Background: Living in the time of the COVID-19 means experiencing not only a global health emergency but also extreme psychological stress with potential emotional side effects such as sadness, grief, irritability, and mood swings. Crucially, lockdown and confinement measures isolate people who become the first and the only ones in charge of their own mental health: people are left alone facing a novel and potentially lethal situation, and, at the same time, they need to develop adaptive strategies to face it, at home. In this view, easy-to-use, inexpensive, and scientifically validated self-help solutions aiming to reduce the psychological burden of coronavirus are extremely necessary. Aims: This pragmatic trial aims to provide the evidence that a weekly self-help virtual reality (VR) protocol can help overcome the psychological burden of the Coronavirus by relieving anxiety, improving well-being, and reinforcing social connectedness. The protocol will be based on the “Secret Garden” 360 VR video online (www.covidfeelgood.com) which simulates a natural environment aiming to promote relaxation and self-reflection. Three hundred sixty–degree or spherical videos allow the user to control the viewing direction. In this way, the user can explore the content from any angle like a panorama and experience presence and immersion. The “Secret Garden” video is combined with daily exercises that are designed to be experienced with another person (not necessarily physically together), to facilitate a process of critical examination and eventual revision of core assumptions and beliefs related to personal identity, relationships, and goals. Methods: This is a multicentric, pragmatic pilot randomized controlled trial involving individuals who experienced the COVID-19 pandemic and underwent a lockdown and quarantine procedures. The trial is approved by the Ethics Committee of the Istituto Auxologico Italiano. Each research group in all the countries joining the pragmatic trial, aims at enrolling at least 30 individuals in the experimental group experiencing the self-help protocol, and 30 in the control group, over a period of 3 months to verify the feasibility of the intervention. Conclusion: The goal of this protocol is for VR to become the “surgical mask” of mental health treatment. Although surgical masks do not provide the wearer with a reliable level of protection against the coronavirus compared with FFP2 or FFP3 masks, surgical masks are very effective in protecting others from the wearer’s respiratory emissions. The goal of the VR protocol is the same: not necessarily to solve complex mental health problems but rather to improve well-being and preserve social connectedness through the beneficial social effects generated by positive emotions.
Introduction Background Living in the time of the COVID-19 means experiencing not only a global health emergency but also extreme psychological stress that puts a strain on our identity and our relationships. Coronavirus and the associated isolation and quarantine require people to manage three different psychological dilemmas simultaneously (1). i. the stress due to the disease, ii. the inaccessibility to physical places, iii. and the sense of community crisis. The core stress of the disease comes from the worry and concerns about personal health and the health of friends and family members. This stress can be exacerbated both among general public and medical staff via the vicarious traumatization effect (2) when empathizing with those suffering, resulting in fatigue, physical decline, sleep disorder, irritability, inattention, fear, and despair (3). The traumatic effects are further aggravated by living in quarantine and its restrictions on movement and social interaction. In fact, evidence has shown that quarantine causes significant psychological effects including post-traumatic stress symptoms, confusion, and anger (4). The inaccessibility to physical places is one of the first clear negative effects of quarantine. A conflict arises that is provoked by losing access to physical places where people can meet and that we feel belongs to us. A “place” can be understood as any space delimited by borders and that gives identity to individuals and represents a space to be. Related to place is the concept of place attachment (5) which is the bonding of people to places. This bond includes cognitive and emotional components and is a common phenomenon observed across cultures with significant psychological benefits (6). However, quarantine disrupts place attachment, and therefore, has negative implications. As noted by Scannel and Gilford (6), separation from one’s significant place can be devastating: “broken or stretched place bonds are associated with physical health problems, lower grades, sadness, longing alienation, and disorientation” (pp. 256–257). Women tend to report stronger place attachment than men (6) and, therefore, the disruption of place attachment provoked by the quarantine may have stronger psychological effects in women. Å crisis of the sense of community is caused by disconnect from the places where communities are born (7), and provide significant negative effect on subjective well-being (8, 9). The disruption of places produced by the quarantine also affects the communities that use these places to meet and interact. Without everyday places to meet at—such as the workplace and the classroom—friends and acquaintances are more difficult to reach and to interact with. This weakens social bonds and declines the social significance of the local community in terms of social capital and interpersonal support. These negative psychological effects may be aggravated by other stressors such as having inadequate basic supplies (e.g., food, etc.), insufficient clear guidelines about actions to take and the prolonged duration of quarantine, the interruption of professional activities and the subsequent