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Can Intergroup Contact in Virtual Reality (VR) Reduce
Stigmatization Against People with Schizophrenia?
Daniela Stelzmann 1,* , Roland Toth 2and David Schieferdecker 2
Citation: Stelzmann, D.; Toth, R.;
Schieferdecker, D. Can Intergroup
Contact in Virtual Reality Reduce
Stigmatization Against People with
Schizophrenia? J. Clin. Med. 2021,10,
Academic Editors: Andreas Reif,
Blazej Misiak and Jerzy Samochowiec
Received: 29 May 2021
Accepted: 26 June 2021
Published: 30 June 2021
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1Institute of Computer Science, Freie Universität Berlin, 14195 Berlin, Germany,
2Institute for Media and Communication Studies, Freie Universität Berlin, 14195 Berlin, Germany;
email@example.com (R.T.); firstname.lastname@example.org (D.S.)
People with mental disorders such as schizophrenia do not only suffer from the symptoms
of their disorders but also from the stigma attached to it. Although direct intergroup contact is an
effective tool to reduce stigmatization, it is rare in real life and costly to be established in interventions,
and the success of traditional media campaigns is debatable. We propose Virtual Reality (VR) as
a low-threshold alternative for establishing contact since it involves less barriers for affected and
unaffected persons. In a 2 + 1 experiment (n= 114), we compared the effects of encounters with a
person with schizophrenia through a VR video with contact through a regular video and no contact
at all on anxiety, empathy, social proximity, and benevolence towards people with schizophrenia.
We found that contact via VR reduced stigmatization only for participants who liked the person
encountered. Our data suggest that it is crucial how participants evaluate the person that they
encounter and that stronger perception of spatial presence during reception plays an important role,
too. Therefore, we discussvarious boundary conditions that need to be considered in VR interventions
and future research on destigmatization towards mental disorders, especially schizophrenia.
Keywords: stigma; schizophrenia; mental disorders; virtual reality (VR); intergroup contact
In 2017, approximately 792 million people suffered from mental disorders world-
]. Affected persons do not only suffer from the symptoms of their mental disorder,
but also from the stigma attached to it [
]. The consequences of such stigmatization
are tremendous: It lowers affected persons’ self-esteem and their likeliness of seeking
professional help [
]. Accordingly, the World Health Organization (WHO) has made
stigma reduction one of its top priorities .
One approach to reducing stigmatization is to establish meaningful encounters be-
tween those who are affected by a mental disorder and those who are not [
direct intergroup contact is an effective tool for reducing stigmatization in the realm of
mental disorders, it only infrequently happens in real life and can be costly to establish
in the context of stigmatization campaigns and educational programs. Seeking alterna-
tive forms of contact, mass media campaigns yielded non-satisfying results [
], but ﬁrst
studies showed that computer-mediated intergroup contact can be an auspicious tool for
decreasing stigmatization [11,12].
We set out to test the potential of a digital technology that has not yet been in focus
regarding stigmatization towards people with mental disorders: Virtual Reality (VR).
The high sensual richness and involvement make VR a promising tool for intergroup
]. In the context of mental disorders, VR technology has mainly been studied
in the domain of cognitive behavioral therapy [
]. We are not aware of any study that
investigates intergroup contact via VR in the context of mental disorders [
]. To close
this gap, we conducted an experiment that tested the effects of VR/360
-3D videos on
J. Clin. Med. 2021,10, 2961. https://doi.org/10.3390/jcm10132961 https://www.mdpi.com/journal/jcm
J. Clin. Med. 2021,10, 2961 2 of 11
stigmatization towards people with schizophrenia, one of the most stigmatized mental
1.1. Stigma Towards People with Mental Disorders and Their Consequences
According to Goffman, a stigma is a deeply discrediting attribute attached to a person
or group [
]. Individuals who suffer from mental disorders are affected by various forms
of stigmatization [
]. The symptoms of the mental disorders are often cited as the
main cause of stigma since they can lead to deviant behavior and are sometimes hard to
comprehend for bystanders [
]. Particularly mental disorders that can induce psychotic
episodes—like schizophrenia—are commonly associated with danger, crime, and unpre-
]. These beliefs neglect the fact that mental disorders such as schizophrenia
are neither a necessary, nor a sufﬁcient precondition for violent behavior
stereotypes largely persist because media coverage is perpetuating images of violent “mad
men”, serial killers, and psychopaths and involves people with mental disorders like
schizophrenia primarily in the context of violence [24–27].
The stigma around mental disorders such as schizophrenia has real consequences for
affected persons. The unaffected majority feels more anxious, less empathic, more socially
distant towards affected persons, and is less supportive of policies that beneﬁt people with
mental disorders [
]. As a result, it can become even harder for affected individuals
to engage in positive contact with others—they feel socially isolated and disconnected
from society and suffer from low self-esteem [
]. Moreover, people with strongly
stigmatized mental disorders such as schizophrenia take longer to seek therapy and engage
in treatments [
] which may exacerbate existing symptoms [
]. Even when they do engage
in therapy, they are often faced with discrimination in the health care system .
