Enhancing Social Functioning using Multi-user, Immersive Virtual Reality

doi:10.21203/rs.3.rs-4707220/v1

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Enhancing Social Functioning using Multi-user, Immersive Virtual Reality

https://doi.org/10.21203/rs.3.rs-4707220/v1

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Background

Rates of loneliness and other forms of social disconnection have been increasing worldwide over the past decade. Prior studies have suggested that brief behavioral interventions can impact this problem but, currently, access to such interventions is very limited. One previously untested approach for addressing this gap is immersive, multi-user virtual reality (VR).

Methods

To measure the feasibility and preliminary efficacy of this approach, 33 young adults experiencing social discomfort were enrolled in a study of an immersive, multi-user VR behavioral intervention called Reconnecting with Ourselves and Others in virtual Meetings (ROOM), which was adapted from a previously validated, mindfulness-based intervention. Quantitative measures of aspects of social functioning, including social comfort, interpersonal distance and facial affect recognition, were collected before and after participants completed ROOM.

Results

All of the participants attended more than half of the sessions and 90.3% found ROOM to be beneficial and useful. In addition, comfort with others in the real world (p = .02) and facial affect recognition accuracy (p = .02) significantly increased, while interpersonal distances remained unchanged, following ROOM.

Conclusions

An immersive, multi-user VR, mindfulness-based intervention may represent one feasible, scalable approach for disseminating skills that can improve social functioning and connection.

Clinicaltrial.org # NCT06360562

Brief psychotherapeutic interventions focused on introducing skills that can improve emotion regulation and social functioning may have a protective function, in that they may “inoculate” individuals, protecting them from the effects of stress that could lead to a deterioration in mental health. Although interventions with this goal have been developed and tested^1–3, none have been widely adopted. This is likely due to a number of factors, including the limited availability and access to such interventions and widespread shortage in trained behavioral health clinicians⁴.

However, recent developments in virtual modes of mental health care have provided new potential avenues for disseminating these types of potentially preventive programs. This virtual care model has emerged in the context of a society-wide increase in the reliance, accelerated by the COVID-19 pandemic, on virtual or digital means for communication and social interactions, including a rapid expansion of the use of applications based on virtual reality (VR) technology⁵. VR has notably gained in popularity and become more accessible in recent years, with VR headsets becoming more affordable for the general public and increasingly adopted as a clinical tool in healthcare⁶.

VR has been used for a number of clinical purposes in multiple patient populations, with many applications used in rehabilitation programs for improving physical movement or promoting relaxation^7,8 or treating chronic pain⁹. Many of these VR applications have shown efficacy, which may be in part linked to the highly engaging, attention-capturing nature of VR experiences¹⁰. VR has also been employed as a therapeutic tool for the treatment of psychiatric conditions such as anxiety, substance use, post-traumatic stress and eating disorders^11,12 and has been frequently used to implement in-vivo exposure therapy to treat these conditions¹³. These applications typically consist of an individual patient having a VR experience alone, sometimes while interacting with a clinician who is physically nearby, outside of the VR experience.

However, VR technology has now evolved such that several users can enter and interact with each other within a shared virtual space (in a “multi-user” environment). Multi-user VR can offer an engaging, gamified, and attention-capturing meeting environment for participants. These types of virtual meeting spaces have been used for a range of purposes, such as weight loss support groups¹⁴, business meetings, and multidisciplinary medical team meetings, with users reporting that they are easy to use and decrease external distractions, allowing users to focus fully on the VR experience^15,16. Multi-user VR has also been used with clinical populations such as stroke survivors to conduct rehabilitation and reduce isolation¹⁷.

