Complex Socio-emotional Learning in VR-based Simulation Training Among Persons With Mental Health and/or Substance Use Disorders"
Conditions: Substance Use Disorders, Mental Disorder
Sponsor: Sykehuset Innlandet HF

 
 
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Research Protocol 
 
“Complex socio-emotional learning in VR-based simulation training among persons with 
mental health and/or substance use disorders” 
1. 
Introduction 
This Ph.D. study is a part of a larger project called «Virtual Reality (VR) as a facilitator for participation 
in society among persons with mental health/substance use disorders» in which aims to explore, 
develop and evaluate a VR-based paradigm that facilitates social participation and promotes social 
recovery of individuals with mental health and/or substance use disorders (MHD/SUD). The overall 
project comprises three work packages: an exploration study, a development study, and an evaluation 
study. This Ph.D. study will make up work package 1. 
 
Overall VR- project organization 
 
 
2. 
Hypothesis, aims and objectives 
The primary aim of this study (WP1) is to explore facilitators and barriers for participation in society 
among person with MHD/SUD, and to provide an understanding of mechanisms of social participation 
and social cohesion among persons with MHD/ SUD that may be affected by VR-based interventions. 
Finally, we will derive a socio-emotional learning domain to facilitate key interpersonal and social 
processes among persons with MHD/SUD in VR-based interventions. To achieve the purpose of this 
study we will explore facilitators and barriers for social participation as experienced as by individuals 
with MHD/SUD and identify key interpersonal and social processes suitable to be addressed by tailored 
VR based interventions.  
A key factor in the utilization of VR-based learning is to target the simulation scenarios and learning 
mechanisms toward specific learning objectives, situations and circumstances to promote real life 
value of the VR experiences [5-9]. Facilitators and barriers of participation in society among persons 
with MHD/SUD is a topic of severe complexity. In addition, VR-based learning interventions carry a 
substantial learning complexity with a vast variety of learning mechanisms affecting the learning 
outcome of the simulations [1-4]. In computer-simulated learning environments, all the significant 
learning mechanisms must be created artificially. Thus, we need to provide a comprehensive 
understanding of both social participation mechanisms and learning prerequisites among the target 
group in the exploratory study (WP1) for the research group in the development study (WP2) to be 
able to tailor the VR-paradigm to the user’s needs and preferences. Based on the service user’s needs, 
preferences and wishes, we will determine specific learning goals needed to gain necessary skills, 
abilities, attitudes, and knowledge to participate fully in economic, social and cultural life in the society 
in which they live.  
 
Moreover, we will explore the didactical aspects of how we can create tailored learning experiences 
that facilitates the achievement of the service user’s (persons with MHD/SUD) desired learning 
objectives. [1, 2, 6]. The didactical approach to the VR-intervention development is crucial for the 
utility value of VR-based interventions in real life. The theoretical foundation of adult learning is 
primarily based on healthy and well-functioning adults. However, the combination of mental health 
WP 1
Explorative 
study
WP 2 
Development 
study
WP 3 
Evaluation 
study
VRT

 
 
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disorders, childhood trauma experiences, different kinds of acute and sustained substance use effects, 
long-term substance use consequences  and different kinds of withdrawal effects often found among 
people with concurrent MHD/SUD both enhances dissocial behaviours and paralyze inhibitory 
behavioural regulation that for many leads to substantial social impairment [10-19].  
Thus, we must anticipate that we not only need to study what the persons in our target group need to 
learn in order to increase their social skills mastery, but that it will be equally important to study how 
our respondents learn, in order to create an effective learning paradigm that will provide real life value 
for the participants.  
 
To our knowledge, the interpersonal determinants and prerequisites of adults with MHD/SHD have 
not been studied in this kind of context.  
 
The secondary aims of the study are: 
1. To explore key interpersonal and social processes of social inclusion and social exclusion among 
persons with mental health and/or substance use disorders from the service provider’s 
perspective. 
2. To derive a socio-emotional learning domain for facilitating participation in society among 
persons with mental health and/or substance use disorders 
3. To explore the application of VR in complex socio- emotional learning domain for facilitating 
participation in society among persons with mental health and/or substance use disorders. 
 
