Psychology student opinion of virtual reality as a tool to educate about schizophrenia.

VR techniques are being increasingly used in training and education generally (MacPherson & Keppell, 1998; Romano & Brna, 2001) and specifically within healthcare education (Riva & Gamberini, 2000). A project at the University of Queensland constructed a number of three-dimensional demonstration models of the phenomena seen in schizophrenia. Reproduced symptoms of schizophrenia included delusions, hallucinations and thought disorder. Auditory hallucinations were also included, consisting of voices ranging from muffled whispers to a cacophony of voices.

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Schizophrenia is a debilitating mental illness which affects 1 to 2% of the population at some point in their lives. Tragically, suicide is more common among sufferers of this illness, which often strikes people in their prime. At present, patients with schizophrenia have to describe their symptoms to their therapists and there is no objective way for therapists to evaluate these experiences. Therapists often find it extremely difficulty to learn about and fully understand this illness because they have no personal experience with it.

The teaching methods and/or tools currently being utilized to educate psychiatry and psychology students about schizophrenia and psychosis in many universities and training centers consist predominantly of abnormal psychology textbooks. The specific aim for many of these textbooks is to provide students with a clear understanding of the history, etiology and the various diagnostic classifications used for schizophrenia and psychosis. Research has acknowledged the importance of attempting to engage students to feel and to experience patients' symptoms at a more basic level and acknowledge the importance of student's "experiencing" an illness (Oltmanns and Emery, 2001; Van Hasselt and Hersen, 2001). Empathy is widely understood to be a critical skill for future therapists.

TRAINING AND CLINICIAN EMPATHY

Empathy, as regards to schizophrenia, has been defined as: " ... an ability to:

(a) understand the patient's situation, perspective, and feelings (and their attached meanings);

(b) to communicate that understanding and check its accuracy; and

(c) to act on that understanding with the patient in a helpful (therapeutic) way."

Mercer & Reynolds (2002). Empathy is recognized as an essential component of effective mental health care. It is related to the constructs of rapport (Sharpley & McNally, 1997), therapeutic alliance (Martin, Garske, & Davis, 2000) and forms part of the core clinical skills repertoire for health professionals.

Health professionals have a capacity to develop empathy with many of the experiences of people suffering from emotional problems or mental illness. Experiences such as anxiety and depression are very common at a sub-clinical level and are similar to the more severe symptoms. It is therefore quite easy for a counselor or clinician to "know" what it must feel like when dealing with a depressed or anxious client. It is also possible for helping professionals to draw on their own repertoire of effective responses to such symptoms when they utilize therapies designed to reduce such symptoms.

Empathy with symptoms, however, is much more difficult when the client suffers from psychotic illness. Symptoms such as delusions and hallucinations do not commonly occur in everyday life and while the helping professional can acknowledge and appreciate that such symptoms produce problems, it is unlikely that she or he will have personally experienced such symptoms. Therefore, it is very difficult for the helping professional to have a clear sense of what it is like to experience such symptoms. Professionals who have spent many years working closely with people with mental illness may develop capacity for empathy through listening to accounts of symptoms. However, we suspect that many experienced professionals rely on treatments such as medications to address the symptoms and do not seek empathy or understanding of experience.

Although findings from training outcome studies have been mixed, the balance of scientific opinion is that training for empathy is possible and should form part of professional training programs (Mercer & Reynolds, 2002). Confronted with the challenges of communicating the complex nature of schizophrenia to students, experiential learning through role playing has been one method utilized by educators to teach about the experience of schizophrenia. The ability to empathize or to "take on another's role" has long been considered to be an essential component for successful therapeutic encounters (Gladstein, 1983; Goldstein & Michaels, 1985). In addition, role playing also facilitates a greater understanding of various psychological concepts (Johnson & Corser, 1998; Sheldon, 1996) and has the added benefits of decreasing undergraduates' negative stereotypes of people with mental health problem as well as increasing their empathy for future clients (Anderson, Gundersen, Banken, Halvorson, & Schmutte, 1989).

However, lecturers from an earlier study (Tichon & Loh, 2002) have said role playing is not as useful a tool for schizophrenia as it is for blindness, for example.

A recommendation for education in the field of mental health suggests that, in addition to the traditional lecture and textbook mode of teaching, educational planners must investigate other less traditional methods of teaching such as multimedia to increase students' experience of an illness (MacPherson & Keppell, 1998).

