Acceptability, feasibility, and preliminary evaluation of an animated VR game for reducing mental health stigma in health-care students and trainees: a mixed-method study

Abstract

Purpose

This study aims to pilot-test the acceptability, feasibility, preliminary efficacy and user experience of an animated virtual reality (VR) game (“Goliath: Playing with Reality”) aimed at reducing stigma related to psychosis and schizophrenia among health-care students and trainees.

Design/methodology/approach

A mixed-methods design was used. Sixteen trainee clinical psychologists with experience working with service users with psychosis/schizophrenia engaged with the VR game using a headset and controllers, and completed measures before and after. Quantitative measures assessing intervention acceptability, appropriateness and feasibility were collected and analysed descriptively. These were complemented by qualitative feedback on user experience, analysed through content analysis. Pre- and post-intervention mental health stigma-related measures were also collected and analysed inferentially.

Findings

Most participants found the VR game acceptable, appropriate and feasible for reducing mental health stigma. Although there were no significant changes in stigma-related measures, participants were impressed by the immersive storytelling and the symbolic portrayal of psychosis. Participants also valued the educational aspect, empathised with people living with psychosis/schizophrenia and experienced a range of emotional reactions. However, participants noted usability concerns, and suggestions for improvement were made.

Originality/value

This is one of the first studies to show the potential of “Goliath: Playing with Reality” as a mental health educational intervention for health-care students and trainees. Drawing on narrative theory and immersive-interactive storytelling techniques, the VR game provides experiences that can foster narrative engagement and emotional connection, potentially enhancing its effectiveness in mental health stigma reduction efforts.

Citation

Szekely, R., Mason, O., Frohlich, D.M. and Barley, E.A. (2024), "Acceptability, feasibility, and preliminary evaluation of an animated VR game for reducing mental health stigma in health-care students and trainees: a mixed-method study", Mental Health and Digital Technologies, Vol. 1 No. 2, pp. 173-192. https://doi.org/10.1108/MHDT-03-2024-0010

Introduction

Despite increased apparent awareness and openness about mental health in the public discourse in recent years, stigma remains a pervasive issue, significantly affecting the lives, employment opportunities and adequate health-care access for people with serious mental health conditions such as psychosis and schizophrenia (Charette-Dussault and Corbière, 2019; Perry et al., 2020; Walsh et al., 2016). Psychotic conditions continue to be poorly understood or accepted, with stigmatising beliefs, attitudes and behaviours widely perpetuated by the general public and media (Cadge et al., 2019; Joseph et al., 2015; Maletta and Vass, 2023; Pescosolido et al., 2021; Schomerus et al., 2022).

Critically, health-care students and qualified practitioners also exhibit similar negative attitudes towards people with psychosis and schizophrenia (Chen et al., 2023; Le Glaz et al., 2022; Magliano et al., 2017, 2020; Valery and Prouteau, 2020). This is particularly concerning as these attitudes can influence the quality of care provided, exacerbating the already poor health outcomes experienced by this population (Reininghaus et al., 2015; Schoepf et al., 2014). Furthermore, while health-care education presents inherent opportunities for targeting mental health stigma through educational content and clinical contact, the effects of these on health-care students’ attitudes are relatively superficial, diminishing over time (Ay et al., 2006; Telles-Correia et al., 2015; Totic et al., 2012). In this context, and given the short-lived effects, limited quality and resource intensity of conventional stigma reduction interventions (Carrara et al., 2021; Gronholm et al., 2017; Stubbs, 2014; Yamaguchi et al., 2013), a call for novel, more effective and accessible approaches is needed.

