studies were included but reviews and systematic reviews were excluded. The inclusion criterion was for the study to have been published between 2010 and 2020, in English. Also, study participants should have been diagnosed with SZ and have used VR technology in the intervention. Studies were excluded in which the participants presented another diagnosis, also interventions without the use of VR and in which SS were not measured. We researched the databases B-on, PubMed, Clinical trials and Cochrane Library. Grey literature was also researched. The search terms [“Social skills training”], [“virtual reality” OR “game environment” OR “simulation training”], [“social skills”] and [“schizophrenia”] were used. A search strategy with different combinations of search terms was used, using the term “and” between each one.

In the research, 336 studies were identified, and the first step was to remove duplicate titles. Then, the titles and abstracts were reviewed by two independent researchers and, in case of doubt about the inclusion of the study only by its abstract, an evaluation of the complete article was made. For studies that met the eligibility criteria, the full text was revised. A data-charting form was developed to determine which variables to extract and Figure 1 outlines the study selection process. Bibliographic information, design, purpose, participants, measures, interventions, VR technology and key findings were collected and summarized in Table 1.

Figure 1.

Preferred reporting items for systematic reviews and meta-analyses(PRISMA) flowchart of the selection process.

Table 1.

Studies included in the systematic review.

Reference\| country	Purpose	Design	Measures	Participants	Intervention	VR technology	Key findings
(Adery et al., 2018) United States	Design and implement a potentially effective, high-compliance VR SST game for individuals with SZ by capitalizing on/technological innovations in adaptive, non-immersive VR technology.	Longitudinal study	- National adult reading test, revised; - Wechsler abbreviated scale of intelligence; - Brief psychiatric rating scale; - Scale assessment negative symptoms; - Scale assessment positive symptoms; - Social function scale.	- n = 16; - Individuals from the community who met the DSM-5 criteria for SZ.	- 10 sessions; - Twice a week; - MASI-VR sessions: Participants complete 12 social “missions” four easy, four medium and four hard missions sequentially at each training session.	- MASI-VR; -Non-immersive; -Video game; -Social parameters and social interaction could be repeatedly explored and systematically altered to avoid habituation; - Three different social contexts (bus stop, shop, and cafeteria); -Exercise starting a conversation with an unfamiliar person to make requests or ask for information; - Real-time feedback was provided to the participant after each response was made.	High levels of overall satisfaction with MASI-VR; - Improving the severity of general psychiatric symptoms; - Decreased severity of negative symptoms; - No significant changes in SFS. As the SFS inquiries about the prior 3 months, no change was expected during the duration of the intervention. However, follow-up testing may reveal more significant improvements;
(Rus-calafell et al., 2014) Spain	The main purpose of the present study was to explore the effectiveness and utility of a VR programme as an adjunct tool to deliver an individual SST intervention.	Longitudinal study	- Positive and negative symptoms scale; - Assertion inventory; -Simulated social interaction test; - Social avoidance and distress scale; - Social function scale; - Committed errors; - Assertive behaviours; - Time spent in a conversation; - VR acceptance assessment.	- n=12. All patients with SZ or schizoaffective disorder were clinically stable and had not been hospitalized at a psychiatric institution within the past 6 months.	- 16 sessions; - Individual; - Twice a week; - Each session lasts 60 min: The first 30 min to discuss the content of the SST intervention and the remained to practice with the VR programme.	Soskitrain: Consists of seven activities based on the seven target behaviours; - Practice social interactions with virtual avatars; - Progressive learning; - The therapist can observe the patient’s real-time manifestations, modify and manipulate environments and characters according to the user’s responses and stop the interactions whenever is necessary to discuss a single situation and its implications; - The programme provides information concerning committed errors, percentage of correct assertive behaviours and time expended during a conversation; - The Soskitrain provides a matrix that comprises direct scores about patients’ performances in every session.	- Improvement psychopathological, maintained at follow-up; - Decreased social anxiety and these changes were maintained at follow-up; - Improvements in social functioning. Gains were maintained at follow-up; - High level of satisfaction concerning the perceived intervention’s benefits; - The use of the VR programme contributed to the generalization of new skills into the patient’s everyday functioning.