The following research questions will be addressed:  
1
What is the significance of interpersonal, social, and circumstantial barriers of social cohesion 
and social participation among persons with concurrent MHD/SUD? 
2
What is the significance of social inclusion for individual well - being and instrumental 
functioning among persons with MHD/SUD? 
3
What are the most suppressing social and circumstantial barriers for social participation among 
persons with MHD/SUD from municipal service provider’s point of view? 
4
What is the best way to facilitate the necessary skills, abilities, attitudes and knowledge to 
participate fully in economic, social and cultural life and to enjoy a standard of living and 
wellbeing among persons with MHD/SUD and substantial social impairment in VR-based 
learning experiences? 
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What is the best way to efficiently applicate VR based learning for complex social learning in 
terms of real-life value for the service users? 
3. 
Project justification 
 
VR development has so far either been commercially driven or aimed at health professional’s skills 
training. This study will focus on the exploration of the service user’s needs, wishes, preferences and 
terms for learning and form a knowledge foundation to tailor the VR-paradigm to the learning 
determinants and learning prerequisites among the MHD/ SUD service users. This study fills the 
research gap between real-life and health technology, in this case virtual reality (VR), that may enhance 
the social participation and quality of life of one of the most vulnerable service user groups.  
Our study has desired societal impacts for several stakeholders: 

 
 
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Anticipated mechanisms and outcome 
 
We anticipate both direct real-life user value from VR-participation, and additionally increased 
knowledge about the socio-emotional disabilities among person with MHD/SUD. In turn, we may 
increase the understanding of these peoples struggles with social impairments and lack of social 
support. Ultimately, this study also will contribute to a better facilitation of external social 
participation mechanisms and social opportunities.  
 
4. 
Research participants, organization and collaborations 
The initiative for this research project comes from the Norwegian Advisory Unit on Concurrent 
Substance Abuse and Mental Health Disorders (NKROP), which has established a research group in 
cooperation with Innlandet Hospital Trust, Hamar municipality, the user organization RIO and VID 
Specialized University.  
 
Lars Lien, senior researcher at NKROP, will take on the role as project manager.  
NKROP has been collaborating previously with the partners of this project: RIO was involved in the 
development of the National guideline for patients with concurrent mental health and addiction 
disorders, which was led by NKROP. In addition, the municipality Hamar cooperated with NKROP on 
several recovery projects and recently on a project on the impact of COVID-19 on persons with 
MHD/SUD. In this study, we cooperate with excellent international partners from: Yale School of 
Medicine (USA), the University of Regensburg (Germany), Hamburg Centre for Health Economics 
(Germany), University of Stockholm (Sweden) and King's College, London (UK). 
 
Service User involvement 
Our study approach provides for service user involvement from the design of the study to 
dissemination of the results. The Norwegian service user board, established by NKROP in 2012, has 
approved the final study protocol. Service users from our collaboration partner RIO (service user 
organization) act as multipliers; they will disseminate the project into their peer communities where 
we will also recruit the 20 participants in WP2 (the development study). Service users and peers with 
training in research will be invited to co-author articles, take part in conferences, and plan community 
meetings based on the project results. 

 
 
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The Research Group comprises 
Name 
Affiliation 
Core Competencies 
Task 
Lars Lien 
Professor HINN, UIO, UIT. 
Former director of NKROP 
Project management 
Social psychology 
Project leader 
Marja Leonhardt 
Lecturer at VID specialized 
University. Post.doc NKROP 
Epidemiology 
Mixed methods 
Project Leader 
Main Supervisor 
Bente Røstad  
RIO  
Peer support research  
Project partner  
Håvard Vibeto 
Associate Professor HINN 
VR-development 
Project Partner 
Phillip Lindner 
Psychologist 
VR-researcher 
Karolinska Institutet 
Clinical VR-development 
Project Partner 
Anita Østheim  
 