In response, interventions based on virtual reality (VR) technologies, which primarily capitalise on the potential of perspective-taking but may also integrate elements of education and/or contact, have emerged as promising avenues for reducing mental health stigma in different populations, including among health-care students (Lem et al., 2024; Rodríguez-Rivas et al., 2022; Szekely et al., 2023; Tay et al., 2023; Wan and Lam, 2019). Previous work has suggested that VR-mediated, embodied perspective-taking might be an effective stigma reduction strategy as it allows the user (e.g. the health-care student without lived experience of psychosis/schizophrenia) to “step into the shoes” of an out-group member (e.g. the person with psychosis/schizophrenia), providing insight into an otherwise difficult-to-grasp and, generally, epistemically inaccessible experience (e.g. hearing voices, seeing things, having unusual beliefs and their impact on functioning) and fostering understanding and empathy (Chen and White, 2024; Lara and Rueda, 2021; Nikolaou et al., 2022).

Mere perspective-taking interventions such as symptom-focused simulations, however, often fall short of providing the necessary contextual information and a relatable, person-centred narrative, which may be needed to enable stigma reduction (Ando et al., 2011; Clement et al., 2013; Szekely et al., 2023). A similar sentiment was also shared by lived experience experts, health-care educators and students in a recent qualitative study, advancing several recommendations for the design, content and delivery of VR interventions in mental health education (Szekely et al., 2024). In this respect, drawing on narrative theory and immersive-interactive storytelling techniques (Aylett and Louchart, 2003; Bizzocchi, 2011; Bucher, 2017; Dooley, 2023; Ryan, 2015), VR narrative games, playable stories and other ludo-narrative applications and gamified experiences (referred to as VR games, for brevity purposes) can add an extra layer of depth by transporting users in a compelling narrative and facilitating psychological immersion, thereby increasing their receptivity to messages embedded within the story and influencing their beliefs and attitudes (Burrows and Blanton, 2016; Green and Brock, 2000). Moreover, through their interactive nature, these experiences can bring users closer to the characters and their identities, values and perspectives, creating a feeling of identification and promoting empathy within users (Bachen et al., 2012; Cohen, 2001; Felnhofer et al., 2023). Indeed, there is literature to suggest that narrative persuasion mechanisms can contribute to destigmatisation (Ferchaud et al., 2020; Tamul and Hotter, 2019; Zhuang and Guidry, 2022) and, in the case of VR, these mechanisms are believed to be further enhanced by the affordances of immersive technologies (Canet and Pérez-Escolar, 2023; Ma et al., 2024). On these grounds, researchers have started to direct their attention towards the stigma reduction potential of immersive VR games that focus on serious mental health conditions, including commercially available games such as “Hellblade: Senua’s Sacrifice” (Mason and Westhead, 2023) or custom-made educational applications such as “Inclúyete-VR” (Rodríguez-Rivas et al., 2024), showing some encouraging results.

“Goliath: Playing with Reality” (Anagram, 2021) is a novel, animated VR game that portrays, in an immersive and interactive way, the story of a person with paranoid schizophrenia, who, after enduring difficult years alone and hospitalised, finds refuge in the online gaming community. Incorporating elements of narrative theory and immersive-interactive storytelling, alongside embodied perspective-taking, education and contact-based strategies (Bakk, 2023; Freeman, 2022; Tucker and Kiss, 2023), the VR game may prove a successful intervention for reducing stigma towards people with psychosis/schizophrenia, with potential applications in the mental health education of health-care professionals. However, to date, no studies have formally assessed the potential of “Goliath: Playing with Reality” (Anagram, 2021) in this regard. Therefore, as a primary objective, this study aims to pilot-test the user experience of the VR game and its acceptability, appropriateness and perceived feasibility as a mental health stigma reduction intervention for health-care students and trainees. Secondarily, this study seeks to address whether the VR game shows promise in changing stereotypes, prejudice and discriminatory intentions as core manifestations of stigma (Corrigan, 2000; Corrigan et al., 2005).

Method

Participants

Trainee clinical psychologists, as a subgroup of health-care students/trainees, were purposefully selected as the target population. Participants were recruited from a clinical psychology doctoral programme in southeast England between December 2023 and January 2024 and, to be eligible, they were required to have experience working with service users with psychosis/schizophrenia. Furthermore, participants who were pregnant or had specified health conditions that may contraindicate the use of VR equipment were not able to take part. Participants with a current or prior history of psychotic conditions were also not eligible for inclusion.