1.2. Reducing Stigma Towards People with Mental Disorders
For a long time, scholars have studied ways to reduce stigmatization towards peo-
ple with mental disorders [
]. Among others, direct intergroup contact—face-to-face
encounters with affected persons—has emerged as an effective tool for improving attitudes
towards people with mental disorders in general [
] and schizophrenia in particular [
Having said this, opportunities for direct contact are scarce in real life because the lifetime
prevalence of mental disorders such as schizophrenia is low at approximately 0.5% [
Moreover, affected individuals either avoid contact, are being avoided, or will not reveal
their condition at all due to fear of stigmatization .
In response to the lack of direct contact, researchers investigated indirect forms of con-
tact, among others via media [
]. Contact via media can come as unidirectional, one-sided
exposure to one or more out-group member(s) (e.g., an affected person who recounts their
medical history). Theoretically, such encounters should be less anxiety-provoking, more
scalable for interventions and should protect people with mental disorders from stressful
experiences of unsupervised interactions in non-therapeutic settings. Since ﬁndings about
contact through traditional media are inconsistent and provide no clear effect patterns [
scholars began exploring contact in digital, computer-mediated settings [
]. For in-
stance, Maunder et al.
found a reduction of fear, anger, and stereotyping towards
people with schizophrenia after computer-mediated interaction.
One technology that has received little attention as a means for intergroup contact and
destigmatization, is VR. VR allows recipients to freely adjust their view in a 360
video or a
computer-animated space using a headset. Moreover, it enables rendering the perceived
scene in 3D as both eyes are provided separate screens. As such, VR allows for high levels
of perceived realism and immersion during media reception [14,41].
In the context of mental disorders, VR has been primarily studied in the context of
cognitive behavioral therapy for inducing attitudinal and behavioral change in patients
with mental disorders, for example, by exposing them to virtual situations that elicited
their fears, such as public speaking or spiders [
]. With regards to destigmatization,
ﬁrst research indicates that ﬁrst-hand experiences of the perceptions of an affected person
J. Clin. Med. 2021,10, 2961 3 of 11
(e.g., psychotic symptoms such as hearing noises) in a simulated VR environment can
increase empathy and positive attitudes towards persons with schizophrenia—at least
when the intervention is accompanied with additional empathy-inducing information [
Outside the realm of mental disorders, VR was also used to induce empathy by taking
virtual ﬁrst-person perspectives of racialized minorities [
], women experiencing partner
violence , and elderly help-seeking people .
Empirical studies that assess the effects of contact with an out-group member in VR
are scarce [
]—and with regards to mental disorder such as schizophrenia, to the best of
our knowledge, non-existent. This is a serious shortcoming, since exposure in VR—deﬁned
here as one-sided exposure to an affected person—should combine the advantages of
direct contact with those of mediated contact. VR should offer levels of sensual richness
and involvement—two core dimensions used to categorize different forms of intergroup
]—that are much higher than in other forms of media exposure, even if they lack
the interactive quality of direct contact [
]. At the same time, VR contact should not be
burdened by the anxiety that is often evoked by face-to-face contact and spares affected
people negative experiences, since their physical presence is not required. We therefore ask
the following explorative research question:
To what extent can contact with a person with schizophrenia through VR reduce stigma
associated with the mental disorder in comparison to no contact at all and a regular video?
2. Materials and Methods
We employed a 2 + 1 experimental design with two experimental groups that watched
either a VR video or a regular video and a control group.
2.1. Stimulus Material
We recorded a video of an actor portraying a young man with schizophrenia using a
-3D camera with multiple lenses (Insta360 Pro). As we expected our participants to be
fairly young, we chose a young actor to increase the likelihood that recipients relate and
identify with him due to their age. In line with this, we chose a male actor since males are
usually diagnosed with schizophrenia at a younger age compared to females [
on a bench outdoors, the young man spoke of his life with the schizophrenic disorder. In his
monologue, he recounted the appearance of ﬁrst symptoms and his medical history, gave
an account of his daily routines, and explained how his loved ones were trying to cope with
the situation. Although ﬁctitious, the monologue merged various real-life histories and
applied principles of narrative medicine [
] in order to make the person more relatable
and to allow for an empathetic response.
We rendered two videos from the recording. The ﬁrst video was a 360
that could be watched on a VR device. The option to freely look around the scene and the
perception of depth and distance ought to ensure maximum involvement and engagement
in the scene. The second video was a regular video with a ﬁxed perspective, centering on
the actor. Apart from the rendering modes, the videos were identical.
Assuming a small effect size,
= 0.15 [
] and allowing for
errors of 0.05 each,
a priori power analysis suggested a desirable sample size of 120 participants. We recruited
114 participants (n
= 31, n
= 45, n
= 38) via advertisements at a German public
university in June 2019. The mean age was M= 24 years (SD = 6.6 years), 58% of participants
were female and 63% had a high-school diploma. These demographics suggest that our
pool of participants consisted of majority, but not solely, students.