Head of Centre for Life 
Mastery Hamar 
municipality  
Cognitive therapy  
 
Project partner  
 
Torgeir 
Sørensen 
Associate professor at VID 
specialized University 
 
Co-supervisor 
Jan Aasen 
Ph.D. Candidate at NKROP 
 
Recruitment, interviews, 
analysis, & publications  
Kari Galaaen 
Psychologist Specialist 
Hamar Municipality 
Lecturer VID 
 
Researcher Study 2 
Recruitment, interviews, 
analysis, & publications 
Morten Brodahl  
 
Peer support worker 
NKROP, leader service user 
board  
Peer support research 
Advisory board member, 
Recruitment WP1-2, 
Observer focus groups 
WP1  
 
Fredrik Nilssen 
Regional head of RIO 
Rune Lundquist  
 
Sagatun Brukerstyrt Senter, 
Hamar  
Michael Rowe 
Prof of Psychiatry, Yale 
School of Medicine, USA  
Research on citizenship as 
an applied theoretical 
framework for social 
inclusion with MHD  
 
 
 
Members of the advisory 
board  
 
Morris Bell 
Prof. of Psychiatry, Yale 
School of Medicine, USA 
VR job interview training 
program, clinical trials 
Lucia Valmaggia 
Prof. of Psychology at 
King’s College London, UK 
Clinical psychology and 
digital mental health,  
RCT with VRT 
Valerie 
DeMarinis 
Prof. public MH & 
psychology of religion at 
Inland Hospital Trust & 
Uppsala University, SI 
Cultural psychology, 
intervention and prevention 
program 
5. 
Subject recruitment 
Target Group 
The target group of this project are both male and female adults diagnosed with mental health and 
substance use disorders (MHD/SUD), and substantial social impairment in the last two years 
Participants 
We will recruit the participants of this study among adults diagnosed with MHD/SUD, receiving local 
services in our collaborating municipality (Hamar). Inclusion criteria are being above 18 years of age 
and receiving services in the municipality of Hamar due to mental health and /or addiction problems. 
Exclusion criteria will be visual and hearing impairment, neurological disorders, and mental retardation 
[score ≤70 on the Test of Intelligence]. Participant recruitment will be conducted by, and in 
collaboration with the peer support researchers at NKROP, RIO, Sagatun Brukerstyrt Senter and Hamar 
commune. 

 
 
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6. 
Project arrangements, method selection and analysis 
Studies and data collection  
To facilitate a comprehensive understanding of the factors that contribute to both social participation 
and real-life learning outcome from VR-based learning for WP 2, we need to collect a wide variety of 
data and a conduct a variety of analysis. Therefore, we will organize our work package in three 
empirical studies and one literature survey. Each of these studies will generate data for publication. 
Finally, we will synthesize all four studies together in one compound socio-emotional learning domain, 
tailored to the MHD/SUD service user’s learning prerequisites in VR-based learning disseminations. 
The separate studies will be differently analyzed, both by quantitative and qualitative analysis. The 
reason for this mixing of methods is to utilize the advantages from different methods and use the 
results from the different data sets to explain each other’s patterns in the analysis. To achieve the 
proper understanding of data during the analysis we will need to consecutively exchange preliminary 
findings between the studies. In addition, WP1 and WP2 needs to be coordinated in a joint planning 
and preparation process. WP1 is therefore carefully orchestrated: 
 
Work package 1 orchestration 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

 
 