Sixteen UK-based trainee clinical psychologists took part in this study. Of these, 12 (75.0%) identified as female and 4 (25.0%) as male. The mean age of the participants was 28.81 (SD = 3.31). Seven participants (43.8%) reported they had used VR before. None of the participants was familiar with the VR game. The characteristics of the sample were summarised in Table 1.

Design and procedure

This study was based on a single-group, uncontrolled mixed-methods design, with research data collected at two time points – baseline, before the VR game (T₀ – quantitative data only), respectively after the VR game (T₁ – quantitative and qualitative data). Figure 1 illustrates the participant flow.

Virtual reality game and equipment

Developed by the creative studio Anagram (2021), “Goliath: Playing with Reality” is a 25-min VR game that explores the intersection between a serious mental health condition, online gaming and human connection. There are four main scenes in the VR game (see Figure 2). A more detailed description of the VR game is included in Supplementary Material 1. The trailer can be watched online: https://youtu.be/uiX0umyu8mU.

To run the game, the Meta Quest 2 128GB, an immersive, all-in-one VR set comprising a pair of motion controllers and a headset with six degrees-of-freedom tracking and three-dimensional positional audio, was used. Running the VR game also required a stable internet connection and an active Meta account.

Measures and instruments

Baseline measures.

To capture the baseline characteristics of the sample, sociodemographic data were collected at T₀. Participants’ extent of contact with serious mental illness (Level-of-Contact Report, Holmes et al., 1999) and their mental health literacy (Mental Health Knowledge Schedule, Evans-Lacko et al., 2010) were also measured at T₀.

Intervention acceptability, appropriateness and feasibility measures.

To determine the acceptability, appropriateness and perceived feasibility of the VR game as a mental health stigma reduction intervention for health-care students and trainees, the set of measures developed by Weiner et al. (2017) was applied at T₁.

Mental health stigma-related measures.

To gauge the preliminary efficacy of the VR game in changing mental health stigma, measures of stereotypes, prejudice and discriminatory intentions were applied at both T₀ and T₁. Where relevant, item wording was adapted to better fit the context of the study by focusing specifically on psychosis/schizophrenia. The Mental Illness Clinicians’ Attitudes Scale v4 (Gabbidon et al., 2013) is a 16-item measure which assessed participants’ attitudes towards people with psychosis/schizophrenia. The Prejudice towards People with Mental Illness Scale (PPMI) (Kenny et al., 2018) is a 28-item measure with questions which assessed participants’ explicit prejudice against people with psychosis/schizophrenia across four subscales – fear/avoidance, malevolence, authoritarianism and unpredictability. The Intended Behaviour, a four-item subscale derived from the Reported and Intended Behaviour Scale (Evans-Lacko et al., 2011), assessed participants’ discriminatory intentions towards people with psychosis/schizophrenia.

Qualitative feedback.

Participants were asked to provide qualitative feedback at T₁ through six open-ended questions covering various aspects related to their experience with the VR technology and the game.

Data analysis

The sociodemographic characteristics of the sample and the intervention acceptability, appropriateness and feasibility measures were analysed using descriptive statistics. Changes in mental health stigma-related measures were analysed using paired-sample t-tests. The significance level was set at 0.05. The qualitative feedback was analysed using a directed content analysis approach (Hsieh and Shannon, 2005; Zhang and Wildemuth, 2016). The coding framework was based on the Component User Experience model developed by Thüring and Mahlke (2007).

Ethical considerations

This study received a favourable ethical opinion from the University of Surrey Ethics Committee (FHMS 23–24 033 EGA). Informed consent was obtained electronically, via Qualtrics, and re-confirmed verbally at the study visit. Participation incentives were offered as part of this study.

Results

Main quantitative results

Intervention acceptability, appropriateness and feasibility.