After arriving at the laboratory, participants were seated in front of a laptop and
randomly assigned to one of the three groups. They were informed about the study
procedure and their right to stop participation anytime. All participants were informed
J. Clin. Med. 2021,10, 2961 4 of 11
that they were about to answer questions regarding their perceptions of persons with
schizophrenia. Participants in the VR group and in the regular video group were addi-
tionally informed that they were about to watch a video of a person who suffered from
schizophrenia talking about their experiences, and—in the case of the VR video—that this
may cause slight dizziness.
In the VR group, the assistant then revealed the VR headset (Zeiss VR One with
aSamsung Galaxy S8) that was hidden in a drawer and helped the respondent mount
it. Participants were then given about 90 seconds to become acquainted with the virtual
surroundings. The assistant then started the video on the phone. In the regular video group,
the assistant started the video on the laptop. In the control group, no video was shown.
All participants then ﬁlled out a questionnaire on the laptop. At the end, participants
were comprehensibly debriefed and handed over a fact sheet about schizophrenia. For the
debrieﬁng document, see the online supplementary material (OSM) .
Since scholars have not agreed upon one uniﬁed measure of stigmatization, we used
four related constructs as outcome variables: anxiety, social proximity, empathy, and
benevolence. Knowing that intergroup contact is a powerful instrument for altering out-
group attitudes [
], we controlled for past exposure to people with schizophrenia (i.e.,
quantity of prior out-group contact). In addition, we controlled for two qualities of the
reception experience that are crucial in the context of contact, especially in VR settings: the
perceived attraction of the encountered person (i.e., evaluation of the out-group member)
and the immersion in the contact situation (i.e., feeling of spatial presence). Finally, we
controlled for gender and age as core demographic indicators.
We assessed all measures but contact frequency with a Likert-type scale ranging
from 1 (do not agree at all) to 7 (totally agree). Where applicable, we applied Conﬁrmatory
Factor Analysis (CFA) and Exploratory Factor Analysis (EFA) for uncovering underlying
dimensions within the scales. For all items and the analysis code, see the OSM.
We measured how anxious a participant would feel meeting a person with schizophre-
nia using items from intergroup anxiety scales [
]. Items included, for example, feeling
“nervous” or “alarmed”. The one-dimensional measure consisted of four items (ω= 0.85).
2.4.2. Social Proximity
We measured social proximity to persons with schizophrenia by inverting a scale
previously used by Angermeyer and Matschinger
. Items included, for
example, “I would accept a schizophrenic person as a coworker”. The one-dimensional
measure contained six items (ω= 0.86).
We measured empathy toward persons with schizophrenia using an indicator devel-
oped by Kinnebrock et al.
and used by Röhm
. The scale included items such as
“People underestimate the emotional burden caused by schizophrenia”. Since multiple EFA
did not lead to a satisfactory solution, we used the two highest-correlated items (r= 0.53)
and created a mean index (M= 5.54, SD = 1.06).
We measured benevolence toward persons with schizophrenia with the benevolence
dimension of the Community-Attitudes-Toward-the-Mentally-Ill Inventory (CAMI), trans-
lated to German by Angermeyer et al.
. We replaced the phrase “mentally ill” with
“persons with schizophrenia”. Items included, for example: “As a society, we need to adopt
a much more tolerant attitude towards persons with schizophrenia.” Since multiple EFA
J. Clin. Med. 2021,10, 2961 5 of 11
did not lead to a satisfactory solution, we used the two highest-correlated items (r= 0.48)
and created a mean index (M= 6.14, SD = 0.99).
We asked how much contact participants have had with persons with schizophrenia
within their “family, circle of friends or acquaintances within the past ﬁve years” on a scale
ranging from 0 (not at all)to5(a lot).
2.4.6. Spatial Presence
We measured feelings of spatial presence within the VR/regular video with the Spatial
Presence sub-scale from the MEC Spatial Presence Questionnaire [
]. It includes items
such as “I felt like I was actually there in the environment of the presentation”. The
one-dimensional measure included four items (ω= 0.93).
We measured the valence of participants’ evaluation of the person in the VR/regular
video with items from the General Evaluation Scale [
] and the intergroup anxiety
]. Attributes included, e.g., “likeable” or “natural”. The one-dimensional measure
contained four items (ω= 0.81).
2.5. Statistical Analysis
For data cleansing and analysis, we used R (Version 4.0.3; [
]) and the R-packages
lavaan (Version 0.6.8; [
]), and tidyverse (Version 1.3.1; [
]). Additional information, the
data, the analysis scripts, and a completely reproducible version of this manuscript can be
found in the OSM.