(Park et al., 2011) Republic of Korea	This study aimed to find advantages of the use of VR in social rehabilitation for patients with schizophrenia	Randomized controlled trial	- Social behaviour scale; - Rathus assertiveness schedule; - Short version of the social problem-solving inventory revised; - Motivation and generalization questionnaire.	- n = 64; - Ages of 18 and 45 years old.	- 10 sessions for 5 weeks; - Group (4 or 5 members); - 90 min; - The sessions consisted of 3 consecutive trainings: 5 sessions of conversation skills training, 3 sessions of assertiveness skills training, and 2 sessions of emotional expression skills training; - Homework; - Every session included therapist modelling followed by the participant’s role-playing and then positive and corrective feedback from the therapists;	- Immersive; - The participant wore the HMD and the position tracker, which provided “immersive” virtual environments, and the rest of the group members observed the same scenes on the big screen.	- No changes in psychiatric symptoms; - Improvement of social skills (non-verbal skills), but the SSTs-TR shows better results in nonverbal skills; - The VR application has an advantage over SST-TR in increasing assertive behaviours, participation, generalization, and motivation; - VR application may be clinically feasible for conversational skills training for patients with SZ.
(Rus- Calafell et al., 2013) Spain	The present study aims to evaluate the relationship between patients’ cognitive deficits, their sense of presence and their ratings of the programmeme’s acceptability.	Longitudinal study	- Screen for cognitive impairment in psychiatry; - Continuous performance test; -Questionnaire regarding their experience with the VR programme: - SUS questionnaire (for the present study, an additional item about acceptance/aversiveness of the VR system was included. The ratings used a Likert scale ranging from 1 (minimum) 7 10 (maximum).	- n = 12; - Clinically stabilized outpatients with a diagnosis of either SZ or schizoaffective disorder.	- 16, one-on-one sessions, conducted twice weekly over 8 weeks; - Approximately 60 min: The first 30 min to discuss the content of the SST intervention and the remainder to practice with the VR programme.	Soskitrain (software previously described) - The VR programme consists of seven activities in which the therapist can modulate the patient’s behaviour using CBT; - Presentation of virtual faces, interactions and characters to offer participants a wide range of experiential options and to provide novelty during each session.	- Patients gave high ratings for a sense of being there; - Participants report that virtual environments were like their natural living environment; - Ratings of the acceptability of the VR system were high.
(Rus- Calafell et al., 2012) Spain	- Help people with SZ to overcome everyday social difficulties via the use of new technologies.	- Case study.	- Three targets behaviours: Facial emotion recognition, assertive behaviours and time spent on conversation (measured by a VR conversation activity); - Positive and negative symptoms scale; - Social function scale; - Social anxiety and distress scale.	- The participant was a 30-year-old woman with a well-established diagnosis of SZ; - At the time of recruitment, she was in a stabilized period (>6 months).	- 4 baseline sessions, 16 treatment sessions and 4 follow-up sessions 3 months after the end of the treatment; - First stage: Facial emotion recognition and social information processing; - Second stage: The therapist and the patient dealt with social anxiety and interpersonal interactions; - Lastly: Communication and conversational skills.	-Practice behaviours in simulated environments representing daily situations, such as going to the supermarket, dealing with an angry security guard in a museum or trying to negotiate with a manipulative friend over who would drive a car to a party.	- Changes in the three target behaviours; - Significant differences for facial emotion recognition; - Increase in the frequency of assertive behaviours, the time spent on the conversation and social functioning specifically to interpersonal communication; - Decrease in negative symptomatology, general psychopathology, social anxiety, and social discomfort.

VR: virtual reality; SS: social skills; SZ: schizophrenia; SST: social skills training; MASI-VR: Multimodal Adaptive Social Intervention in Virtual Reality; SST-VR: Social Skills Training using Virtual Reality.

Assessment of risk of bias

To assess the risk of bias, we use the criteria advocated by the Cochrane Collaboration (Higgins et al., 2011): (i) selection bias, (ii) performance bias, (iii) detection bias, (iv) attrition bias, (v) reporting bias and (vi) other bias. For each criterion, studies were given a rating of ‘high risk of bias’, ‘low risk of bias’ or ‘unclear’.(Table 2)

Table 2.

Summary of results.