In these initial applications, multi-user VR has been associated with a greater sense of being with others, with participants experiencing a greater “social presence” when meeting in immersive VR, when compared to other forms of virtual group interaction (e.g., videoconferencing)¹⁸. This more authentic feeling of being with others may be particularly important for individuals experiencing various forms of psychopathology, especially for young people who may be at risk for developing a psychiatric illness. It has been established that healthy social relationships in adolescence and young adulthood is protective for mental health¹⁹. Thus, developing interventions that promote a sense of connection and provide a platform for learning relationship-building skills may be particularly important during this period of time in society that is characterized by increased levels of social fragmentation, loneliness and isolation²⁰.

Multi-user VR can also provide a sense of anonymity and a higher level of confidentiality, because participants are represented as avatars during the interventions and can join and participate in sessions from any location. Thus, the delivery of group-based mental health care via multi-user VR could be particularly useful for high-risk populations who experience a range of barriers to receiving mental health services and may be influenced by the stigma associated with receiving such services. Although patients with depression have expressed openness to trying multi-user VR group therapy because of the anonymity afforded by participating as avatars,²¹ to our knowledge, no peer-reviewed published studies have tested the use of multi-user group therapy to date.

Based on this literature, in the current study we adapted a previously validated brief, group-based intervention called Resilience Training (RT)^22–24 for delivery via a multi-user, virtual reality application customized for the intervention. RT focuses on teaching three evidence-based skills, mindfulness, self-compassion and mentalization, using didactic material, experiential exercises, and discussions^25–27. In prior studies, RT has been shown to increase resilience-related capacities, reduce levels of symptoms of psychopathology and loneliness, and improve social functioning in young adults (college students) with mild symptoms of psychopathology^22–24.

Thus, given the advantages of multi-user VR, we developed a VR version of RT, called “Reconnecting with Ourselves and Others in virtual Meetings” (ROOM), and assessed its feasibility and acceptability in college students who were not currently receiving any mental health care. Because multi-user VR simulates the experience of being in the same space as others, and RT aims to improve social functioning, we also explored the effects of the intervention on participants’ level of comfort being with others in their real lives and two related types of implicit, objective measures of social functioning: 1) interpersonal distance preferences²⁸ and 2) facial affect recognition accuracy²⁹. Thus, the primary aim of this study was to test the feasibility and acceptability of the ROOM application using a single-armed design, with a secondary goal of assessing potential effects of ROOM on measures of social functioning.

Participants

This study enrolled 33 participants (see Table 1), who were recruited through mental health surveys that were disseminated via email or in-person to students enrolled in one of four undergraduate institutions (one community college and three private institutions) in the Boston area, as in prior studies^22,23. The survey collected demographic information (age, sex, year in college, and any history of psychiatric diagnoses or treatment) as well as standardized, well-validated mental health assessments. Participants who completed the survey (n = 884) were asked if they would be interested in potentially participating in a VR-based workshop that focuses on learning resilience-enhancing skills.

Table 1

Participant Clinical and Demographic Characteristics (n = 33)
Characteristic	M
Age		20.91		2.51
Mean Parental Education (years)		14.07		4.21
Years of School Completed by Participant		13.55		2.69
	N		%
Sex Male		10		30.3
Female		23		69.7
Ethnicity
Hispanic or Latinx		6		18.2
Not Hispanic or Latinx		27		81.8
Race
Asian		11		33.3
Black or African American		4		12.1
White		14		42.4
Other		3		10.0
Born in the United States		23		69.7
Sexual Orientation
Bisexual		8		24.2
Heterosexual/Straight		14		46.6
Gay/Lesbian		4		12.1
Other		4		12.1
Pansexual		1		3.0
Prefer not to say		1		3.0

Note: A total of 36.7% (n = 11) of the participants met DSM-V criteria for a psychiatric diagnosis, including major depressive disorder (n = 5), generalized anxiety disorder (n = 2), panic disorder with agoraphobia (n = 2), social anxiety disorder (n = 1), alcohol use disorder (n = 1), and anorexia nervosa (n = 1). Also, 12.1% (n = 4) of the participants were being treated with psychotropic medication (dextroamphetamine (n = 1), escitalopram (n = 1), fluoxetine (n = 1), and sertraline (n = 1) at the time of the study.

