Review

British Journal of Occupational Therapy

2021, Vol. 0(0) 1–11
Virtual reality in social skills training programs for © The Author(s) 2021
Article reuse guidelines:
people with schizophrenia: A systematic review sagepub.com/journals-permissions
DOI: 10.1177/03080226211011391
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Catarina Oliveira, Raquel Simões de Almeida , António Marques

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
Received: 28 September 2020; accepted: 31 March 2021

Introduction of the emotional climate in the family. It also allows people

Around the world, about 20 million people have been di-
agnosed 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 con-
versation and, consequently, has a salutary impact on the level
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). Occu-
pational 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
Center for Rehabilitation Research - Psychosocial Rehabilitation
Laboratory, Department of Occupational Therapy, School of Health of
P.PORTO, Porto, Portugal
Corresponding author:
António Marques, Center for Rehabilitation Research - Psychosocial
Rehabilitation Laboratory, Department of Occupational Therapy, School of
Health of P.PORTO, Rua Dr. António Bernardino de Almeida, 400, Porto
4200-072, Portugal.
Email: ajmarques@ess.ipp.pt
2 British Journal of Occupational Therapy 0(0)
practical self-care, domestic skills, work skills, leisure ac-
tivities, 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’ per-
formance increased during the intervention periods and that
as their adaptive response improved, the psychotic charac-
teristics 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 psy-
chological 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 prom-
ising 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, in-
dividuals 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 envi-
ronment for making social mistakes, without the anxiety or
fear of rejection commonly associated with face-to-face so-
cial 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 oc-
currence 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 Re-
views 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 ab-
stracts were reviewed by two independent researchers and, in
case of doubt about the inclusion of the study only by its
Oliveira et al.
Figure 1. Preferred reporting items for systematic reviews and meta-analyses(PRISMA) flowchart of the selection process.
abstract, an evaluation of the complete article was made. For
studies that met the eligibility criteria, the full text was re-
vised. A data-charting form was developed to determine
which variables to extract and Figure 1 outlines the study
selection process. Bibliographic information, design, pur-
pose, participants, measures, interventions, VR technology
and key findings were collected and summarized in Table 1.
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)
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 occupa-
tional therapy professionals trained in mental health, with
a minimum experience of 5 years, working in institutions/
3
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 partic-
ipants (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 per-
mission 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
 4
Table 1. Studies included in the systematic review.
Reference|
country Purpose Design Measures Participants Intervention VR technology Key findings

(Adery et al., Design and implement Longitudinal - National adult reading - n = 16; - 10 sessions; - MASI-VR; High levels of overall
2018) a potentially effective, study test, revised; - Individuals from the - Twice a week; -Non-immersive; satisfaction with MASI-VR;
United high-compliance VR - Wechsler abbreviated community who met - MASI-VR sessions: -Video game; - Improving the severity of
States SST game for scale of intelligence; the DSM-5 criteria for Participants complete 12 -Social parameters and social general psychiatric
individuals with SZ by - Brief psychiatric rating SZ. social “missions” four interaction could be repeatedly symptoms;
capitalizing on/ scale; easy, four medium and explored and systematically - Decreased severity of
technological - Scale assessment negative four hard missions altered to avoid habituation; negative symptoms;
innovations in adaptive, symptoms; sequentially at each - Three different social contexts (bus - No significant changes in
non-immersive VR - Scale assessment positive training session. stop, shop, and cafeteria); SFS. As the SFS inquiries
technology. symptoms; -Exercise starting a conversation about the prior 3 months,
- Social function scale. with an unfamiliar person to no change was expected
make requests or ask for during the duration of the
information; intervention. However,
- Real-time feedback was provided follow-up testing may
to the participant after each reveal more significant
response was made. improvements;
(Rus-calafell The main purpose of the Longitudinal - Positive and negative - n=12. - 16 sessions; Soskitrain: Consists of seven - Improvement
et al., present study was to study symptoms scale; All patients with SZ or - Individual; activities based on the seven psychopathological,
2014) explore the - Assertion inventory; schizoaffective - Twice a week; target behaviours; maintained at follow-up;
Spain effectiveness and utility -Simulated social disorder were - Each session lasts 60 min: - Practice social interactions with - Decreased social anxiety and
of a VR programme as interaction test; clinically stable and The first 30 min to discuss virtual avatars; these changes were
an adjunct tool to - Social avoidance and had not been the content of the SST - Progressive learning; maintained at follow-up;
deliver an individual distress scale; hospitalized at intervention and the - The therapist can observe the - Improvements in social
SST intervention. - Social function scale; a psychiatric remained to practice with patient’s real-time functioning. Gains were
- Committed errors; institution within the the VR programme. manifestations, modify and maintained at follow-up;
- Assertive behaviours; past 6 months. manipulate environments and - High level of satisfaction
- Time spent in characters according to the user’s concerning the perceived
a conversation; responses and stop the intervention’s benefits;
- VR acceptance interactions whenever is - The use of the VR programme
assessment. necessary to discuss a single contributed to the
situation and its implications; generalization of new skills
- The programme provides into the patient’s everyday
information concerning functioning.
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.

(continued)
British Journal of Occupational Therapy 0(0)
Table 1. Continued.
Oliveira et al.