	Study 1	Study 2
Structure	Twice a week; For five to 8 weeks; Duration 60–90 min; Division of intervention time into different intervals; Follow-up; Homework.	Holistic, integrated, multidisciplinary, systemic and two-dimensional view; Learning tasks, reinforcement techniques and modelling in line with a cognitive-behavioural approach; VR as a complement to traditional training; Individual and group sessions; Preparation for using VR.
VR software	Immersive VR technology; ‘Social missions’ in different contexts; Progressive learning; Feedback after each choice/answer.	Neurofeedback; Body swap; Simulation of everyday situations; gamification logic, multilevel.
Target skills	Conversation and communication skills; Assertiveness skills; Emotional expression skills; Facial emotion recognition; Social information processing; Starting a conversation to place orders or ask for information; Social perception; Responding and sending skills; Affiliative skills; Instrumental role skills.	Identification of social rules; Recognition of socially accepted behaviours; Creation of strategies to mediate the relationship with each other in a way satisfactory to both parties.
VR barriers		Reservations of the health professionals;Cost of VR equipment;The insecurity of the person with SZ about what will be done with their data;A game environment that allows the SST that the person needs;Cyber sickness.
VR potential	Improvements in SSs (more pronounced improvements in verbal skills and assertive behaviours);Improvement of psychiatric symptoms;Improvement in social functioning;Generalization of skills;Motivation;Improvement of assertive behaviours;Increased time spent talking;Provision of information that is not measurable to the naked eye.	Motivation;Flexible profile;Facilitates the generalization of skills worked on.

VR: virtual reality; SS: social skills; SZ: schizophrenia

Study 2

A focus group was held to explore the perspective of health professionals on the guidelines for an SST programme using VR for people with SZ. Eligible participants were occupational therapy professionals trained in mental health, with a minimum experience of 5 years, working in institutions/services that implement SST programmes, and multimedia professionals with experience in the design and use of VR technology. Seven participants were recruited in April 2020 by reference to various sources and contacted via email. All participants were adequately and intelligibly informed about the purpose of the study and their role in it. The focus group took place by videoconference using Zoom. Seven participants (three women and four men, mean age 45 years), were included in the study.

Before data collection, all participants signed consent forms, responded to a survey related to socio-demographic data and, before starting the debate, gave their verbal permission for it to be recorded. The focus group was conducted using semi-structured interview guidelines that included open questions about SS in people with SZ, SST, VR and using VR for SST. The topics were introduced starting with general open questions resulting in a good interaction between the various participants from which important information emerged.

Data analysis was based on the technique of qualitative content analysis. The focus group was audio-recorded, and the information collected was encoded. In the next step, similar codes were grouped and organized into major themes and topics. The categories respected the criteria of mutual exclusivity, pertinence, homogeneity, objectivity, purpose and productivity. Two independent researchers conducted the coding and resolved discrepancies through analysis of the raw data and input from experts on the topic.

Results

Study 1

336 studies were identified in the databases researched, of which five were included as meeting the eligibility criteria (Figure 1).

On the structure of an SST programme for people with SZ using VR, all of the studies reviewed conducted sessions twice a week, two of them for 5 weeks, three of them for 8 weeks and only one study did not mention the duration of the intervention. The duration of the sessions was also reported in half of the studies reviewed, with two studies reporting having 60-min sessions and one study having 90-min sessions. Also, they divided the time of the session into different periods. The studies divided the total intervention time into different periods of time and grouped the sessions according to the skills to be worked on. In the study by Park et al. (2011) the sessions consisted of three consecutive pieces of training: five sessions of conversation skills training, three sessions of assertiveness skills training and two sessions of emotional expression skills training. In the studies by Rus-Calafell et al. (2013, 2014), they divided the sessions into two periods, initially discussing the content of SST and in the second part, practising the same content using VR. In another study by Rus-Calafell et al. (2012), the intervention was carried out in three different parts – initially, facial emotion recognition and social information processing training was carried out, in a second period the therapist and the person with SZ dealt with social anxiety and interpersonal interactions, and in the last period, communication and conversation skills were addressed. The study by Adery et al. (2018) describes the intervention as ‘missions’ and, in each training session, completed 12 social missions, four easy, four medium and four difficult, sequentially. The same study used non-immersive VR technology and the rest used immersive VR. Comparing the results of the studies, we can see that immersive technology achieved better results in SS. All the studies indicated that VR technology allowed the user to receive feedback on their responses.