This is especially important in the discipline of psychology given the breadth of its subject matters, its variety of methods and its contrasting perspectives and arguments. VR is a leading-edge multimedia tool which has enormous potential in teaching students about the complex nature of schizophrenia.

VIRTUAL REALITY AND EDUCATION

VR has been successfully used in training and education domains outside the research environment for some years (MacPherson & Keppell, 1998). Many of the real-world applications of VR-based education involve modifying human behavior; the most prevalent being flight and driving simulators that allow a hands-on experience without the risks associated with a novice controlling a rapidly moving vehicle (Jang, Kim, Nam, Wiederhold, Wiederhold, & Kim, 2002). Goals of educating in virtual environments (VEs) include training individuals to operate complex machinery, to respond appropriately to rapidly unfolding events (such as combat decisions), or to function in environments that would otherwise be too expensive to be used on a day-to-day basis (Tarr & Warren, 2002). Such established uses of VR are becoming both more widespread and more compelling.

VR techniques are also increasingly being used specifically in healthcare education. Utilizing augmented reality, a visualization tool named Virtual Reality Dynamic Anatomy (VRDA) tool has been designed for teaching the motion of anatomical joints by allowing superimposition of virtual inner bone anatomy on model patients (Baillot, Rolland, & Wright, 1999). A major advantage of this system over traditional teaching methods is that it allows students to view internal and external structures simultaneously, providing them with a better understanding of the relationships between gross anatomy and pathology. It also allows students to interact with whole live models rather then isolated disarticulated limbs, providing a more holistic approach to learning.

The user interactivity feature of virtual reality has permitted the development of CathSim[TM], a procedural simulation designed to assist students in learning how to perform venipuncture. Results on a survey conducted on confidence levels indicated that students felt more confident on being able to perform the procedure on real patients after practicing on CathSim[TM] (Barker, V., 1999). This increase in self-confidence improves the students' abilities to perform venipuncture accurately and safely on actual patients.

Users can revisit simulations generated through VR continuously. The ability to continually regenerate identical simulations has been crucial in supporting repetitive training of complicated surgical procedures. For example, the nasal endoscopy training simulator (NES), a training system integrating VR and multimedia, has been developed for training in endonasal sinus surgery where various procedures often require substantial amounts of training before they can be adequately performed (Bockholt, Ecke, Muller, & Voss, 1999). PreOp[TM] Endoscopic simulator is another example of virtual training system which assists students in learning complex endoscopic procedures including "bronchoscopy, flexible sigmoidoscopy, colonoscopy, EGD, ERCP, and ureteroscopy" (Bro-Nielsen, Tasto, Cunningham, & Merril, 1999). The advantage for this is that students are able to gain necessary skills and confidence in performing complex surgical procedures without having to learn through trial-and-error on actual patients, especially when mortality rates of certain procedures are quite high. Students are also able to rehearse appropriate medical responses to various complications before they occur during an actual procedure, as well as receive realistic training without placing patients at risk.

In addition to education and training, the second highest use of VR has been to modify behavior in the treatment of psychological and mental health disorders. VR, in this field, has been successfully used to enhance human abilities rather than merely modify them (Tarr & Warren, 2002). In mental health research, one of the most important consequences of a concept referred to as "presence," is that a virtual experience can evoke the same reactions and emotions as a real experience (Schumie, Van Der Straaten, Krijn, & Van Der Mast, 2001). Clearly this is important to potential training outcomes in the field of Psychosis where trainee clinician's psychological reactions and emotions felt toward simulated hallucination environments will impact on both their empathy and therapeutic performance with regard to patients with psychosis.

Can VR, implemented as a tool to educate mental health students about schizophrenia, provide students with a true understanding of what these patients experience?

METHODS

The study employed a descriptive exploratory design utilizing a self-report questionnaire. The questionnaire explored student's perceptions of a new Virtual Reality teaching tool. It was designed specifically for this study to identify any potential limitations of using virtual environments as a teaching method, particularly in terms of student's understanding of schizophrenia, and any expectations students may have about VR if it were to become a part of the teaching method lecturers' use in class.