Those who indicated interest in this workshop were then contacted via email to assess further eligibility and interest. Potential participants were deemed eligible if they were: 1) at least 18 years old; 2) not currently receiving psychotherapy; and 3) endorsed some discomfort in the presence of others on a 6-level Likert scale (a score > 0, see below); see Supplementary Materials for additional details regarding recruitment. A total of 33 participants were enrolled in the study. Informed consent was obtained from all subjects and/or their legal guardian(s)

All procedures were approved by the Mass General Brigham Institutional Review Board (IRB) as well as the IRBs of each participating university or college and all research was performed in accordance with relevant guidelines/regulations, and in accordance with the Declaration of Helsinki. Each participant was sent a VR headset (Oculus Quest 1) by mail, which they used to complete one task-based assessment (see below) and to participate in the weekly ROOM sessions. Following completion of the ROOM workshop and the post-intervention assessment, participants mailed their headsets back to the research team, or if on campus, study staff picked up the headset from the participant.

Assessments

During the baseline assessment only, all participants underwent a diagnostic assessment using the Mini International Neuropsychiatric Interview (MINI)³⁰. The MINI was used to assess whether any psychiatric diagnoses were present, as well as previous and current treatment and medication usage.

Outcomes

Feasibility and acceptability

Feasibility and acceptability were measured using participant attendance and both quantitative and qualitative feedback data collected after completion of ROOM. The feedback form included Likert scale ratings of benefit, usefulness, and whether they would recommend the program to a friend. Also, brief semi-structured qualitative interviews were completed following the intervention to assess the degree of benefit and satisfaction with the program experienced by participants, ease of participation and use of the VR app, and any suggestions for changes.

Social discomfort and social cognition assessments

Discomfort with others: Discomfort in the presence of others was assessed using one item rated on a 6-level Likert scale, asking each participant to rate the statement “I am uncomfortable being in the physical presence of others”, from “not at all” to “most of the time, every day”. This question was followed by a multiple-choice item that listed five possible reasons for the discomfort, including: “I generally don’t enjoy being around others”; “I’m generally concerned about what others think of me”; “I’m worried about COVID-19 (becoming infected or infecting someone else)”; “I don’t know why”, and “other reason”.

Personal space: Personal space (also commonly referred to as interpersonal distance) is the space around the body into which another person cannot enter without arousing discomfort³¹. Prior studies have found that personal space preferences are linked to aspects of social functioning and comfort with others^32,33, i.e., an enlarged personal space (lower comfort with the physical proximity of others) has been linked to social anxiety³⁴, loneliness³⁵, and social anhedonia³⁶. Personal space size, as well as its “permeability”, the degree to which intrusions into personal space elicit arousal, can be measured reliably with the classic Stop Distance Procedure²⁸. A VR-adapted version of the Stop Distance Procedure (SDP), customized for use in the ROOM application, was used in this study to measure personal space size and permeability, at baseline and post-intervention. Previous research has found that personal space measured with respect to humans and to human-like avatars is highly correlated^37,38. The VR-adapted SDP procedure used in the current study consisted of a human-like avatar slowly walking towards the participant while standing in a virtual “hallway” (Fig. 1A). The participants were asked to press their controller to stop the avatar at two different times, first when the avatar is at a distance from the participant at which the participant would have a casual conversation with a stranger, second when the participant experienced discomfort with how close the avatar is standing to them (after their personal space boundary has been crossed). This procedure was conducted twice, with a male and female -appearing avatar.

Facial affect recognition: ROOM focuses on several skills that are critical for social functioning, including mentalization, the ability to flexibly represent and identify the mental states of others. Mentalization has been linked to lower-level, perceptual forms of understanding the mental states and emotions of others, including facial affect recognition^39,40. Thus, we measured facial affect recognition at baseline and post-intervention using the Penn Emotion Recognition Test (ER-40)²⁹, a 15-minute computer task which involves identifying the emotion (neutral, sad, happy, angry, or scared) expressed in 40 images of real human faces (actors), half of which are male and the other half female in appearance.