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Study descriptions 
Study 1 
Exploration of key interpersonal and social barriers among persons with mental health and 
/ or substance use disorders from the users perspective  
Quantitative approach 
Research 
Questions 
1. What is the significance of interpersonal, social, and circumstantial barriers 
of social cohesion and social participation among persons with concurrent 
MHD/SUD? 
2. What is the significance of social inclusion for individual well - being and 
instrumental functioning among persons with MHD/SUD? 
Method 
In this study we will conduct a quantitative interview survey, as this method is 
suitable for a vulnerable target group such as persons with MHD/SUD and promises 
a higher commitment and validity of data as an interviewer guides the participants 
through the assessment tools[20] 
Data 
Collection 
Health and social workers from our collaboration partner (Hamar municipality) and 
the members of the research group will conduct the interviews on an individual 
basis – either in person or via telephone. Data collection will be managed by 
designated and trained local health care workers in cooperation with service user 
representatives who also will take part as peer researchers. 
Subject 
Recruitment 
For this study, we will recruit 100 persons receiving services in Hamar, Stange, Løten, 
Ringsaker, Elverum and/ or Oslo due to their MHD/SUD. N=100 
Assessment 
Tools and 
Analysis 
Social and Community Opportunities Profile (SCOPE) measuring social participation 
[21], MANSA quality of life [22], R-CD-Risc10 resilience[23], and Practical & social 
functioning  (PSF) version 2.1. The SCOPE questionnaire is being translated and 
culturally adapted to the Norwegian context by the Norwegian Advisory Unit for 
Concurrent MHD and SUD (NKROP). The instruments QoL-MANSA , R-CD-Risc10, and 
PSF 2.1 have all been validated in a Norwegian context [24] The results will be 
analyzed by using linear and multiple regression models 
 
 
Study  2
Exploration of key interpersonal and social barriers among persons with mental 
health  and / or substance use disorders from the users perspective 
Qualitative approach 
Research 
Questions 
1. What is the significance of interpersonal, social, and circumstantial barriers 
of social cohesion and social participation among persons with concurrent 
MHD/SUD? 
2. What is the significance of social inclusion for individual well - being and 
instrumental functioning among persons with MHD/SUD? 
Method
We will conduct qualitative individual interviews applying the method of “user 
interviews user” [25]. 
Data 
Collection 
Members of our collaborating service user organization RIO, and peer support 
worker at NKROP will perform the interviews. 
Data collection will be managed by designated and trained local health care 
workers in cooperation with service user representatives who also will take part as 
peer researchers. 
Subject 
Recruitment
We will use a criterion-based sampling procedure in the recruitment of a 
heterogeneous sample of max. 20 persons (adults diagnosed with MHD/SUD with 
substantial impairment in the last two years), receiving local services in our 
collaborating municipalities. 
Assessment 
Tools and 
Analysis  
Transcripts from the individual interviews will be analyzed using Brown and Clark’s 
thematic analysis[26]. The steps include coding, categorizing, and meaning -making, 
moving from the manifest to the latent content of the text. 

 
 
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Study  3
Exploration of key interpersonal and social barriers among persons with mental 
health  and / or substance use disorders from municipal  health service providers 
point of view, qualitative approach 
Research 
Questions 
3. What are the most prominent barriers for social participation among 
persons with MHD/SUD from municipal service provider’s point of view? 
Method
Qualitative focus group interviews. 
 
Data 
Collection 
For RQ4, we will conduct two focus group interviews (each group ca. 5-7 persons)
Subject 
Recruitment
Service providers, recruited from Hamar municipality (N total = ca. 10-14 persons)
Analysis
Transcripts from the individual interviews will be analyzed using Brown and Clark’s 
thematic analysis[26]. Data collection and analysis will be conducted by project 
partner in Hamar municipality 
 