RESEARCH SITE

The Visualisation and Advanced Computing Laboratory (VISAC) at the University of Queensland consists of an immersive curved screen environment with a 2.5m radius and provides 150 degrees field of view. The laboratory uses three projectors separated by 50 degrees to project the images onto the curved screen. The curved screen environment is suitable for having small groups of people, e.g., patients and care-givers, to share the immersive experience including a significant 12-month research project undertaken at the University of Queensland's Centre for Online Health and VISAC that concluded at the end of 2003. The Virtual Reality Laboratory for Psychotic Symptoms (VRLPS) was developed in consultation with people affected by psychotic symptoms, to provide a simulated environment in which the participant experiences delusions and hallucinations in the context of the globally distorted reality characteristic of acute psychosis. This original VR software was used in the current research project.

PARTICIPANTS

In the second semester of 2002, 10 third-year psychology students were given a demonstration of the VR psychosis software, in the VISAC laboratory, and asked to complete a survey immediately on completion of the demonstration. Participation in the study was strictly voluntary; students did not receive academic credit for participation.

INSTRUMENT

The first 19 items of the Survey inquired about perceptions in three major domains:

Education and understanding of schizophrenia after VR presentation. Example items: VR did successfully facilitate my learning about schizophrenia; The VR presentation assisted me to understand issues about schizophrenia I had not resolved from other forms of teaching about the subject.

Teaching approaches/techniques, materials and tools. Example items: VR assists to clarify aspects of the lecture content for me; VR did not provide any useful insights for me on the subject of schizophrenia.

Virtual Reality software-benefits and problems. Example items: I expect to be able to adapt to VR in the classroom; I expect there to be problems in using VR as a learning tool.

The possible answers were: Strongly Agree, Agree, Uncertain, Disagree and Strongly Disagree. The three last items of the survey were qualitative and asked for answers to three open-ended questions: What are the strengths of using VR to teach about schizophrenia in the classroom?

What improvements would you suggest when using VR to teach about schizophrenia in the classroom? Did the VR presentation assist to convey a greater understanding about what it feels like to have schizophrenia? Why or why not?

DATA ANALYSIS

Statistical analyses were performed using the Statistical Package for the Social Sciences (SPSS). Descriptive statistics included simple percentage occurrence, frequencies and dispersion. Qualitative content analysis was conducted on open-ended questions to identify themes among students.

RESULTS

Students reported the amount and type of feedback as shown in the following three tables as a percentage. The results are presented in separate tables to reflect the three major domains covered in the questionnaire.

The first objective of the survey pertained to students' education and understanding of schizophrenia after viewing the VR demonstration. Survey findings indicated that 62.5% of the students strongly agreed and 37.5% of the students agreed that VR is a tool that can facilitate education about schizophrenia.

Students were also asked to rate whether they attained a greater understanding about what it feels like to have schizophrenia after viewing the VR presentation. Thirty-seven and one-half percent of the students strongly agreed and 50% of the students agreed that their understanding of what it feels like to have schizophrenia improved greatly after viewing the VR presentation. Only 12.5% of the students were uncertain about whether their understanding about schizophrenia increased as a result of watching the VR presentation.

The second objective of the survey explored students' opinions about using VR as part of the teaching techniques, material and tools in their course curriculum. Sixty-two and one-half percent of the students strongly agreed VR assisted to clarify aspects of the lecture content for them, 12.5% of the students agreed and 12.5% of the students disagreed. 12.5% of the students were uncertain about whether VR clarify or does not clarify aspects of the lecture content.

The final objective of the survey was to identify VR software benefits and problems. All the students either strongly agreed (50%) or agreed (50%) that the expanded use of VR in the classroom will help them to better understand schizophrenia.

Students were then asked to comment on the strengths and weaknesses of the VR Psychosis teaching tool. Overall, VR was able to facilitate an understanding of what the symptoms of schizophrenia "feel" like. Weaknesses predominately related to the technology itself and improvements required in making movement within scenes smoother as some students experienced nausea during the demonstration. All students responded positively to the open-ended question exploring whether the demonstration had increased their understanding of schizophrenia, although the virtual environments assisted individual students to different degrees.