Reference|
country Purpose Design Measures Participants Intervention VR technology Key findings

(Park et al., This study aimed to find Randomized - Social behaviour scale;
2011) advantages of the use of controlled - Rathus assertiveness
Republic VR in social trial schedule;
of Korea rehabilitation for - Short version of the social
patients with problem-solving
schizophrenia inventory revised;
- Motivation and
generalization
questionnaire.
(Rus- Calafell The present study aims to Longitudinal - Screen for cognitive - n = 12;
et al., evaluate the study impairment in psychiatry; - Clinically stabilized
2013) relationship between - Continuous performance
Spain patients’ cognitive test;
deficits, their sense of -Questionnaire regarding
presence and their their experience with the
ratings of the VR programme:
programmeme’s - SUS questionnaire (for the
acceptability. 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 = 64; - 10 sessions for 5 weeks;
- Ages of 18 and 45 years - Group (4 or 5 members);
old. - 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;
- 16, one-on-one sessions,
conducted twice weekly
outpatients with over 8 weeks;
a diagnosis of either - Approximately 60 min: The
SZ or schizoaffective first 30 min to discuss the
disorder. content of the SST
intervention and the
remainder to practice
with the VR programme.
- 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. - The VR application has an
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.
- No changes in psychiatric
symptoms;
- Improvement of social skills
(non-verbal skills), but the
SSTs-TR shows better results
in nonverbal skills;
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.
- 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.

(continued)
5
 6

Table 1. Continued.
Reference|
country Purpose Design Measures Participants Intervention VR technology Key findings
(Rus- Calafell - Help people with SZ to - Case study. - Three targets behaviours: - The participant was - 4 baseline sessions, 16 -Practice behaviours in simulated - Changes in the three target
et al., overcome everyday Facial emotion a 30-year-old woman treatment sessions and 4 environments representing daily behaviours;
2012) social difficulties via the recognition, assertive with a well- follow-up sessions situations, such as going to the - Significant differences for
Spain use of new behaviours and time established diagnosis 3 months after the end of supermarket, dealing with an facial emotion recognition;
technologies. spent on conversation of SZ; the treatment; angry security guard in - Increase in the frequency of
(measured by a VR - At the time of - First stage: Facial emotion a museum or trying to negotiate assertive behaviours, the
conversation activity); recruitment, she was recognition and social with a manipulative friend over time spent on the
- Positive and negative in a stabilized period information processing; who would drive a car to a party. conversation and social
symptoms scale; (>6 months). - Second stage: The functioning specifically to
- Social function scale; therapist and the patient interpersonal
- Social anxiety and distress dealt with social anxiety communication;
scale. and interpersonal - Decrease in negative
interactions; symptomatology, general
- Lastly: Communication and psychopathology, social
conversational skills. 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.
British Journal of Occupational Therapy 0(0)
Oliveira et al. 7

Table 2. Summary of results.

Study 1 Study 2

Structure Twice a week; Holistic, integrated, multidisciplinary, systemic and two-

For five to 8 weeks; dimensional view;
Duration 60–90 min; Learning tasks, reinforcement techniques and modelling in line
Division of intervention time into different intervals; with a cognitive-behavioural approach;
Follow-up; VR as a complement to traditional training;
Homework. Individual and group sessions;
Preparation for using VR.
VR software Immersive VR technology; Neurofeedback;
‘Social missions’ in different contexts; Body swap;
Progressive learning; Simulation of everyday situations; gamification logic, multilevel.
Feedback after each choice/answer.
Target skills Conversation and communication skills; Identification of social rules;
Assertiveness skills; Recognition of socially accepted behaviours;
Emotional expression skills; Creation of strategies to mediate the relationship with each other
Facial emotion recognition; in a way satisfactory to both parties.
Social information processing;
Starting a conversation to place orders or ask for information;
Social perception;
Responding and sending skills;
Affiliative skills;
Instrumental role skills.
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 Motivation;
skills and assertive behaviours); Flexible profile;
Improvement of psychiatric symptoms; Facilitates the generalization of skills worked on.
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.
VR: virtual reality; SS: social skills; SZ: schizophrenia

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 re-
ported in half of the studies reviewed, with two studies re-
porting 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 inter-
actions, and in the last period, communication and conver-
sation 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 me-
dium 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.
8 British Journal of Occupational Therapy 0(0)
Figure 2. Risk of bias ratings.
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 pro-
gramme. 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.
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, in-
tegrated, 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, re-
inforcing what is well done, using reinforcement and be-
havioural 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 tra-
ditional 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 im-
portant. “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 them-
selves regarding the use of VR with people with schizo-
phrenia. 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”.
Oliveira et al.
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, “Moti-
vating, 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 pro-
gressive learning using reinforcement and modelling tech-
niques. 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 sub-
system 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 oc-
cupational 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 con-
centration 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 in-
tervention can also be carried out in an individual format
9
(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 tra-
ditional 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 tech-
nology gives feedback on choices/responses allows the
person to readjust their behaviour and facilitates the
identification of target behaviours. As VR provides a pro-
tected, 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 ac-
cepted 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 con-
versation 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
10
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 opportu-
nity, 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 im-
provements 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 hu-
mans 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 un-
derstand their difficulties and needs. Having carried out
a greater number of focus groups and having included a more
British Journal of Occupational Therapy 0(0)
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 comple-
ment 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.
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  https://orcid.org/0000-0003-4703-1712
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