Study  4 
Explore the application of VR-based learning in complex socio-emotional learning among 
persons with MHD/SUD,  
Research 
Questions 
4. 
What is the best way to facilitate the necessary skills, abilities, attitudes and 
knowledge to participate fully in economic, social and cultural life and to 
enjoy a standard of living and wellbeing among persons with MHD/SUD in 
VR-based learning experiences? 
5. What is the best way to efficiently applicate VR based learning for complex 
social learning in terms of real-life value for the service users? 
Method 
The main purpose of research questions 4 and 5 is to bridge the gap between the 
understanding of barriers for social participation among individuals with MHD/SUD 
and VR-intervention development. In this study we will also determine which 
learning goals will be best suited for specifically tailored VR- based learning, and 
which didactical requirements will be best suited for the facilitation of the 
determined learning goals. To answer these research questions, we will perform a 
literature survey on adult learning theories and adult learning taxonomy and focus 
group interviews with VR- engineering experts at the Virtual Reality Lab 
NIHR/Welcome Trust King’s College Clinical Research Facility in London. These focus 
group interviews will be arranged as dialogue conferences where the preliminary 
analysis of study 1-3, and VR application will be discussed. 
Data 
Collection 
Literature survey
Focus group interview 
Subject 
Recruitment 
We will recruit VR- developers with expert knowledge on development of VR 
paradigms for social learning. N=5 
Analysis 
We will audiotape the dialogue conference and the transcriptions will put together 
into one compound text material that will be analyzed using Lindwalls (2010) five- 
step hermeneutical text interpretation. This analyzing process includes text 
integration, fusion of pre-understandings, text questioning, categorization of themes 
and sub-themes, and summary of the new understandings. This analysis process can 
be seen as a dialogue between the scientific researcher’s theoretical pre-
understanding and the co-researches empirical pre-understandings in the text. It is 
through this dialogue the theoretical and empirical pre-understandings merge into 
new knowledge[28].  
 

 
 
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7. 
Plan for implementation 
Our developed and tested VR-paradigm will be implementation ready if the evaluation shows sufficient 
learning outcome. The implementation may be conducted through NKROP, in which provides the 
training of the Norwegian FACT-Teams (Flexibel Assertive Community Treatment). These FACT teams 
provide assertive outreach treatment for persons with concurrent mental health and substance abuse 
disorders and specialize in taking the services directly to the patients in their own home environment 
and their local community.  In addition, this study will provide knowledge on what hinders or promotes 
social inclusion within their recovery process. This understanding will facilitate not only the 
development of tailored recovery measures, but also measures to prevent persons with MHD/SUD 
being marginalized and falling out of society. Further, applying the newly culturally adapted 
assessment tool SCOPE in a large study to measure social inclusion will be of great additional value, 
not only in public health but also in social science research in Norway, as it will be the first tool to 
measure social inclusion of persons with MHD/SUD. The development of a prototype of VRT to 
enhance social inclusion will have a far-reaching impact for several disadvantaged groups, which may 
face difficulties participating in society; our “welfare technology” will easily be adaptable for other 
groups than those with MHD/SUD. Our research will provide a blueprint for how a VR experience may 
be designed. Although developed and applied in the welfare sector, it may encourage use in other 
sectors as well.  
8. 
Funding and interests 
This project is funded by the Research Council of Norway (projectnr 326773) and is administrated by 
the research department at Innlandet Hospital Trust, The National Advisory Board of Concurrent 
Mental Health and Substance Abuse Disorders.  
9. 
Ethical Considerations 
The project will be conducted in line with the Norwegian guidelines for medical and health research 
as well as the Declaration of Helsinki. Consent to participate in the research project will be collected 
from service users by the recruiting service. All participants will be informed about the benefits and 
risks of participating in the project and give written consent to participate. The Ph.D. fellow will 
process collected data. Data will be stored in the hospital's approved research server in unidentified 
form. The link between the data files and the person identity will be stored separately in locked 
cabinet. Participation can be withdrawn at any time without giving a reason. 
10. 
Safety Considerations  
This study will focus on the mechanisms and significance of social participation and social cohesion 
for persons with mental health and/or substance abuse disorders.  We will conduct individual 
interview survey and individual interviews among the service user participants, who is considered a 
vulnerable group. Peer service users and/ or trained service providers will conduct the interviews. We 
consider this to entail a low risk, in which to a very small extend will constitute any safety issues for 
the participants. Nevertheless, professional peer research workers will supervise the interviews. I 
addition, we will also conduct focus group interviews, where professional service providers will be 
participants. We do not consider this group of participants as a vulnerable group, and see no safety 
issues regarding the focus group interviews. There will not be conducted any VR-based simulation 
testing in this study. However, the results of this study are intendent to be utilized in the further 
development of a VR-based paradigm, in which makes it necessary for us to take safety considerations 
of VR simulation into account from the very beginning of the VR-development process.  
 