Most studies included in the systematic review verified the existence of improvements in SS. Only one of the studies reported that SS remained the same, but added that this may have been related to the fact that the Social Functioning Scale used evaluated the previous 3 months and this study did not, as follow-up sessions were not carried out, adding that follow-up sessions were needed after the end of the programme. A study (Park et al., 2011) that compared traditional SST with VR showed that in both interventions there were improvements in SS and, looking more in detail, found that in traditional SST the improvements were more focused on non-verbal skills, while in VR SST the improvements were more pronounced in verbal skills and assertive behaviour.

As a rule, studies showed that social skills training using VR contributed to the improvement of psychiatric symptoms and social functioning, facilitating the generalization of learned skills, and increasing the motivation to adhere to treatment. In addition, the studies verified the importance of VR in measuring parameters that would not otherwise be possible (e.g. the amount of time in which eye contact is established).

Risk of bias

Overall, the risk of bias appears to be relatively low (Figure 2), with the main threat to be found in incomplete or undisclosed data.

Figure 2.

Risk of bias ratings.

Study 2

The focus group was conducted for about 90 min. The debate flowed easily, without the need for much guidance from the investigator. Content analysis emerged on five main themes that matched the findings of the systematic review: (1) structure, (2) VR software, (3) target skills, (4) VR barriers and (5) VR potential.

Structure

All participants stated that a programme for SST using VR for people with SZ must have a holistic, integrated, multidisciplinary, systemic and two-dimensional view, with gamification logic, complexification of tasks, repetition, behaviour reinforcement and, progressive task learning. One participant stated, “I think it makes perfect sense to have a more integrated approach”. Another added, “If we think of the logic of having a set of environments and multi-levels, of moving from one level to the next, of complexification, this is in principle based on a theory of learning the task, of repetition, reinforcing behaviour, reinforcing what is well done, using reinforcement and behavioural modelling techniques. It is clear that this all fits into a more cognitive-behavioural approach.” The use of VR was seen by the participants as complementary to traditional SST and, as such, other strategies for SST should be added, “I think that a programme with only technology is poor”. They also considered that individual sessions and group sessions in which there could be sharing were important. “There may be a phase when the person in a more individualized way is doing this training, but later on there may even be some interaction between the various users”. According to the participants, the SST using virtual reality should be presented to the users after an initial adaptation to the technology. “I think, as in everything, that there is a need to have desensitization and habituation to what is unknown (…)”.

VR software

Participants showed an interest in neurofeedback as it allows for the possibility of adjusting the activity being performed according to the person´s physiological responses. “Galvanic sensors can measure in real-time how many electrophysiological changes there are and from these, we can see that we have managed to recharacterize the context itself as a result of this information.” The fact that the participant could embody a character when using VR was another aspect in which the participants expressed an interest. “This idea of body swap, or in other words, embodying the other (…) is already starting to be implemented”.

Target skills

VR technology should allow the simulation of everyday situations so that people with SZ can identify where their main difficulties are and practice socially accepted behaviours. During the simulations, people with SZ must have the opportunity to learn social rules, recognize what socially accepted behaviours are and create strategies to mediate the relationship with each other in a way that is satisfactory to both parties. Also, the therapist must teach a set of resources so that the person with SZ is successful in their day-to-day tasks. “So, basically, we try to create/replicate a real community context, thinking about those services, the cafe, the health centre, that everyone uses so the patient can see how it is and what are the difficulties they might face”.

VR barriers

The biggest obstacle identified by the participants related to the reservations of the health professionals themselves regarding the use of VR with people with schizophrenia. For example, “Sometimes it is us, the professionals, who have a little prejudice”. They also added the cost of VR equipment was very expensive to be accepted for general use in the mental health services. “Sometimes services end”, and the person with SZ could feel insecure about what will be done with their data: “Many people are also afraid of using technologies because of where this information may end up”. Participants also referred to the fact that it is not always possible to have a game environment that allows the SST that the person needs, stating, “We have the ability to develop game environments that allow us to work with people, which is the objective of the work, but not always the possibility.” The emergence of cyber sickness also worried professionals when they used virtual reality. “What sometimes occurs is cyber sickness, as anyone can feel discomfort using virtual reality”.