The ROOM Intervention

A previously validated 4-session intervention, Resilience Training^22–24, was adapted for use in this multi-user VR application called Reconnecting with Ourselves and Others in virtual Meetings (ROOM). When RT is delivered in-person, it consists of four 1.5-hour group sessions. In order to minimize the possibility of VR-related motion sickness or dizziness, which are more likely to occur with longer exposures to VR⁴¹, the sessions were shortened to one hour in ROOM, and the material of RT was delivered over 6 one-hour sessions.

All sessions were co-facilitated by two clinicians or a clinician and a trainee (a doctoral level psychologist, psychiatrist, or a doctoral student in clinical psychology). ROOM begins by introducing the concept of resilience and that it can be modified using resilience-enhancing skills, which will be taught in the workshop via didactic materials and experiential exercises. The three skills covered during the sessions are: mindfulness, self-compassion, and mentalization^25–27. Sessions focus first on understanding the skill, learning how it is beneficial, then practicing how to use it with other participants through experiential exercises during the session, as well as during home practice exercises (see Table 2 for an outline of the sessions).

Table 2

ROOM Outline
Session Title (6 sessions)	Session Description
1. Introduction to Resilience	- Introduce the concept of resilience and its promotors and detractors - Introduce mindful breathing activity
2. Mindfulness	- Introduce and discuss mindfulness - Practice mindful sensory activity
3. Self-Compassion	- Introduce and discuss self-compassion - Practice self-compassion break
4. Mentalization	- Introduce and discuss mentalization - Practice mentalization activity: flexible thinking
5. Mentalization of Self	- Introduce and discuss mentalization of self - Practice mentalization activity examining self-criticism - Introduce resilience plan
6. Review and Real-Life Applications	- Reflect and discuss implementation of skills - Practice letter to self - End by reviewing resilience plans

The Multi-User Virtual Reality Application

Participants used the Oculus Quest 1 headset to enter the ROOM application remotely. They first underwent a brief training (approximately 5–10 minutes long) via Zoom with a person from the research team in the use of the VR headset and specifically the ROOM application. The majority of the participants needed no more than 5 minutes of training to report that they felt comfortable using the application.

Participants then entered the main menu of the ROOM app and designed their avatar, choosing the skin color, face type, body type, hair color and cut, clothing, and accessories such as glasses. Participants also chose the name that showed above their avatar throughout the ROOM sessions. During the sessions, they joined the virtual environment (appearing as the avatar that they designed) with the other participants and the two facilitators, who were also represented as avatars. In the immersive virtual environment of ROOM, participants sit in a virtual chair among other participants in a half circle (and can virtually reach out and “touch” the person next to them) and have the ability to move their head with a 360-degree view of their virtual surroundings. During sessions, participants can also view a virtual projector screen that displays slides that contain information about the concepts being taught. The slides are selected before the session and the facilitators advance the slides during the session.

The first three sessions of ROOM take place in a virtual outdoor park environment and the last three sessions are conducted in an environment that simulates an indoor college common area (see Fig. 1b). The outdoor park environment was designed to appear open and calming, with bushes to create privacy and a blue sky with clouds. The indoor environment includes couches, vending machines, flyers on the walls, backpacks, and pizza boxes to represent a college setting. Each of the two environments has 12 chairs arranged in a semi-circle; each participant has a full view of a screen showing the slides for each session. Throughout the six-sessions of ROOM, the inter-chair distance was decreased between sessions, to move the participants closer to one another, in order to gradually expose participants to being virtually closer to another individual. The virtual chairs were initially placed far apart (5.5 feet from the mid-point of the headset, with approximately 3.3 feet of space between the chairs during the first session). By the final session, the chairs were touching and the distance between the mid-point of the headsets was 2.79 feet.