Most participants (n = 12, 75.0%) agreed or completely agreed that the VR game met their approval to be used as a mental health stigma reduction intervention. Almost all participants (n = 15, 93.8%) agreed or completely agreed that the VR game was appealing, whereas all participants (n = 16, 100%) agreed or completely agreed that they liked the VR game. Moreover, most participants (n = 13, 81.3%) agreed or completely agreed that they welcomed the VR game. Overall, as presented in Figure 3, the VR game was perceived to be an acceptable intervention for reducing mental health stigma in health-care students and trainees, showing a mean acceptability score of 4.28 (SD = 0.65).

Among participants, most (n = 12, 75.0%) agreed or completely agreed that the VR game seemed fitting as a mental health stigma reduction intervention, most (n = 13, 81.3%) agreed or completely agreed that the VR game seemed suitable and all (n = 16, 100%) agreed or completely agreed that the VR game seemed applicable. Furthermore, most (n = 12, 75.0%) agreed or completely agreed that the VR game seemed like a good match. Overall, the VR game was perceived to be an appropriate intervention for reducing mental health stigma in health-care students and trainees, showing a mean appropriateness score of 4.09 (SD = 0.92).

A majority of participants (n = 11, 68.8%) agreed or completely agreed that the VR game seemed implementable as a mental health stigma reduction intervention, while four participants (25.0%) neither agreed nor disagreed. Only one participant (6.3%) disagreed or completely disagreed with this statement. Moreover, most participants agreed or completely agreed that the VR game seemed possible (n = 12, 75.0%), doable (n = 12, 75.0%) and easy to use (n = 12, 75.0%) respectively. Overall, the VR game was perceived to be a feasible intervention for reducing mental health stigma in health-care students and trainees, showing a mean feasibility score of 4.03 (SD = 0.74).

Preliminary efficacy.

The mean score for stereotypes towards people with psychosis/schizophrenia decreased non-significantly from before (M = 31.50, SD = 4.03) to after (M = 31.19, SD = 3.80) the VR game, t(15) = 0.23, p = .411. There was no statistically significant change in the mean overall score for participants’ prejudice from before (M = 2.73, SD = 0.68) to after (M = 2.93, SD = 0.55) the VR game, t(15) = −2.14, p = .975. Across the prejudice subscales, there was a non-significant increase in the mean scores for malevolence [t(15) = −7.88, p = 1.000] and authoritarianism [t(15) = −0.45, p = 0.669] and a non-significant decrease in the mean scores for fear/avoidance [t(15) = 0.67, p = 0.256] and unpredictability [t(15) = 0.47, p = 0.321]. Finally, the mean score for discriminatory intentions decreased from before (M = 6.50, SD = 2.22) to after (M = 6.19, SD = 1.91) the VR game. However, this change was not statistically significant, t(15) = 0.54, p = 0.297.

Main qualitative results

Table 2 presents an overview of the coding framework used in the qualitative analysis, including working definitions for each category and code, along with their corresponding coding frequencies and relevant excerpts from participants’ qualitative feedback. A second rater cross-checked the coded excerpts from four out of 16 participants (25.0%), resulting in an inter-coder agreement level of 85.2%.

User experience – functional aspects.

Participants offered varied perspectives on the usability of the VR game, noting both positives and negatives. While some found the technology relatively easy to navigate, others encountered some challenges, such as slight discomfort from the headset or difficulty understanding controls. Furthermore, some found certain scenes less intuitive, and, as a result, several improvements were suggested, such as more detailed instructions and a brief tutorial for familiarisation. Despite initial functional challenges, participants adapted quickly and saw the potential utility of the VR game in improving mental health education for health-care professionals. They valued the insights provided, aiming to improve understanding and challenge stigma, particularly among health-care students and trainees. Some suggested that additional psychoeducation about psychosis and schizophrenia would complement its use in health-care education.

User experience – aesthetic, symbolic and motivational aspects.