DISCUSSION

Students commented that VR as a teaching tool is "better than using words and descriptions about hallucination." This indicates the technology was able to extend on the current teaching methods and outcomes in a manner that students deemed positive. More than 80% of students exposed to the VR software agreed, to some degree, that VR successfully facilitated their learning about schizophrenia. While a small percentage of the students were uncertain whether VR successfully facilitated them to learn about schizophrenia or whether the use of VR had increased their interest to learn more about the experiences of patients with schizophrenia, the majority of the students (87.5%) either strongly agreed or agreed that the use of VR had increased their interest in learning more about the experiences of patients with schizophrenia. Increased interest in learning about a diagnosis and extending understanding about a specific diagnosis would be likely to impact beneficially on the development of empathy for the diagnosis.

In addition to this positive response all of the students who participated agreed that the VR module was relevant to the rest of their course. More than half of the students agreed that the VR material was well-presented. However, 37.5% of the students were uncertain whether the VR material was well-presented. For many students, this was their first experience with a VR laboratory. For many, their preconceptions of the virtual environment were gained from prior experience with video games played on one-dimensional personal computers. There is also a need to improve the VR technology to some extent, however, as a number of students expressed concerns such as, "The VR technology needs to be improved because the presentation was jerky at times and that created the sensation of nausea." Aside from these minor technological issues, it was significant to note that not one of the students found the content of the VR presentation to be deficient.

With regard to whether participants felt their understanding about schizophrenia had increased as a result of watching the VR presentation, one student commented, "It is hard to imagine what it is like to be schizophrenic but the VR presentation really helped me in my understanding of the illness." While less than half of the students strongly agreed that after viewing the VR presentation, they developed a greater understanding about visual and auditory hallucination experiences by patients with schizophrenia, almost two-thirds of students agreed that their understanding of auditory hallucinations had improved greatly. One student stated, "The constant voices, noise and flashes of light occur simultaneously provides a first hand experience of what hallucinations are like and how that could impact on patients' thought, emotion and feelings." One student even went further to suggest, "Perhaps, understanding hallucinations will also make it easier to understand other symptoms of schizophrenia." These responses indicate the VR program did introduce an element of experiential learning to teaching about schizophrenia. Students felt it assisted them to "feel" the illness, a critical skill that has been identified as integral to therapist training (Bailey, 2001).

Students were also asked if the VR presentation caused them to reconsider some of their previous views about schizophrenia. Thirty-seven and one-half percent of the students agreed that some of their views about schizophrenia changed after viewing the VR presentation. For example, one student commented, "I have never thought hallucinations being there constantly." Another student commented, "Students for once can experience what patients with schizophrenia experience daily and the VR program really made it clear just how awful the experiences are." This implies that when students are facilitated to gain a better understanding on how terrifying and difficult it is for a patient with schizophrenia to live with the illness on a daily basis, students potentially can develop a better understanding of the illness and an increased sense of empathy. Empathy will generate a greater understanding about the true nature of schizophrenia. Over two-thirds of the participants agreed the VR presentation assisted them to understand issues about schizophrenia they had not resolved from other teaching formats.

The second objective of the survey explored students' opinions about using VR as part of the teaching techniques, materials and tools in their course curriculum. Half of the students strongly agreed that using VR regularly in the classroom would be helpful in providing them with a deeper level of understanding and insights into this illness. The other half also agreed on the above view. One student stated, "VR is more interesting and different from the usual class which is based predominantly on theories."

In identifying the possible benefits and limitations of using VR software in the classroom, the majority of students found that the VR demonstration had shown the potential to clarify aspects of schizophrenia that have been difficult for students to understand. When asked whether students expected there to be problems in using VR as a learning tool, 37.5% of the students agreed and half of the students (50%) were uncertain whether VR would be problematic as a teaching tool. Only 12.5% of the students expected no problem in using VR as a teaching tool. This result could be a reflection of the fact that many of the student participants had not experienced VR as a teaching tool previously. Despite these reservations more than half of the students agreed they expected to be able to adapt to VR in the classroom. Only 37.5% of the students remained uncertain about whether VR can be adapted into the classroom. It was interesting to note the positive response of students to extending the use of this high-end technology in the delivery of education. This may be a reflection of the positive response other forms of multimedia in the university classroom have received when introduced.

CONCLUSION

The results generated through this limited, exploratory project suggest that VR has the potential to provide students with more realistic knowledge and a greater understanding of the complexities as well as the nature of schizophrenia. As one student nicely summarised, "It is extremely hard to imagine what it is like for schizophrenic suffering from hallucination. But, when this illness is portrayed using VR, students are provided with an opportunity to experience first hand what hallucination is all about."