We ran various Structural Equation Models (SEM) to cover comparisons between our
experimental groups. We always used anxiety, social proximity, empathy, and benevolence
as outcome variables and controlled for the quantity of prior out-group contact, gender,
and age. For the comparison between the VR and regular video groups, we additionally
controlled for evaluation of the encountered group member and spatial presence during
reception. We focus on both statistical signiﬁcance and effect sizes/directions and report
signiﬁcance at p< 0.05.
See Table 1for the results.
In Model 1, we compared the VR group with the control group and found that contact
in VR did not decrease stigmatization in comparison to not having any exposure at all
(RMSEA = 0.070, CFI = 0.921). None of the effects were signiﬁcant, and in terms of mere
effect sizes, the VR video group showed more social proximity than the control group, but
also marginally more anxiety and marginally less empathy and benevolence.
In Model 2, we compared the VR group with the regular video group (RMSEA = 0.049,
CFI = 0.943). In this comparison, VR contact actually increased stigmatization. The VR
group showed signiﬁcantly more anxiety, signiﬁcantly less social proximity and empathy,
and less benevolence judging by the effect only. Contrasting VR with regular video contact
allowed us to account for context variables surrounding the reception experience. The
evaluation of the group member emerged as a crucial predictor: a more positive evaluation
of the encountered person signiﬁcantly decreased anxiety and signiﬁcantly increased social
proximity and benevolence, as well as empathy, judging by the effect only. Moreover, we
found that spatial presence during reception marginally decreased anxiety and increased
social proximity, empathy and benevolence—although only the effect on benevolence
In Model 3, we compared the regular video group with the control group (
RMSEA = 0.082,
CFI = 0.873). In comparison to no exposure, the regular video decreased anxiety, increased
J. Clin. Med. 2021,10, 2961 6 of 11
empathy, social proximity, and marginally benevolence—although only the effect for social
proximity reached statistical significance.
SEM results for group difference, spatial presence, evaluation, contact, female gender, and age predicting anxiety,
social proximity, empathy, and benevolence.
Proximity Empathy Benevolence
Model 1 (VR vs. Control) (n= 60)
VR −0.009 0.943 0.133 0.281 −0.144 0.234 −0.038 0.750
Contact −0.426 0.000 0.365 0.003 0.235 0.048 0.214 0.023
Female 0.020 0.867 −0.051 0.691 −0.056 0.640 −0.060 0.608
Age 0.166 0.131 −0.405 0.000 −0.050 0.739 −0.373 0.000
Model 2 (VR vs. Regular video) (n= 69)
VR 0.508 0.032 −0.506 0.039 −0.507 0.046 −0.328 0.196
Spatial presence −0.052 0.679 0.214 0.097 0.101 0.437 0.247 0.046
Evaluation −0.323 0.004 0.472 0.000 0.254 0.069 0.363 0.003
Contact −0.397 0.000 0.378 0.001 0.084 0.493 0.242 0.003
Female 0.080 0.482 −0.032 0.756 −0.003 0.981 0.118 0.232
Age −0.048 0.547 −0.200 0.023 −0.120 0.124 −0.138 0.403
Model 3 (Regular video vs. Control) (n= 74)
Regular video −0.175 0.157 0.311 0.020 0.098 0.425 0.005 0.967
Contact −0.302 0.009 0.271 0.020 0.199 0.101 0.045 0.650
Female 0.014 0.904 −0.029 0.794 −0.113 0.310 0.024 0.833
Age −0.057 0.507 −0.291 0.011 −0.039 0.718 −0.146 0.400
Model 4 (VR vs. Control, high evaluation) (n= 54)
VR −0.115 0.425 0.414 0.002 −0.029 0.818 0.223 0.071
Contact −0.402 0.008 0.298 0.028 0.284 0.052 0.116 0.319
Female −0.016 0.907 −0.084 0.549 −0.180 0.182 −0.243 0.054
Age 0.121 0.276 −0.467 0.000 0.001 0.994 −0.325 0.001
Note: Robust ML estimation, standardized coefﬁcients
To corroborate the impression from Model 2, we re-ran the comparison between the
VR group and the control group just for participants who evaluated the group member
in the video in a positive way, i.e., who scored higher than the median value, in Model 4
(RMSEA = 0.102, CFI = 0.821). As a result, the effect of the VR video changed directions.
VR exposure signiﬁcantly increased social proximity and—although not signiﬁcantly—also
increased benevolence and decreased anxiety.
Finally, it is notable that more prior direct contact decreased stigmatization constantly
and mostly signiﬁcantly in all models. Although gender had no signiﬁcant effect, older
participants usually showed higher levels of stigmatization.
This study aimed for contributing to the growing literature on destigmatization
of mental disorders via contact interventions by testing the potential of VR technology.
Speciﬁcally, we investigated whether intergroup contact with a person with schizophrenia
through VR technology can decrease stigmatization towards people with schizophrenia.
