Virtual Reality for People With Schizophrenia
By Patricia A. Huber-Villano, LCSW
Social Work Today
Vol. 23 No. 4 P. 20

Improving Psychosocial Rehabilitation Through the Use of Virtual Reality and Supportive Therapeutic Relationships

Virtual reality (VR) is a three-dimensional computer-generated environment that can be explored and interacted with by a person. Unlike traditional 2D displays, VR uses 3D computer graphics to generate an immersive virtual world. Current psychosocial rehabilitation (PSR) interventions for individuals with schizophrenia are offered within conventional clinical settings. Though valuable, the skills acquired in a clinical setting may not transfer to a real-world environment outside the clinic.1

A clinical setting cannot fully replicate the nuances of real-world environments. Using VR technology, individuals can practice task performance in familiar situations. VR may allow skills to be more generalizable to real-world problems while maintaining the safety of the clinical setting.

Several VR applications are utilized for the treatment of schizophrenia. The Multimodal Adaptive Social Intervention in Virtual Reality (MASI-VR) enhances social skills and engages participants in a low-stress environment.2 MASI-VR promotes social skill acquisition by requiring participants to engage with avatars. Tasks include making eye contact and paying close attention to facial expressions and body language across three different environments: a bus stop, a store, and a cafeteria. Participants are encouraged to start conversations with unfamiliar people to request or ask for information. Participants can work through different missions and scenarios to improve their skill-building and social awareness.

The Virtual Supermarket Shopping Task program simulates a shopping activity where participants have to memorize and collect items from a virtual supermarket.3 Simulating a grocery shopping experience allows participants to practice shopping skills and reduce the fear associated with this activity. Practice and mastery of this activity of daily living facilitates the transfer of skills from VR to real-life scenarios.

VR job interviewing training (VR-JIT) is an application introduced to provide participants with disabilities the opportunity to repeatedly practice job interviews in a risk-free environment.4,5 The avatar “Molly Porter,” a human resource manager at a large department store, asks questions about skills and experiences. Molly is customizable, with 1,200 possible question options to tailor each interview based on needs, skill levels, and responses. VR-JIT provides three levels of difficulty that can help participants identify their strengths and areas for improvement. The flexibility of VRJIT allows them to focus their efforts on the areas where they need the most improvement. MASI-VR, the Virtual Supermarket Shopping Task, and VRJIT are all customizable to meet participants’ individualized goals.

VR effectively treats schizophrenia and provides an immersive, lifelike environment to explore without any severe side effects.6 It demonstrates improved self-esteem, reduces isolation, and provides control over the environment through purposeful interactions with objects in the virtual world. PSR VR interventions, such as MASI-VR and VR-JIT, enhance the development of transferable skills to multiple life domains. Interventions are adaptable by practitioners and provide a more immersive and engaging experience for users to develop life skills to overcome their mental health barriers.

Definition and Prevalence of Schizophrenia
Schizophrenia is a chronic psychiatric illness that affects approximately 1% of the world’s population. Losing contact with reality and an inability to reason characterizes the disease. The signs and symptoms of schizophrenia are positive, negative, and cognitive. Positive symptoms are psychotic behaviors that are not present in healthy people, such as delusions or hallucinations. Symptoms can also include incoherent or nonsense speech and behavior that is inappropriate for the situation. Negative symptoms are behaviors that represent a decline in normal functioning, such as apathy or withdrawal from social interactions. Cognitive symptoms include trouble with memory, attention span, problem-solving ability, and organization.3 These symptoms interfere with the ability to learn practical social skills, cope with stress, and fully engage with life, leading to isolation and social withdrawal.

Treatment Options to Reduce Symptoms of Schizophrenia
Typically, the first line of treatment for schizophrenia consists of medical intervention. Andrade et al7 recognize that “More than half a century after the introduction of effective pharmacotherapy for the illness, in most patients, schizophrenia remains a chronic, relapsing condition with poor long-term outcomes.” Medication does not fully improve symptoms, indicating the need for additional alternative interventions to promote sustained recovery. Between the late 1960s to 1980s, the deinstitutionalization process moved individuals affected with schizophrenia from the state hospitals to the community, which broadened the need for psychiatric rehabilitation (PR) skills to reintegrate individuals into their families, workplaces, and general society.8 Studies have demonstrated that PR interventions effectively reduce positive, negative, and cognitive symptoms in individuals with schizophrenia. Evidence-based PR interventions include PSR skill development, such as social skills training (SST), instrumental role skills (IRS), and individual placement and support (IPS) for employment.