Statistical Analyses

Quantitative Data

To examine feasibility and acceptability, frequencies were calculated for participant attendance and feedback ratings. To explore effects of ROOM on the self-report and task-based measures of social functioning, two-tailed paired t-tests were conducted using pre and post intervention scores.

Qualitative Feasibility and Acceptability Analyses

Qualitative feedback data was audio recorded and transcribed for coding. All initial coding of themes were conducted by two individual coders (one doctoral and one bachelor’s level research staff member). Once independently coded using line-by-line open coding, a grounded theory approach⁴² was used to obtain code categories by the doctoral level coder. Then all codes were reviewed by the second coder for consensus. Frequencies of code categories were also collected through the qualitative transcripts.

Feasibility and Acceptability

Of the 33 participants, 66.7% attended all six ROOM sessions, and 100% attended four or more of the six sessions. Participant ratings on the quantitative feedback forms indicated that 90.3% of participants found the intervention to be beneficial and useful, and 90.3% would recommend it to a friend. Examples of the subjective feedback about the ROOM intervention and the ROOM technology are presented in Table 3.

Table 3

Frequencies and Example Quotes Representing Commonly Endorsed Themes during the Qualitative Interview
Themes	n	Participant Quotes
Positive Feedback about the ROOM Intervention
Experiential Exercises	13	“I like some of the activities that we did during the workshop. I feel like they make the whole thing a little less stressful. And obviously these are very relaxing exercises. So, all of that just added to it.” -017 “I really liked doing, like, the guided breathing as a group. Really anything where we were just, like, doing guided exercises and, like, sitting back and just, like, listening. The guided mindfulness or yeah, just like the deep breathing stuff was fun.” -014
ROOM Skills	9	“I feel like learning new techniques through every class was really nice. We got to experience different techniques to handle our emotions every time, which was cool.” -020
Group Discussions	9	“I think my favorite part of the workshop was interacting with the other people participating. When it came time to discussing certain topics or going about their different takes or stories or perspectives.” -020
Ease of ROOM	4	“I think my favorite part was, I could say like the simplicity.” -019
Negative Feedback about the ROOM Intervention
Home practice	3	“Overall, it was positive. I would say as the homework like increased, that became like a stressor, which I'm sure was influenced by just my personal life getting busier and it being harder to manage that stuff. But yeah, it wasn't like offensively busy. It was just maybe like a nuisance sort of thing.” -014
Positive Feedback about the VR Modality
Novel/Fun Technology	11	“Well, I had never done virtual reality, so it was cool, like exploring it and trying it. So the fact that it was new to me was exciting.” -014 “VR is a novelty and super cool to experience.” -029
Convenience	7	“The fact that I could do it from home, I just need five minutes before, and then I'd be there. So that was strategic and accessible.” -017
Comforting Environments	6	“Very serene and mostly relaxing environments.” -029 “I thought that the rooms we were in were calming and, like, visually interesting and just visually comforting.” -014
Feeling Immersed and Connected with Others	5	“I felt really loved and supported throughout it. I felt very safe and secure. I felt like everyone in my group was very open to having this experience and let it be a positive thing for them.” -013 “I think instead of facing a screen, it feels like you're in a room with people, so you could look at someone who's talking, and it’s like more connected.” -022 “It felt like you're sitting in a room with the people you're in a meeting with.” -024
Similarities to Real Life	3	“I think it was a good copy of what the real-life experience would be.” -020 “They just seem fairly real despite being in VR. Like it felt like a place that I could actually go to.” -015
Negative Feedback about the VR Modality
Technical Difficulties	10	“I guess just like, technically, sometimes I get dropped from the app and then I'd have to come back and be like, I don't know what everyone else said.” -010