Our study revealed that contact through VR is not a magic bullet for reducing stigma-
tization in the context of mental disorders. Encountering a person talking about their life
with schizophrenia in VR did not signiﬁcantly decrease stigmatization. Judging by effect di-
rection only, contact via VR may even have negative effects and perpetuate existing stigma.
In comparison to watching the regular video, VR contact was associated with signiﬁcantly
more stigmatization in three out of four outcomes. At the same time, participants who
J. Clin. Med. 2021,10, 2961 7 of 11
watched the regular video showed slightly less stigma than the control group. At ﬁrst
glance, the negative effects of the VR video intervention are counter-intuitive, since the
sensual richness and personal involvement of VR promised to make it an effective form of
intergroup contact [
]. However, considering the effects of our covariates, we can offer a
ﬁrst explanation for this ﬁnding.
In our study, evaluation of the encountered group member emerged as the most impor-
tant factor for a successful destigmatization via VR. A positive evaluation was negatively
associated with all indicators of stigmatization, regardless of the type of video. Moreover,
contact in VR did decrease stigmatization among respondents who evaluated our actor in
a positive way. It is therefore essential to establish in advance that the encountered person
appears likeable to the target audience . This may be particularly important for mental
disorders such as schizophrenia that are stereotypically associated with threat [19,20].
The evaluation of the encountered person was important in VR, but not in the regular
video which decreased stigmatization independently of it. Subjects were likely over-
whelmed by the VR experience and therefore processed the video in a peripheral, heuristic
]. Among participants in the VR condition, none were routine users of the tech-
nology; the majority had rarely tried it and one third reported they had never used it before.
For inexperienced users, the location shift and 3D perspective in a virtual environment
can be a strong sensual experience [
] — many participants in the VR group may have
been primarily concerned with adjusting to it. This probably led to restricted cognitive
capacity and paying attention speciﬁcally to information in the actor’s monologue that
was congruent with existing stereotypes and judging the actor by heuristic cues such as
]. Moreover, participants may have felt as if they had no control or agency
in the contact situation: the setting was a 360
-3D video in which they could not adjust
] and had to dismount the headset in order to interrupt the encounter. In such a
situation, the level of comfort likely depends more strongly on the likeability of the person
encountered. Appropriately, participants who felt higher spatial presence showed slightly
Based on our ﬁndings, future researchers do not only need to choose a likeable person
for VR contact, but simultaneously ensure high levels of immersion without making the
experience overwhelming, which is in line with previous research [
]. Several solutions
might be feasible. First, participants should be offered even more time to become used to
the VR condition, e.g., by showing them one or two unrelated videos in the beginning, and
therefore allowing them to later focus on the encounter itself rather than adjusting to the
]. Second, once likeable actors are identiﬁed, VR-based destigmatization
campaigns could repeatedly expose participants to them. Not only could participants grow
even more familiar with the technology such as this, but repeated, positive intergroup con-
tact such as friendships are known to be more effective than superﬁcial once-off
Familiarity-based liking and decreased (anticipated) anxiety could work particularly well
for a group that is conceived as unpredictable. Third, recipients can be part of an immersive
setting, yet not actively involved, if the VR video presents a situation of so-called vicarious
], meaning that participants are exposed to an interaction between an out-group
and an in-group member rather than directly to the out-group member. Finally, health care
professionals—who represent trustworthy sources of health information [
integrated in the contact setting to moderate, comment and contextualize the narrative
Altogether, we only expect positive effects from VR encounters if the contact situation
is carefully calibrated. The assumed advantages of VR over other forms of mediated
contact may turn out to be disadvantages otherwise. Future research should investigate
the suggestions introduced above. While it was not in the focus of this article, our results
indicate the importance of direct intergroup contact as a means for reducing stigmatization,
as the mere quantity of prior contact was constantly associated with less stigmatization.
J. Clin. Med. 2021,10, 2961 8 of 11
Our study is a ﬁrst exploration of the potential of VR contact for reducing stigmatiza-
tion against persons with schizophrenia. As an explorative study, it is limited regarding
four ways. First, using a sample that predominantly consists of students can have advan-
tages for exploratory studies with limited sample size, since age and education are rather
homogeneous. However, a more heterogeneous sample would yield more generalizable
]. Second, different mental disorders are associated with different types of stigma.
VR interventions might be more effective in the context of mental disorders that are less
associated with threat, such as major depressive disorder or eating disorders [
Third, while we found several consistent effect patterns among our outcome variables,
some of the effects were not statistically signiﬁcant. We already used a small expected
effect size (
= 0.15) in power analysis, so future researchers should use an even smaller
one. Finally, we presented participants with a natural setting in which they could not
engage in a real conversation with the encountered person, but rather in a para-social
form of contact [
]. Since prior studies demonstrated the effectiveness of interactive
computer-mediated contact [
], future studies should explore fully animated VR settings
that allow for interactions—although these may lack in realism and credibility.