financial loss (4). In this view, any strategy that aims to reduce the psychological burden of coronavirus is extremely necessary (10). As recently underlined by Holmes and colleagues (10): “There is an urgent need for the discovery, evaluation, and refinement of mechanistically driven interventions to address the psychological, social, and neuroscientific aspects of this pandemic. This includes bespoke psychological interventions to boost wellbeing and minimize mental health risks across society.” (p. 10). Crucially, given the mandatory loneliness resulting from lockdown measures, easy-to-use, inexpensive, and scientifically validated self-help solutions could be the key (11–16). Aims This pragmatic trial seeks to provide the evidence that a weekly self-help protocol based on a virtual reality experience—“The Secret Garden”, available in the www.covidfeelgood.com website—can help to overcome the psychological burden of the Coronavirus. It is important to underline that the goal of the self-help protocol is not to provide a full structured psychological intervention, but to build the “surgical mask” of mental health support. Surgical Masks do not provide the wearer with a reliable level of protection against coronavirus (20%) versus the 95/99% of FFP2 and FFP3 masks. However, they are very effective in protecting others from the wearer’s respiratory emissions, and their use is significantly better than wearing a scarf. The self-help VR protocol assessed in the trial aims to do the same. The goal is not to solve complex mental health problems, but rather to reduce the burden of the coronavirus: Specifically, the protocol aims at relieving anxiety and stress and improving well-being and social connectedness through these two assets: i. The potential of (also) simulated nature for improving people’ wellbeing, health and ameliorating anxiety and depressive feelings (17–19) with or without a direct interaction with it (20). Crucially, simulated nature can ameliorate negative moods in the short-term, and besides individual preferences towards nature (20); ii. The potential of all types of VR formats, including 360° videos, to resemble even distant, complex, even paradoxical scenarios in a realistic, immersive and engaging way, thus providing the illusion of being really “there”, in the simulated place (21–23). This last asset provided by VR is the pathway to the transformation of people’s experiences in a several and profound ways (24–26). For instance, immersive experiences can enhance individuals’ personal efficacy and self-reflectiveness through the manipulation of the sense of presence, flow, and emotional engagement (27, 28). Moreover, VR’s unique ability to evoke complex emotions, which are drivers of people’ health, wellbeing and sense of social connection (29, 30), would allow designing unique experiences leading to long-terms benefits. The protocol will be based on the same 10-min 360° VR video (“The Secret Garden”) used by Chirico and colleagues (29, 30). “The Secret Garden” VR video has been developed through an integrated process involving psychologists, 3D artists, musicians, storytellers and designers (Figure 1). This immersive experience storyboard has been:
written by well-being psychologists to mimic the structure and the experience of walking in a Japanese garden (31) providing the visual (i.e., the flow of water) and auditory (i.e., the sound of running water) natural elements available outdoors.
● converted in a VR experience by 3D specialists using the Unreal Engine 4 technology.
● dubbed by a professional dubber in the different languages used in the trial using the back-translation method. In all languages a a slow, calm, clear voice provides a relaxation induction structured following the principles of Compassion Focused Therapy (32, 33). Specifically, the induction aims at deactivating the human threat protection system and activating the soothing system (with a mindset attended to giving and receiving care, affecting, and nurturance).
We decided to use a computer-graphic 360° video (artificial) instead of a video-recorded format (natural) for the following reasons. First, we selected a video whose efficacy in positive emotional induction was already validated in a previous study. Second, using computer-graphic it is easier to manipulate specific features of the natural environment aimed at improving positive affect (i.e., the extreme blossoming of the peach trees presented in the VR experience) that are more difficult to achieve using a real natural environment. Third, during lockdown was impossible access to real natural places.
Three hundred sixty–degree videos have the power to virtually transport users, immersing them in the video recording, allowing them to actively explore its content and experience the video from any angle. With this regard, as shown by Robertson and colleagues the neural representations of the part of the 360° video presented in VR (the scene within the current field of view) prime the associated representations of the full panoramic environment (34). In other words, 360° videos generate a dynamic interplay between memory and perception that can be used to improve the features of these cognitive processes and to update their content.
To anchor the generated update to the autobiographical memory of the user, at end of the VR exposure the subjects will be asked to perform together different tasks related to personal identity and interpersonal relationships (35). These tasks, are an adaptation of the different “emotional prescriptions” designed by the psychologist Guy Winch (35) to react to personal experiences that generate emotional pain: loneliness, rejection, or rumination. The tasks want to achieve the following goals: a) to pay attention and recognize emotional pain; b) work to treat it before it feels all-encompassing; c) monitor and protect self-esteem; d) find meaning even in difficult times.