VR potential

For most participants, the great advantages of using virtual reality were the motivation that using these technologies provided and their flexibility, saying, “Motivating, but also flexible, which allows us to adjust to what each person needs”. Participants considered VR to be a promising method of facilitating the generalization of skills worked on in other contexts. “Virtual reality can create an interesting medium for training in context using simulation skills that are later easier to generalize to the real contexts where people work”.

Discussion

According to the results obtained in Study 1 and Study 2, we found that a holistic, multidisciplinary and integrated view is consistent with this type of programme, allowing for progressive learning using reinforcement and modelling techniques. A cognitive-behavioural approach is part of what should be the theory that supports the SST programme for people with SZ using VR, having been mentioned both by the focus group participants and used in the reviewed studies (Rus-Calafell et al., 2012, 2014).

Social interaction and SS have been identified as a subsystem of performance by the Model of Human Occupation (Kielhofner, 2015). They are included as a client factor in the Occupational Therapy Practice Framework: Domain and Process (American Occupational Therapy Association, 2014) and are an area of increasing attention by occupational therapists (Kauffman and Kinnealey, 2015). Evidence-based interventions suggest that the knowledge and skills of occupational therapists can enable people with severe mental illnesses to participate in the community and contribute to society, helping them to become involved in meaningful occupations (Lannigan and Noyes, 2019).

The frequency that most sessions used was twice a week, lasting about 60–90 min for five to 8 weeks. According to Kopelowicz et al. (2006), SST sessions can vary in duration from 45 to 90 min and the frequency can vary from one to five times a week, depending both on the levels of concentration and the control of symptoms that patients have. SST can be carried out for long periods until the individual goals of each patient are achieved as most people with SZ have generalized disabilities. Group and individual sessions must be included. The group format is used more for SST as it offers cohesion among participants, promotes mutual help and support from peers, as well as facilitates the sharing of experiences and the efforts of each individual to resolve problems in their day-to-day lives. However, the intervention can also be carried out in an individual format (Rus-Calafell et al., 2014). Groups usually involve 4 to 12 patients and are typically led by 1–2 therapists (Kopelowicz et al., 2006). Furthermore, the results indicate that dividing the total time of the sessions into separate periods allows different content to be worked on in the same session, or the same content in different ways. For example, specific content can be discussed in the group and later trained with VR resources, thus integrating VR and traditional SST. We found that before starting the programme, rather than at the end, it is important for a person with SZ to have contact with VR to allow habituation. Continuous monitoring is also important. During the programme, tasks should be sent to the person to perform at home. When this occurs, there is increased motivation to implement communication in real-life situations (Kopelowicz et al., 2006). The procedures associated with SST with VR are similar to those of traditional SST, the biggest difference being in the exposure phase when the person is exposed to a virtual environment and not to an imaginary or real environment (Wallach et al., 2009).

Neurofeedback comes together with VR in the sense that by checking the person’s physiological responses to a given task, it may be adjusted in real time. The fact that technology gives feedback on choices/responses allows the person to readjust their behaviour and facilitates the identification of target behaviours. As VR provides a protected, controllable environment, which causes responses similar to reality for the user, it becomes, therefore, an interesting resource for SST as it allows the person’s physiological responses to the tasks being performed to be analysed in real time (Moritz et al., 2014; Rus-Calafell et al., 2014; Veling et al., 2014). The therapist can control the progress of tasks and, in some way, control the anxiety induced by them. Also tasks can be repeated as many times as necessary (Laffey et al., 2009).

It is pertinent that, during training in VR, people with SZ have the opportunity to identify social rules, socially accepted and experienced behaviour and to mediate their relationships with one another, making it satisfactory for both parties. In general, the results show that it is important to approach communication and conversation skills, emotional expression, assertiveness skills, facial emotion recognition, social information processing, starting a conversation to place orders or ask for information, social perception, responding and sending skills, affiliative skills and instrumental role skills. In the study by Kopelowicz et al. (2006), target behaviours for SST are identified, namely, social perception, processing of social information, responding or sending skills, affiliative skills, instrumental role skills, interactional skills and behaviour governed by social norms. So, we found that our findings are in line with what is described in the literature.