In contrast to our expectations, contact through VR did not reduce stigmatization as
compared to no contact and led to more negative attitudes as compared to contact through
a regular video in our study. This effect shifted once we only considered individuals
who evaluated the encountered group member positively. Our ﬁndings offer ﬁrst insights
into the conditions of successful destigmatization through contact in VR—namely how
it could be optimized to maximize positive effects and minimize undesirable outcomes.
We hope this study instills a greater engagement with the potential of new technologies
for generating pro-social attitudes towards people with mental disorders in general and
people with schizophrenia in particular and thus contributes to a better quality of life for
Conceptualization, D.S. (Daniela Stelzmann), R.T. and D.S. (David Schiefer-
decker); Methodology, D.S. (Daniela Stelzmann), R.T. and D.S. (David Schieferdecker); Software,
R.T.; Analysis, R.T.; Writing—Original Draft Preparation, D.S. (Daniela Stelzmann), R.T. and D.S.
(David Schieferdecker); Writing—Review and Editing, D.S. (Daniela Stelzmann), R.T. and D.S. (David
Schieferdecker); All authors have read and agreed to the published version of the manuscript.
Funding: The publication of this article was funded by Freie Universität Berlin.
Institutional Review Board Statement:
This social science study was conducted according to the
norms of the Code of Ethics of the World Medical Association [
]. As is common in social science
studies, the ethical evaluation of the study was conducted within the department. Since no concerns
were expressed about the study and no patients were involved, an external ethical review was waived
for this study. Nevertheless, during recruitment, potential participants were informed about the
content of the study to assure that at the start of the experiment, all participants were fully aware
that mental disorders were addressed. All information acquired was anonymous.
Informed Consent Statement:
Written informed consent was obtained from all subjects involved in
Data Availability Statement:
All data and code to reproduce the analysis is available at https:
//osf.io/9m4ex/?view_only=cc93e18a04024103abddaf734dd7507f, accessed 29 June 2021.
Conﬂicts of Interest: The authors declare no conﬂict of interest.
J. Clin. Med. 2021,10, 2961 9 of 11
Ritchie, H.; Roser, M. Mental Health. 2018. Available online: https://ourworldindata.org/mental-health (accessed on
29 May 2021).
Angermeyer, M.C.; Beck, M.; Dietrich, S.; Holzinger, A. The stigma of mental illness: patients’ anticipations and experiences. Int.
J. Soc. Psychiatry 2004,50, 153–162. [CrossRef] [PubMed]
Latalova, K.; Kamaradova, D.; Prasko, J. Perspectives on perceived stigma and self-stigma in adult male patients with depression.
Neuropsychiatr. Dis. Treat. 2014, 1399. [CrossRef] [PubMed]
Schulze, B.; Angermeyer, M.C. Subjective experiences of stigma. A focus group study of schizophrenic patients, their relatives
and mental health professionals. Soc. Sci. Med. 2003,56, 299–312. [CrossRef]
Franz, L.; Carter, T.; Leiner, A.S.; Bergner, E.; Thompson, N.J.; Compton, M.T. Stigma and treatment delay in ﬁrst-episode
psychosis: a grounded theory study. Early Interv. Psychiatry 2010,4, 47–56. [CrossRef]
Link, B.G.; Struening, E.L.; Neese-Todd, S.; Asmussen, S.; Phelan, J.C. Stigma as a Barrier to Recovery: The Consequences of
Stigma for the Self-Esteem of People With Mental Illnesses. Psychiatr. Serv. 2001,52, 1621–1626. [CrossRef]
Schomerus, G.; Angermeyer, M.C. Stigma and its impact on help-seeking for mental disorders: what do we know? Epidemiol.
Psichiatr. Soc. 2008,17, 31–37. [CrossRef] [PubMed]
8. World Health Organization (WHO). Mental Health Action Plan 2013–2020; WHO: Geneva, Switzerland, 2013.
Maunder, R.D.; White, F.A. Intergroup contact and mental health stigma: A comparative effectiveness meta-analysis. Clin.
Psychol. Rev. 2019,72. [CrossRef]
10. Stuart, H. Reducing the stigma of mental illness. Glob. Ment. Health 2016,3, e17. [CrossRef]
Amsalem, D.; Yang, L.H.; Jankowski, S.; Lieff, S.A.; Markowitz, J.C.; Dixon, L.B. Reducing Stigma Toward Individuals With
Schizophrenia Using a Brief Video: A Randomized Controlled Trial of Young Adults. Schizophr. Bull. 2021,47, 7–14. [CrossRef]
Maunder, R.D.; White, F.A.; Verrelli, S. Modern avenues for intergroup contact: Using E-contact and intergroup emotions to
reduce stereotyping and social distancing against people with schizophrenia. Group Process. Intergroup Relations
Harwood, J. The Contact Space: A Novel Framework for Intergroup Contact Research. J. Lang. Soc. Psychol.