Discomfort from Headset	8	“The VR headset is really bulky and hurt my head to wear.” -028 “The strap is a bit uncomfortable and makes my face red around the area where the headset rested.” -039 “The headset could get pretty uncomfortable, but after a few sessions I figured out how to get it to fit just right.” -021
Eye Strain, Headache, or Dizziness	7	“It started out a little rough. The first few sessions came with a headache, but as the time progressed, it got easier and by the last session, I had no problems.” -035
Avatars’ Appearance	3	“It's just like, I don't know, the features [of the avatars] all seem very strange to me.” -019
Charging the Headset	2	“Because we have to go out of our way to make sure it's fully charged.” -019
Anonymity
Helped Increase Participation	27	“I like just doing the workshop in my own room and I feel like knowing that other people don't really know who I am made it easier to talk about, like to share some things during the workshop.” -021 “It felt a lot easier to share because, you know, it's just your name, nobody knows who you are and you're not really facing real people, so I thought that that was good. It seemed like we were all decently willing to share.” -018 “I was more willing to be open and quickly realized that openness is worth it.” -021
Enjoyed Absence of Physical Appearance	3	“I didn't necessarily have to show my face, like maybe on a particular day, like I wasn't feeling very well. And it was actually beneficial because then I would speak out more just because people can’t actually see me.” -010
Immersive Aspect	3	“It was very immersive and the physical aspect of putting on the headset helped me shift my mind away from what was going on in the day.” -021
Anonymity was Critical/ Appealing	2	“It wasn't the only reason I would ever join in a discussion, but I definitely liked it. I don't think I would have been as forthcoming without it, or even participated at all honestly.” -035 “I would most likely would not have participated without the anonymity.” -029 “Like, there's no way if I see some of these people in person that they'd know it was me unless we had like a full conversation about it, so I like that.” -017
Comparison to Other Delivery Modalities
Preferred VR to Zoom and In-Person	15	“On zoom, everyone has zoom fatigue. People will be tempted to turn off their camera and you can't feel like you're sitting in the same room as people. I liked how VR brought it into a 3D space. It's easier to participate when you feel like you are in a physical space. I definitely prefer VR over zoom.” -009 “I think Zoom or in-person would have made it worse since that anonymous variable would have been taken away. It's hard to talk about these things sometimes and face-to-face (in-person or virtual) can be stressful when going over some of these topics.” -035 “I would have participated if it was over Zoom or in-person, because personally I don't have a problem with it. But it definitely like added some comfort on days where I wasn't feeling very well or just like I wasn't into like seeing people in person.” -010 “I would imagine it's always difficult to share, but I believe that being in VR, it's makes it easier to share just given that unlike in Zoom or in-person, you don't actually see the real person other than their avatar and their names. But in general, yeah, VR is much more like an anonymous forum so it's easier to share.” -020
Prefer In-Person to VR or Zoom	7	“I would prefer this experience in-person. Based on my past experience on Zoom, it just doesn't work and also difficult when you want to participate in activities.” -039
Value Aspects of In-Person Interactions	5	“I think it's better to convey in-person. As it's easier for me to able to talk honest face-to-face.” -039 “In-person it would be more intimidating to start talking, but it might be more rewarding in the later sessions once you get accustomed to everything.” -021

On the quantitative (Likert ratings) survey, 58.1% of the participants reported that the anonymity aspect of ROOM was important or very important to them; in the qualitative survey, 87% stated that they would not have participated as much without the relative anonymity of ROOM. The majority of participants (80.6%) reported that they created a virtual avatar that look similar to their appearance, and 92.5% used their first name as the name of their avatar.

In addition, 77.4% of participants reported that they enjoyed the virtual reality component of the study, and 48% stated that they would prefer VR over in-person or Zoom delivery methods; 22.5% preferred Zoom or in-person over VR; and 29.5% of participants did not have a preference.