When using VR in SST with people with SZ, there is greater motivation for the person to get involved in the programme, which facilitates the generalization of skills learned to other contexts. Virtual environments have a series of resources that offer the possibility of practising behaviours and responses, in a context that shares similarities with the real world, offering greater potential for the generalization of newly learned behaviours from the therapeutic environment to the real context (Bordnick et al., 2012; Wallace et al., 2010). In addition, when people with SZ have the opportunity, encouragement and reinforcement to practise their skills in a way that is relevant to them, the generalization of skills for use in everyday life occurs (Park et al., 2011; Rus-Calafell et al., 2014).

The flexible profile of the technology is interesting and has advantages for SST. Also, by using the technology, it is possible to measure parameters immeasurable to the naked eye, for example, the amount of time in which eye contact is established. Immersive technology shows better results than non-immersive technology and there seems to be greater interest in technology that allows multilevel logic, with the simulation of everyday situations. It is appropriate to use VR to simulate a variety of day-to-day social situations in a structured way that can be repeated in a safe and accessible way (Nijman et al., 2019). One of the prominent features of VR is the sense of presence, which is defined as the feeling of being there, so the simulator must be able to promote it as it is indispensable for the expression of emotions close to reality. The sense of presence seems to be directly proportional to the response to therapy, with better treatment results and prolonging the effects achieved for longer (Zacarin et al., 2017).

Furthermore, the results indicate that the possibility of the person with SZ assuming a character – body swap – through which he performs the proposed tasks is promising. The literature demonstrates that the use of VR for SST with people with SZ improves psychiatric symptoms (Adery et al., 2018; Rus-Calafell et al., 2014), social functioning (Rus-Calafell et al., 2012, 2014), social skills with more marked improvements in verbal skills and assertive behaviours (Park et al., 2011) and increases time spent talking (Rus-Calafell et al., 2012).

However, VR and its use also have limitations. First, the mental health professionals’ reservations about using something new, also the cost of the equipment and the fact that the game environment is not always adjusted to the person’s needs. Some of the interactions with virtual humans are standardized and, as such, may not be tailored to the person’s needs. This is also why it cannot be substituted for traditional SST, but VR can be a useful supplementary tool (Park et al., 2011). People with SZ who take advantage of VR may be unsure about what will be done with their data and, after using VR, cyber sickness may occur. The use of VR in the context of health is a topic which is on the increase but the use of VR SST for people with SZ is a poorly studied subject and about which information is still lacking. This lack of information and the lack of guidelines mean that VR resources are poorly implemented in mental health services (Anderson et al., 2013; Zhou and Deng, 2009).

Our study has some limitations. Firstly, we only held a focus group, in which participants in the health field were only occupational therapists. The debate between different health professionals could be interesting and generate more content for discussion. Also, people with lived experience of SZ should have been included in the focus group to understand their difficulties and needs. Having carried out a greater number of focus groups and having included a more extensive and diversified panel of participants would have allowed us to discuss and reflect on more opinions, which would enrich our study. Finally, randomized controlled trials are necessary to evaluate the quality of SST programmes using VR for people with SZ.

Conclusion

Social Skills Training is part of the treatment guidelines for people with SZ, and VR is a promising method to complement traditional SST. Virtual reality in SST for people with SZ is still a growing topic, but the use of technology seems to involve patients more in treatment, improving the results. While there are a wide variety of programmes that aim to improve SS in SZ, these programmes must directly address social cognition and social competence.

The evaluation of the desired social effects requires an analysis of tasks, dividing each goal into tiny components which increase the likelihood of success during training and in the generalization of the skills learned into daily life. Occupational therapists have the necessary information to carry out the analysis of activities and their role is essential in SST programmes for people with SZ using VR.

Key findings

Virtual reality is a promising method to complement traditional social skills training.

Virtual reality could improve the generalization of the skills learned into daily life.

What the study has added

As virtual reality progresses, occupational therapists must keep up to date with these developments and could use it to improve skills training.

Research ethics

Approved by the School of Health Ethics Committee: CE0040 A/2020.

Footnotes

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship and/or publication of this article.

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This work was supported by Fundação para a Ciência e Tecnologia (FCT) through R&D Units funding (UIDB/05210/2020).

ORCID iD

Raquel Simões de Almeida

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