 
 
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All VR -based simulations creates an altered sense of reality. However, most individuals with intact 
mental functioning can distinguish between virtual and real environments and efficiently detect 
errors or distortions. Persons with already impaired senses of reality may be at high risk for further 
distortion of their reality testing. Persons with higher levels of dissociative symptoms thou far from 
clinical levels of dissociation has shown increased dissociative symptoms and decreased objective 
reality after exposure to VR for 20 minutes. This suggests that dissociation, depersonalization and 
derealization may be triggered through discontinuity in perceptual environments, and that it is 
possible that prolonged periods of discontinuity in objective perception may have harmful effects in 
vulnerable individuals 
 
11. 
Schedule 
 
 
 
 
Year 
2021 2022 
2023 
2024 
Task Quarter 
Q4 
Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 
   Study 1  
 
 
 
 
 
 
 
 
 
 
 
 
 
1.1 Study planning and preparing 
 
 
 
 
 
 
 
 
 
 
 
 
 
1.2 Cultural adaption of SCOPE 
 
 
 
 
 
 
 
 
 
 
 
 
 
1.3 Recruitment and training of peer researchers 
 
 
 
 
 
 
 
 
 
 
 
 
 
1.4 Data collection: User Interview survey 
 
 
 
 
 
 
 
 
 
 
 
 
 
1.5 Data Analysis  
 
 
 
 
 
 
 
 
 
 
 
 
 
1.6 Writing up article 1 
 
 
 
 
 
 
 
 
 
 
 
 
 
  Study 2 
 
 
 
 
 
 
 
 
 
 
 
 
 
2.1 Planning and preparing 
 
 
 
 
 
 
 
 
 
 
 
 
 
2.2 Recruitment 
 
 
 
 
 
 
 
 
 
 
 
 
 
2.3 Data collection:  Focus groups 
 
 
 
 
 
 
 
 
 
 
 
 
 
2.4 Data analysis  
 
 
 
 
 
 
 
 
 
 
 
 
 
2.5 Writing up article 2 
 
 
 
 
 
 
 
 
 
 
 
 
 
Study 3 
 
 
 
 
 
 
 
 
 
 
 
 
 
3.1 Study planning an preparing 
 
 
 
 
 
 
 
 
 
 
 
 
 
3.2 Recruitment 
 
 
 
 
 
 
 
 
 
 
 
 
 
3.3 Data Collection 
 
 
 
 
 
 
 
 
 
 
 
 
 
3.4 Data Analysis 
 
 
 
 
 
 
 
 
 
 
 
 
 
3.5 Writing up article 3 
 
 
 
 
 
 
 
 
 
 
 
 
 
Study 4 
 
 
 
 
 
 
 
 
 
 
 
 
 
4.1 Planning and preparing 
 
 
 
 
 
 
 
 
 
 
 
 
 
4.2 Litterature Survey 
 
 
 
 
 
 
 
 
 
 
 
 
 
4.3 Dialouge Conference King’s College London UK.  
 
 
 
 
 
 
 
 
 
 
 
 
 
4.4 Data analysis  
 
 
 
 
 
 
 
 
 
 
 
 
 
4.5 writing up article 4 
 
 
 
 
 
 
 
 
 
 
 
 
 
Cross study tasks 
 
 
 
 
 
 
 
 
 
 
 
 
 
1 
 Study protocol revision 
 
 
 
 
 
 
 
 
 
 
 
 
 
2 
Research Group meeting 
 
 
 
 
 
 
 
 
 
 
 
 
 
3 
PHD Courses 
 
 
 
 
 
 
 
 
 
 
 
 
 
4 
Writing up meta report and synopsis 
 
 
 
 
 
 
 
 
 
 
 
 
 
5 
Defense 
 
 
 
 
 
 
 
 
 
 
 
 
 

 
 
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12. 
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