Participants appreciated the immersive storytelling and symbolic portrayal of psychosis experiences in the VR game, finding the audio-visual elements effective in conveying sensory and perceptual changes. Participants valued the inclusion of a narrative and personal story in the VR game as this helped them emotionally connect with the protagonist and the challenges faced by people living with psychosis. However, participants’ engagement with the narrative varied based on prior experiences. While some found the game artistically compelling, others questioned its authenticity in capturing the breadth of experiences within the psychosis spectrum and suggested more diverse narratives and interactive elements, especially from a health-care professional’s perspective. Despite this, many found the portrayal realistic and believed it could motivate health-care students to learn about the complexities of mental health.

User experience – emotional reactions.

The VR game left a strong impression on participants, immersing them in the virtual world and generating a sense of enjoyment. Besides its entertainment value, the VR game elicited a positive emotional response, fostering empathy and a compassionate attitude. Participants also reported gaining a better understanding as they reflected on personal and clinical experiences. Some felt unease during scenes depicting the acute phases of psychosis, while some sought even more emotionally evocative stimuli. A few noted heightened physiological reactions to unexpected elements in the VR game, emphasising the intensity of the immersive experience. However, it was recognised that these reactions served as a reminder of the pervasive nature of the condition, prompting further reflection and appreciation towards those with lived experience.

Discussion

The quantitative findings from this study indicate high levels of acceptability and appropriateness for “Goliath: Playing with Reality” (Anagram, 2021) as a mental health stigma reduction intervention for health-care students and trainees. The majority of participants agreed that the VR game met their approval, and was appealing, liked and welcomed. The findings also suggest that the content was well-received and considered suitable for addressing mental health stigma in this population. These results are promising, especially as acceptability is a key prerequisite for success at both individual (e.g. actual use behaviour) and organisational or systemic levels (e.g. effective implementation) (Davis, 1989; Proctor et al., 2011; Weiner et al., 2017).

While the acceptability and appropriateness of the VR game were high, feasibility ratings were slightly lower. In the qualitative feedback, participants noted usability concerns, and, although not related to the VR game per se but rather to the equipment, these might have been seen as a potential practical barrier. Nonetheless, these concerns were perceived as addressable, and, generally, the VR game was considered implementable and easy to use by most participants. The feasibility ratings may also be attributed to participants’ limited experience with VR technologies, as more than half had never used one before. What is noteworthy, however, is that the overall experience was well-tolerated and deemed safe, primarily evidenced by the minimal incidence of reported side effects (as shown in Figure 1). Encouragingly, this was markedly lower than those documented in the VR literature (Caserman et al., 2021), possibly due to the high quality of the VR equipment and game.

The qualitative findings about the aesthetic and symbolic aspects of the user experience, as well as the associated emotional reactions are also of great interest. Participants reported a sense of immersion into the story underpinning the VR game and described feeling emotionally connected with the character, akin to the mechanisms of transportation and identification discussed in the narrative persuasion literature and proposed as potential drivers of stigma reduction (Ferchaud et al., 2020; Tamul and Hotter, 2019; Zhuang and Guidry, 2022). Furthermore, participants experienced a range of emotional responses, largely influenced by the auditory, visual and haptic elements encountered through the VR headset and accompanying peripherals. The emotional shifts experienced during the VR game arguably amplify the mechanisms of narrative persuasion and potentially lead to a more enduring impact on users (Nabi and Green, 2015).

The point made above is essential because it has been posited that immersive technologies do not present any advantage over non-immersive ones in changing attitudes and behaviours (Ma, 2020; Pressgrove and Bowman, 2021). Indeed, the same content should not be expected to make a tangible difference, other than perhaps in terms of presence, when viewed through a VR headset compared to viewing it on a screen. Following the reasoning of Makransky and Petersen (2021), the difference lies in the way the narrative of the VR game is tailored to, and capitalises on, the affordances provided by the technical features of immersive VR (e.g. head orientation and positional tracking, hand and finger configuration tracking via inside-out cameras, haptic feedback via motion controllers, sound recording via built-in microphones/speakers), which can make the experience qualitatively different, and, ultimately, enhance the effects of narrative persuasion on stigma. However, this hypothesis requires further experimental investigation.