VR can be used alongside traditional teaching methods. The interactive nature of VR provides an ideal method of educating students about schizophrenia because it enhances the "personal" experience of patients who suffer from schizophrenia or hallucinations. Students can then better understand what it is like to "almost" experience what schizophrenia or hallucination is like for patients with schizophrenia.

This project explored the reactions and responses from students about the use, the effect and the problems associated with using VR as part of the teaching technique in an educational setting. Planned future studies include determining the extent to which students are checked as "empathic" by standardised patients on a performance-based examination after being exposed to the virtual environment educational setting. Finally, if empathy has increased, we can investigate whether the VR exposure is related to clinical performance on the clinical history taking and physical examination of patients with schizophrenia.

Table 1. Student feedback on items relating to "Education and
Understanding of Schizophrenia after Virtual Reality Presentation"

Questions                      Results in Percentages
                               Strongly   Agree    Uncertain   Disagree
                               Agree

 1. Virtual reality is a
    tool that can facilitate
    education about
    schizophrenia              (62.5%)    (37.5%)
 2. Virtual Reality did
    successfully facilitate
    me learning about
    schizophrenia              (25.0%)    (62.5%)  (12.5%)
 3. The use of Virtual
    reality has increased my
    interest in learning more
    about the experiences of
    patients with
    schizophrenia              (50.0%)    (37.5%)  (12.5%)
 4. The VR module was
    relevant to the rest of
    my course                  (25.0%)    (75.0%)
 5. The VR material was
    well presented             (25.0%)    (37.5%)  (37.5%)
 6. After viewing the VR
    presentation. I have
    developed a greater
    understanding about what
    it feels like to have
    Schizophrenia              (37.5%)    (50.0%)  (12.5%)
 7. After Viewing the VR
    presentation, I have
    developed a greater
    understanding about
    visual hallucinations
    experienced by patients
    with Schizophrenia         (37.5%)    (37.5%)  (25.0%)
 8. After viewing the VR
    Presentation, I have
    developed a greater
    understanding about
    auditory hallucinations
    experienced by patients
    with schizophrenia         (37.5%)    (62.5%)
 9. After viewing the VR
    presentation, I have
    reconsidered some of my
    previous views about
    schizophrenia                         (37.5%)  (37.5%)     (25.0%)
10. The VR presentation
    assisted me to understand
    issues about
    schizophrenia I had not
    resolved from other forms
    of teaching about the
    subject                     12.5%)    (62.5%)  (25.0%)

Table 2. Student feedback on items relating to "Teaching Approaches/
Techniques, Materials and Tools"

Questions                             Results in Percentages
                                      Strongly Agree  Agree    Uncertain

1. VR used more regularly in the
   classroom would be helpful in
   providing                                          (50%)    (50%)
2. VR assists to clarify aspects of
   the lecture content for me         (12.5%)         (62.5%)  (12.5%)
3. VR did not provide any useful
   insights for me on the subject of
   schizophrenia                      (12.5%)         (25.0%)  (62.5%)
4. The benefits of using VR in the
   classroom are limited              (12.5%)         (25%)    (62.5%)

Questions                            Results in Percentages
                                     Disagree  Strongly Disagree

1. VR used more regularly in the
 classroom would be helpful in
 providing
2. VR assists to clarify aspects of
 the lecture content for me          (12.5%)
3. VR did not provide any useful
 insights for me on the subject of
 schizophrenia
4. The benefits of using VR in the
 classroom are limited

Table 3. Student feedback on items relating to "Virtual Reality
Software-Benefits and Problems"

Questions                     Results in Percentages
                              Strongly     Agree    Uncertain  Disagree
                              Agree
1. The expanded use of
   Virtual Reality in the
   classroom will help me to
   better understand
   schizophrenia              (50%)        (50%)
2. I expect there to be
   problems in using VR as a
   learning tool              (37.5%)      (50.0%)  (12.5%)
3. I expect to be able to
   adapt VR in the classroom  (12.5%)      (50.0%)  (37.5%)
4. The virtual reality
   demonstration has shown
   the potential to clarify
   aspects of Schizophrenia
   that have been difficult
   for students to
   understand                 (62.5%)      (37.5%)

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JENNIFER TICHON, JENNIFER LOH, & ROBERT KING, UNIVERSITY OF QUEENSLAND, AUSTRALIA

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