Approximately one third of participants (34.4%) reported that they experienced some technical difficulties when using the ROOM app. These included difficulties related to sound quality, hearing others (n = 2), or others hearing them (n = 4), and being disconnected from the app (n = 3). Also, 36% of the participants noted having at least one experience of dizziness or physical discomfort while in the ROOM app (however, all of these participants continued to participate in ROOM following these experiences). Reports of physical discomfort were related to the comfort of the headset, i.e., some describing it as heavy (n = 8). Two participants noted in their qualitative interviews that they felt dizzy or disoriented in the first session in the virtual environment, but this experience was diminished or resolved itself in subsequent sessions. Additional participant feedback is presented in Table 2.

Social Functioning Outcomes

Social discomfort and social cognition assessments. Among the ROOM participants, the most common reason for discomfort (n = 11; 33.3%) was not enjoying being around others; the second most common response was concern about what people think of them (n = 10; 30.3%), followed by a fear of Covid-19 infection (n = 7; 21.2%). The frequency of discomfort scores and reasons for discomfort were similar in the 33 participants of ROOM at baseline and the larger screened sample (see Supplementary Fig. 1).

Following ROOM, the degree of self-reported discomfort with others significantly decreased relative to baseline (t = 2.42, p = .022; Fig. 2A). There were no significant changes in personal space measures (all ps > .194; Supplementary Fig. 2) but there was a significant improvement in emotion recognition accuracy (t = -2.46, p = .020) following ROOM (Fig. 2B and Supplementary Fig. 3).

Here we found that a behavioral intervention focused on improving resilience and social functioning in an immersive, multi-user virtual reality environment was highly feasible and useful for participants. To our knowledge, this is the first multi-user virtual reality application tested for this purpose. Preliminary evidence was also found for beneficial effects of ROOM on aspects of social functioning, with improvements in the degree of comfort participants experienced with others in the real world. In addition, an objective measure of one aspect of social functioning, facial affect recognition, improved following the intervention. Overall, these results suggest that this multi-user immersive virtual reality application represents one novel and scalable approach for teaching evidence-based skills that have been shown to improve social functioning in prior studies.

The majority of participants reported that ROOM was beneficial and useful, that they liked the VR aspect of the program, and that they would recommend ROOM. These results are consistent with prior studies of VR-based behavioral applications which have generally found that participants rate them as enjoyable, engaging, and helpful^15,16.

Over half of the participants of this study reported that the anonymity aspect of this intervention in multi-user VR was an important or very important reason they chose to participate. Although most of the participants used their real first name or created an avatar that looked like them, 87% of participants reported in their qualitative interview that the anonymity aspect of ROOM made it much easier to participate in the sessions. Four participants emphasized the absence of any attention to their physical appearance as an appealing feature of the program, and some reported that they felt “less awkward” in VR compared to virtual modalities in which people could see them, e.g., Zoom. Others noted that the anonymity helped them feel “less judged” and “more open”. Thus, the anonymity afforded by VR could lead to greater levels of engagement and dissemination of mental health-promoting skills to populations who are currently less likely to participate in such programs, due to concerns about mental health-related stigma, or general discomfort with mental health-related topics.

Following ROOM, participants reported significant reductions in the subjective discomfort felt in the presence of others in their real lives. This finding suggests that this intervention delivered through VR may have real-world implications related to social discomfort. In other words, although participants learned skills in a virtual group setting that promote better social functioning (such as self-compassion and mentalization), these skills and the group experience may have translated into increasing their comfort during social interactions in the real world. This effect, if replicated, may represent an important beneficial aspect of ROOM, particularly in light of the increased rates of loneliness and social isolation that have been documented worldwide during the past decade⁴³. Prior studies have shown that loneliness is paradoxically linked, in some individuals, to a bias towards withdrawing socially from others, due to feelings of discomfort with others or fears of rejection⁴⁴. Thus, convincing such individuals to participate in a virtual group-based intervention in which they are exposed to being with others and learn skills that may ultimately enhance their social comfort may represent a strategy that “meets people where they are” – leveraging many isolated individuals’ greater comfort with virtual, as opposed to in-person, interactions.