In terms of preliminary efficacy, while stigma measures did not change significantly from before to after the VR game, the direction of change tends to align with previous literature on mental health stigma reduction interventions (Na et al., 2022; Szekely et al., 2023). Several factors may explain the lack of statistical significance, including the relatively small sample size and low levels of stigma among participants at baseline, which, given their background, was expected. In addition, usability issues and/or novelty effects may have distracted participants from fully engaging with, and absorbing the narrative. Nonetheless, the qualitative feedback suggests that participants recognised the educational utility of the VR game, particularly for those new to the field who may have higher levels of mental health stigma initially. However, research with larger sample sizes and more robust experimental designs is warranted to confirm the stigma reduction effects of the VR game before making any practice recommendations.

While potential limitations of the study have already been acknowledged, several strengths should also be discussed. Firstly, trainee clinical psychologists were purposefully selected as the target population due to their combined clinical and research expertise. The decision was made with the anticipation that these participants could offer a clinically informed evaluation of the portrayal of psychosis/schizophrenia in the VR game, while also sharing feedback from a research-oriented standpoint. Secondly, the use of a commercially available VR game offers several advantages, including versatility (can be used for different educational and/or research purposes), quality (provides high-quality graphics, user interface, and/or performance), accessibility (can be easily purchased and/or accessed through online platforms) and resource efficiency (saves development and testing time and/or costs for researchers). A third and final strength refers to the mixed-method design, whereby the qualitative findings confirm, explain and/or add to the quantitative ones, producing a more rigorous and nuanced analysis.

To conclude, the VR game received positive feedback regarding the user experience provided and was generally perceived as acceptable, appropriate and feasible for reducing mental health stigma among health-care students and trainees. Suggestions for improvement were made, and further investigations are warranted to confirm its efficacy.

Figures

Figure 1.

Diagram illustrating participant flow throughout the study

Figure 2.

Screen captures from “Goliath: Playing with Reality” (Anagram, 2021) illustrating the main scenes in the VR game

Figure 3.

Mean acceptability, appropriateness and feasibility scores for the VR game

Table 1.

Sociodemographic and baseline characteristics of participants in the study (N = 16)

Characteristic	M (SD)	n (%)
Age	28.81 (3.31)
Gender
Female		12 (75.0)
Male		4 (25.0)
Ethnicity
Asian or Asian British		1 (6.3)
Black or black British		3 (18.8)
White		12 (75.0)
Year of training as a clinical psychologist
Year 1		10 (62.5)
Year 2		3 (18.8)
Year 3		3 (18.8)
Level-of-contact with serious mental illness	9.63 (1.09)
Mental health literacy	50.94 (3.80)
Experience working with service users with psychosis/schizophrenia
Yes		16 (100)
Previous VR experience
Yes		7 (43.8)
No		9 (56.3)

Source:

Created by the authors

Table 2.

Coding framework, coding frequencies and relevant excerpts from the qualitative feedback