O’Donnell, A.W.; Friehs, M.T.; Bracegirdle, C.; Zúñiga, C.; Watt, S.E.; Barlow, F.K. Technological and analytical advancements in
intergroup contact research. J. Soc. Issues 2021,77, 171–196. [CrossRef]
Meyerbröker, K.; Emmelkamp, P.M.G. Virtual reality exposure therapy in anxiety disorders: a systematic review of process-and-
outcome studies. Depress. Anxiety 2010,27, 933–944. [CrossRef] [PubMed]
Feldman, D.B.; Crandall, C.S. Dimensions of Mental Illness Stigma: What About Mental Illness Causes Social Rejection? J. Soc.
Clin. Psychol. 2007,26, 137–154. [CrossRef]
17. Goffman, E. Stigma: Notes on the Management of Spoiled Identity, 26th ed.; Simon and Schuster: New York, NY, USA, 1986.
Corrigan, P.W.; Rao, D. On the Self-Stigma of Mental Illness: Stages, Disclosure, and Strategies for Change. Can. J. Psychiatry
2012,57, 464–469. [CrossRef] [PubMed]
Angermeyer, M.C.; Dietrich, S. Public beliefs about and attitudes towards people with mental illness: a review of population
studies. Acta Psychiatr. Scand. 2006,113, 163–179. [CrossRef]
Wood, L.; Birtel, M.; Alsawy, S.; Pyle, M.; Morrison, A. Public perceptions of stigma towards people with schizophrenia,
depression, and anxiety. Psychiatry Res. 2014,220, 604–608. [CrossRef]
Large, M.M.; Ryan, C.J.; Singh, S.P.; Paton, M.B.; Nielssen, O.B. The Predictive Value of Risk Categorization in Schizophrenia.
Harv. Rev. Psychiatry 2011,19, 25–33. [CrossRef]
22. Stuart, H. Violence and mental illness: an overview. World Psychiatry 2003,2, 121. [PubMed]
Varshney, M.; Mahapatra, A.; Krishnan, V.; Gupta, R.; Deb, K.S. Violence and mental illness: what is the true story? J. Epidemiol.
Community Health 2016,70, 223–225. [CrossRef]
Aragonès, E.; López-Muntaner, J.; Ceruelo, S.; Basora, J. Reinforcing Stigmatization: Coverage of Mental Illness in Spanish
Newspapers. J. Health Commun. 2014,19, 1248–1258. [CrossRef] [PubMed]
Delahunt-Smoleniec, N.; Smith-Merry, J. A Qualitative Analysis of the Portrayal of Young People and Psychosis in Australian
News Reports. J. Pract. 2019, 1–16. [CrossRef]
Ischebeck, J.; Kuhle, L.F.; Rosenbach, C.; Stelzmann, D. Journalism and pedophilia: Background on the media coverage of a
stigmatized minority. Stigma Health 2021. [CrossRef]
Stelzmann, D.; Jahnke, S.; Kuhle, L.F. Media Coverage of Pedophilia: Beneﬁts and Risks from Healthcare Practitioners’ Point of
View. Int. J. Environ. Res. Public Health 2020,17, 5739. [CrossRef] [PubMed]
Parcesepe, A.M.; Cabassa, L.J. Public stigma of mental illness in the United States: A systematic literature review. Adm. Policy
Ment. Health 2013,40, 384–399. [CrossRef] [PubMed]
29. Hirschberg, W. Social isolation among schizophrenic out-patients. Soc Psychiatry 1985,20, 171–178. [CrossRef]
Kleim, B.; Vauth, R.; Adam, G.; Stieglitz, R.D.; Hayward, P.; Corrigan, P. Perceived stigma predicts low self-efﬁcacy and poor
coping in schizophrenia. J. Ment. Health 2008,17, 482–491. [CrossRef]
Lysaker, P.H.; Tsai, J.; Yanos, P.; Roe, D. Associations of multiple domains of self-esteem with four dimensions of stigma in
schizophrenia. Schizophr. Res. 2008,98, 194–200. [CrossRef] [PubMed]
J. Clin. Med. 2021,10, 2961 10 of 11
MacDonald, E.; Sauer, K.; Howie, L.; Albiston, D. What happens to social relationships in early psychosis? A phenomenological
study of young people’s experiences. J. Ment. Health 2005,14, 129–143. [CrossRef]
Drake, R.J.; Haley, C.J.; Akhtar, S.; Lewis, S.W. Causes and consequences of duration of untreated psychosis in schizophrenia. Br.
J. Psychiatry 2000,177, 511–515. [CrossRef]
Mestdagh, A.; Hansen, B. Stigma in patients with schizophrenia receiving community mental health care: A review of qualitative
studies. Soc. Psychiatry Psychiatr. Epidemiol. 2014,49, 79–87. [CrossRef] [PubMed]
Alexander, L.; Link, B. The impact of contact on stigmatizing attitudes toward people with mental illness. J. Ment. Health
12, 271–289. [CrossRef]
West, K.; Hewstone, M.; Lolliot, S. Intergroup Contact and Prejudice Against People With Schizophrenia. J. Soc. Psychol.