In contrast to the findings with ratings of subjective comfort with others, an objective measure of discomfort with the physical proximity of others (interpersonal distance/personal space preferences) did not show any change following ROOM. This negative finding may be related to the fact that participants were not enrolled based on this characteristic (i.e., they generally exhibited “normal” personal space preferences) and were not psychiatrically ill. Additional research is needed to further understand the relationships among objective and subjective measures of comfort with others and to test whether ROOM leads to greater comfort in these domains in individuals with specific social functioning impairments or high levels of loneliness, which is associated with greater interpersonal distancing^35,45.

An overall increase in facial affect recognition accuracy was observed following ROOM. This may be unexpected given the brevity of the intervention and the fact that participants are not exposed to any real human facial expressions during ROOM, since the ROOM avatars have emotionally neutral facial expressions. However, an improved ability to recognize emotions in faces in the ROOM participants may have been a consequence of acquiring skills that increased their exposure and comfort with other people in the real world. One of the skills that ROOM teaches, mentalization, is the ability to represent the mental states of others, which is closely linked to the ability recognize facial emotion³⁹. Thus, ROOM may have indirectly led to improvements in facial emotion recognition. However, additional controlled research is needed to investigate this model further.

This study identified several advantages of using VR to deliver a mental health-promoting intervention. One key benefit, similar to other virtual modes of care delivery, is the increase in access; participants were able to join ROOM sessions from locations that were most convenient for them, including their dorm rooms or homes, and even while traveling.

Multi-user, immersive VR has been shown, in previous research, to provide a greater sense of being with others than other modalities such as Zoom and other video conferencing platforms¹⁸. Thus, this technology may provide individuals who experience some social discomfort or impairments related to social functioning an opportunity for exposure to simulated physical proximity to others in a safe and controlled setting. Individuals who experience discomfort or anxiety in the presence of other people may benefit from virtual interactions with a group of others, while simultaneously remaining in a familiar environment in reality. This is in contrast to most other virtual applications that either involve an individual interacting one-on-one with an avatar or with a two-dimensional image of a person on a screen.

Another benefit of this technology is that immersive VR is fully attention-capturing, which is dictated, by design, by the VR headset. Participants are unable to view external devices, such as their phones or computer screens, during the group sessions, leading to uninterrupted engagement in the session.

Approximately 35% of participants reported experiencing a technical difficulty during ROOM, although none discontinued the program as a result or were notably distressed by the issue they experienced. Another eight participants noted that the headset was uncomfortable (heavy) to wear, but again, did not drop out or report much distress related to this discomfort. The participants of this study used the Oculus Quest 1 headset (weight = 571 grams), which was widely available at the beginning of this study. More recently released headsets, such as the Oculus Quest 2 (503 grams), are noticeably lighter and more comfortable. Future work with ROOM will use these superior headsets and take advantage of other improvements in VR technology and accessibility.

The current mental health care workforce shortage⁴, accompanied by the widespread “mental health crisis” occurring in young people^46,47, suggest that the development and validation of a group-based, scalable, virtual mental-health promoting intervention could be timely. In the current study, the use of a multi-user, immersive VR platform permitted many individuals to receive a brief resilience-boosting intervention that was deemed helpful by 90.3% of the participants. Further studies of the longer-term outcomes and efficacy associated with ROOM, using a randomized controlled design, are needed to measure the impact of this intervention and its unique mode of delivery.

Data Availability Statement

The data that support the findings of this study are available by request to the corresponding author.

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No competing interests reported.

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Enhancing Social Functioning using Multi-user, Immersive Virtual Reality

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Abstract

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Introduction

Methods

Participants

Assessments

Outcomes

Feasibility and acceptability

Social discomfort and social cognition assessments

The ROOM Intervention

The Multi-User Virtual Reality Application

Statistical Analyses

Quantitative Data

Qualitative Feasibility and Acceptability Analyses

Results

Feasibility and Acceptability

Social Functioning Outcomes

Discussion

Declarations

References

Additional Declarations

Supplementary Files

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