Recovery Is More Than Symptom Management
Recovery is not strictly about managing psychiatric symptoms. It’s about personal growth, development, and an ongoing process of learning how to live with a mental illness. Recovery is personal and individual. Recovery is defined as “an attitude, a stance, and a way of approaching the day’s challenges. It is not a perfectly linear journey. Each person’s journey is unique.”9 Recovery from chronic mental illness such as schizophrenia requires multiple interventions that address the psychosocial components of learning how to navigate daily life challenges. Fairburn et al9 states, “The experience of mental health recovery occurs through multiple pathways; community integration, social support, and personal and clinical recovery.” Bridging the gap between clinical recovery and community living is essential to recovery. Social support and a shared relationship foster a successful transition from recovery to community living.10 Social support is necessary to provide a sense of belonging, self-worth, and recognition. Resources and practitioners should be coordinated, integrated, and recovery-oriented to optimize the rehabilitative process,11,12 thus improving recovery outcomes. VR can promote the skill development necessary for successful reintegration into the community.

PR Key Components
PR has moved from the traditional illness management of symptoms toward a model of reducing functional impairment and reengagement with the community. PR aims to help individuals develop the emotional, social, and intellectual skills needed to function in the four rehabilitation domains: living, learning, working, and socializing in the community with the least amount of professional support.12 Treatment outcomes, rather than symptom management, are more critical to recovery. PR improves outcomes such as decreased rates and durations of inpatient hospitalizations,13 increased community inclusion,8 and improved vocational outcomes.14 PR focuses on individual strengths. Vita and Barlati11 state, “PR offers structured PSR interventions, defined by approved procedures and accurate assessment tools, with clear targets, to achieve specific outcomes” for individuals with severe and chronic mental illness.

Psychosocial Interventions to Promote Recovery
Individuals with schizophrenia have difficulties identifying, understanding, and describing their emotional states, which can significantly impact positive social outcomes.15 SST increases socialization among patients and leads to greater satisfaction with life. SST is a type of skill-building that aims to help people with difficulties in social interactions. It utilizes behavior therapy principles and techniques, teaching individuals to communicate their emotions and requests socially. The skills taught include social perception, processing of social information, responding or sending skills, connection skills, IRS, interactional skills, and behavior governed by social norms.16 SST interventions include problem identification, goal setting, positive and corrective feedback, social modeling, and behavioral feedback.16 Living independently in the community requires a particular set of learned skills. IRS, or task development training,3 focuses on the development of activities of daily living. These include building skills to navigate a grocery store, rent and manage an apartment, and work successfully on a job.

IPS is a critical psychosocial model for employment. Approximately 60% of individuals receiving mental health services want to work and may actively seek employment.4 They have lost jobs due to illness or disability or because their employer does not accommodate their needs. They may be unemployed or underemployed due to difficulties in finding or maintaining employment owing to symptoms related to their condition. They may be unable (or unwilling) to work without adequate support.4 IPS incorporates eight fundamental principles: focus on competitive employment, job development, rapid job search, integrated services, benefits planning, zero exclusion, time-unlimited support, and worker preference.5,17 Employment provides a sense of purpose, self-esteem, and hope for the future. It increases prosocial behavior, builds natural social support, and offers reintegration into the community. SST, IRS, and IPS are effective in community integration, developing social support, and recovery for individuals with schizophrenia. PSR interventions are customizable, and person-centered approaches focus on goal attainment. Practitioners by creating real-life simulations help individuals practice skill development and mastery based on their strengths and deficits. Safe and controlled spaces explore complex social situations and emotions. The VR environment allows clients to gain a new perspective on their experiences and allows the opportunity for growth and corrective feedback.

VR Promotes Gainful Employment
Using VR to treat schizophrenia allows for effective and brief interventions without psychotropic medication and corresponding side effects. It’s highly customizable to the individual and can represent social environments that trigger responses, reactions, and emotions equivalent to a real-world context.6 Research has demonstrated that VR improves memory, attention, and planning and increases overall cognitive functioning.1 There are marked improvements in conversational skills, assertiveness, emotional expression skills, and negative symptoms such as paranoia, stress, and suspiciousness following VR SST interventions.1,6,18 VR fosters tailored and personalized interventions and encourages active engagement in the recovery process.