Category	Code	Working definition	Coding frequency	Relevant excerpts
Functional (instrumental) aspects		Aspects of the VR game that contribute to its utility and usability in achieving the needs or goals of the user	85
	Usability	Ease of use, comfort and navigability of the VR game interface and the equipment used	36	“I found it all easy to use and very comfortable. I liked the fact that you were able to sit down but still feel immersed in the VR world.” (P7)
				“It took a little while to settle into feeling comfortable and intuitive using the controllers, but that went away quite quickly.” (P3)
				“I found the gaming section where I was in the arcade game slightly challenging to begin with as I was not sure what I needed to do but I picked this up quickly.” (P8)
	Utility	Usefulness and practical value of the VR game in achieving its goals related to mental health education and stigma reduction	49	“I think the VR experience could be very useful in helping people maintain an empathetic attitude when working with people experiencing psychosis. For me, the VR experience brought Goliath’s story “to life” and I think that’s where it’s strength lies.’ (P9)
				“I found the intervention really useful. […]I think if someone was new to a role which required working with people with psychosis then this may be useful. […]I think it would give people an understanding of what it’s like to have psychosis and the impact of this.” (P16)
				“I think there needs to be more education at the start in terms of what psychosis is, positive and negative symptoms, sensory and perceptual changes. Many people think it is just hearing voices or seeing things but it is much broader than that.” (P8)
Aesthetic, symbolic and motivational (non-instrumental) aspects		Aspects of the VR game that contribute to the satisfaction of the user beyond its functional value	53
	Aesthetic aspects	Sensory elements of the VR game, including auditory, visual and haptic elements, which contribute to immersion in the experience	11	“[…]the audio was particularly insightful for portraying someone with psychosis and the fast changing of images – not knowing what was real/unreal.” (P13)
				“It is a useful exercise to highlight how psychosis distorts someone’s reality which influences their sensory and perceptual experiences. I thought the most effective parts was the bug on the hand to illustrate this and the visuals and sounds effects – especially hearing my name, that was really effective.” (P8)
				“Very enjoyable experience, felt nice to see how things changed visually and hearing Goliath’s story.” (P2)
	Symbolic aspects	Interpretations of the narrative, metaphors and symbolic elements used to represent psychosis experiences within the VR game	27	“The VR experience brought Goliath’s story to life and kept me engaged with the content and his story and experiences.” (P9)
				“I found the intervention interesting and artistic, but in terms of feeling or moments of identification with a person with psychosis, I found the intervention too abstract to be able fully understand the difficulties/challenges/strengths that a person with psychosis goes through.” (P6)
				“The story was not dissimilar to most people I have worked with, it felt believable and realistic.” (P3)
	Motivational aspects	Attitudes towards the ability of the VR game to capture interest, maintain attention and promote learning	15	“I am not sure I was able to completely understand this person’s experience because of my lack of experience with gaming. Had I had prior experience I might have had a different experience of the study and be better able to connect with this person’s story.” (P12)
				“It was engaging and encompassed a lot of elements, across different environments, which was good. I liked that it uses old-school games too like street fighter stuff that people can relate too.” (P4)
				“VR is fun and interactive and a very memorable experience for most who haven't used it before, and can be a good way to educate.” (P5)
Emotional reactions		Positive or negative subjective feelings, physiological changes, motor expressions, cognitive appraisals and/or behavioural tendencies experienced in response to the VR game	32
	Subjective feelings	Subjective experiences of emotions and affective states in response to the VR game	20	“The content was engaging and interesting. I enjoyed that it was spoke from the perspective of someone experiencing psychosis.” (P16)
				“I found it a bit scary at times but I think that is almost a good thing as it shows the how this disorder can be quite scary for people who are experiencing psychosis.” (P7)
				“There was a mention of being followed but the VR experience didn’t evoke this in me. In fact, I am not sure I felt the sense of threat/fear as much as patients have described experiencing.” (P12)
	Physiological changes and/or motor expressions	Perceptions of alterations in bodily sensations or functions, such as changes in heart rate, breathing patterns, muscle tension and/or motor reactions, such as startle reflexes or movements, in response the VR game	3	“When we were in the home environment and there was a robot crawling on the floor that took me by surprise initially.” (P8)
				“The repeat back of my name raised the HR [heart rate] but I think in a good way, as it truly shows how scary and inescapable it can be.” (P14)
				“I suppose my hands got a bit sweaty too!” (P16)
	Cognitive appraisals	Cognitive evaluations, interpretations and reflections in response the VR game	9	“I think that the use of VR technology and seeing this different reality through our own lens and eyes will help increase our knowledge as healthcare professionals that we are all susceptible to viewing different realities that affect us emotionally. Therefore, we are more likely moving forwards to appreciate if someone tells us that they are experiencing hallucinations and not be so stigmatising or judgemental […].” (P10)
				“I found myself empathising more with people who have lived experience and considering the impact on myself and loved ones.” (P15)
				“Having worked on psychiatric wards, I think there can sometimes be a dehumanising culture, and something like this could help change attitudes and behaviours.” (P9)

Source: Created by the authors

Supplementary material

The supplementary material for this article can be found online.