Employment is a critical factor in recovery from mental illness and provides a purpose, meaning, and a sense of community connection. The social deficits experienced by an individual with schizophrenia may interfere with successful navigation of the job market and workplace because the individuals may not understand social cues or pick up on subtle hints, which can lead to misunderstandings in conversation or at work. VR-JIT allows individuals to engage in repeated interviewing trials with a virtual human resource representative.4

The VR environment is motivating15 and safe,19 and the interview can be tailored and customized based on skill level and responses. An individual can master skills while utilizing the VR environment for job-related tasks. Mastering skills builds confidence to continue in the employment process. Learned skills are then easily transferable to a real-world job interview. Individuals utilizing the VR-JIT can simulate different job environments replicating worker job preferences. Preference is an essential component of the IPS model. Using VR interventions increases the likelihood of engaging in job interviews and receiving job offers.5 Successful employment creates a sense of meaning and community inclusion and promotes sustained recovery. VR interventions are as effective as face-to-face treatments when accompanied by a cooperative shared relationship with a practitioner.9

Shared Relationships Are Vital to Recovery
Jaiswal et al20 identify the essential factors for recovery: developing purpose, meaning, participation in the community, and relationships. Obtaining employment is one mechanism for reintegrating into the community. Other factors include developing hope, resilience, self-efficacy, social support, and empowerment. Employment can foster recovery; however, the cooperative therapeutic relationship is equally vital. Cooperative therapeutic relationships are essential in affecting change and the recovery process. Jaiswal and colleagues20 and Sanches and colleagues21 discovered that bilateral relationships with practitioners are more facilitative of recovery than are specific treatment interventions. An attitude of equality, acceptance, empathy, and genuineness characterizes shared therapeutic relationships. Studies have emphasized the role of the shared relationship in kindling and sustaining hope as one of the significant factors contributing to full recovery from severe mental illness.22 Opportunities to interact with others, develop social skills, and reduce isolation through building social networks are core mechanisms of recovery. A sense of belonging to the larger community, security, acceptance, and connection to others fosters a feeling that one is a part of a stigma-free community and improves the overall quality of life.20,23

Recovery-oriented practitioners can establish an effective shared relationship by helping the individual effectively navigate the complexities of the recovery process. Practitioners can help the individual understand the strengths of PSR VR in symptom management and life role attainment. The success of rehabilitation efforts is not solely dependent on a shared relationship between the client and practitioner. Discussing and agreeing on goals with individuals is crucial for achieving successful outcomes. Investing in supporting clients in achieving their rehabilitation goals directly impacts their quality of life.21Recovery plans may involve creating virtual environments designed to simulate real-life situations that trigger symptoms while practicing coping skills and other strategies for managing illness. Practitioners can adjust the PSR VR recovery plan to the individual as needed to ensure that it is person-centered and relevant. A recovery-oriented practitioner must have the willingness and ability to shape services and elicit feedback to effectively meet the needs and preferences of each individual.22 VR interventions supported by a practitioner are more effective than unsupported VR interventions in treating schizophrenia.9 Supported VR allows for establishing a shared therapeutic relationship, discussions of individual preferences, and personalized treatment planning, which are essential components of evidence-based practices for schizophrenia recovery.

Conclusion
PSR VR interventions lead to developing essential social skills, IRS, and employment skills necessary to promote recovery for individuals with schizophrenia. The advantages of VR include flexibility, controllability, and an extensive repertoire of stimuli while remaining low burden, cost efficient, and safe for individuals with schizophrenia. VR interventions are adaptable, can be practiced in multiple contexts, and can be generalized to real-world applications.2 The recovery facilitated by supportive shared relationships and person-centered services leads to increased happiness, overall wellness recovery, and quality of life.23 Technology must not replace the shared therapeutic relationship with practitioners but rather become a complement and a facilitating element to improve attention and human connection.24 The relationship combined with VR interventions leads to improved social skills, improved activities of daily living, and employment outcomes, all of which are crucial to a sustained recovery from schizophrenia
and attainment of life role goals.

Implications for Practice
VR has the potential to be a valuable tool for PSR for individuals with schizophrenia, as it can allow them to engage in immersive and interactive experiences that may not be possible in the real world. By using VR, rehabilitation practitioners can provide individuals with opportunities to practice social skills, build confidence, and improve their ability to interact with others in a variety of social settings. Additionally, it can be used to expose individuals to new environments and experiences, which can help increase their sense of community inclusion and reduce feelings of isolation. Overall, the use of VR as a supplement to traditional PSR interventions can be a promising approach for improving the well-being and social functioning of individuals with schizophrenia.

— Patricia A. Huber-Villano, LCSW, is a licensed clinical social worker in New York and a DSW student at the University of Buffalo. She has practiced community mental health for 24 years and has designed and implemented recovery-oriented psychiatric rehabilitation programs utilizing psychosocial rehabilitation interventions that serve adults ages 18+ diagnosed with severe mental illness and substance use. Huber-Villano operates an entirely virtual psychotherapy practice for children and adults and utilizes psychiatric rehabilitation and supported technology.

Acknowledgment
A special thanks to Melanie Sage, PhD, and Catlin Denis, LCSW, RYT, for feedback and support.

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