154, 217–232. [CrossRef]
Simeone, J.C.; Ward, A.J.; Rotella, P.; Collins, J.; Windisch, R. An evaluation of variation in published estimates of schizophrenia
prevalence from 1990-2013: a systematic literature review. BMC Psychiatry 2015,15. [CrossRef]
Lim, M.H.; Gleeson, J.F.M.; Alvarez-Jimenez, M.; Penn, D.L. Loneliness in psychosis: a systematic review. Soc. Psychiatry
Psychiatr. Epidemiol. 2018,53, 221–238. [CrossRef] [PubMed]
Boccanfuso, E.; White, F.A.; Maunder, R.D. Reducing Transgender Stigma via an E-contact Intervention. Sex Roles
84, 326–336. [CrossRef]
40. Mallett, R.K.; Wilson, T.D. Increasing positive intergroup contact. J. Exp. Soc. Psychol. 2010,46, 382–387. [CrossRef]
Freeman, D.; Reeve, S.; Robinson, A.; Ehlers, A.; Clark, D.; Spanlang, B.; Slater, M. Virtual reality in the assessment, understanding,
and treatment of mental health disorders. Psychol. Med. 2017,47, 2393–2400. [CrossRef]
Valmaggia, L.R.; Latif, L.; Kempton, M.J.; Rus-Calafell, M. Virtual reality in the psychological treatment for mental health
problems: An systematic review of recent evidence. Psychiatry Res. 2016,236, 189–195. [CrossRef]
Kalyanaraman, S.; Penn, D.L.; Ivory, J.D.; Judge, A. The virtual doppelganger: Effects of a virtual reality simulator on perceptions
of schizophrenia. J. Nerv. Ment. Dis. 2010,198, 437–443. [CrossRef]
Banakou, D.; Hanumanthu, P.D.; Slater, M. Virtual Embodiment of White People in a Black Virtual Body Leads to a Sustained
Reduction in Their Implicit Racial Bias. Front. Hum. Neurosci. 2016,10, 601. [CrossRef] [PubMed]
Gonzalez-Liencres, C.; Zapata, L.E.; Iruretagoyena, G.; Seinfeld, S.; Perez-Mendez, L.; Arroyo-Palacios, J.; Borland, D.; Slater, M.;
Sanchez-Vives, M.V. Being the Victim of Intimate Partner Violence in Virtual Reality: First- Versus Third-Person Perspective.
Front. Psychol. 2020,11, 820. [CrossRef] [PubMed]
Dyer, E.; Swartzlander, B.J.; Gugliucci, M.R. Using virtual reality in medical education to teach empathy. J. Med Libr. Assoc.
106, 498. [CrossRef] [PubMed]
Riecher-Rössler, A. Geschlechtsunterschiede bei Schizophrenie—mögliche therapeutische Implikationen. In Psychische Erkrankun-
gen bei Frauen; Riecher-Rössler, A., Rohde, A., Eds.; Karger: Basel, Switzerland, 2001; pp. 73–91. [CrossRef]
48. Charon, R. Narrative Medicine: A Model for Empathy, Reﬂection, Profession, and Trust. JAMA 2001,286, 1897. [CrossRef]
49. Stephan, W.G.; Stephan, C.W. Intergroup Anxiety. J. Soc. Issues 1985,41, 157–175. [CrossRef]
Stephan, W.G.; Ybarra, O.; Martnez, C.M.; Schwarzwald, J.; Tur-Kaspa, M.; Martínez, C.M.; Schwarzwald, J.; Tur-Kaspa, M.
Prejudice toward Immigrants to Spain and Israel: An Integrated Threat Theory Analysis. J. Cross Cult. Psychol.
Angermeyer, M.C.; Matschinger, H. Auswirkungen der Reform der psychiatrischen Versorgung in den neuen Ländern der Bundesrepublik
Deutschland auf die Einstellung der Bevölkerung zur Psychiatrie und zu Psychisch Kranken: Ergebnisse Einer Empirischen Erhebung;
Nomos: Baden-Baden, Germany, 1995; p. 130.
Röhm, A. Stigmatisierung und Entstigmatisierung von Menschen mit Behinderungen: Einﬂuss unterschiedlicher medialer Darstellungen
auf Einstellungen und Handlungsintentionen; Universitätsbibliothek Dortmund: Dortmund, Germany, 2017.
Kinnebrock, S.; Hastall, M.; Bilandzic, H. Differential Effects of News Stories: Class, Gender, Format and Narrative Engagement as
Interacting Factors Inﬂuencing News Selection, Learning and Attitude Change; Technical report; International Society for the Empirical
Study of Literature and Media: Utrecht, The Netherlands, 2010.
Angermeyer, M.C.; Heiß, S.; Kirschenhofer, S.; Ladinser, E.; Löfﬂer, W.; Schulze, B.; Swiridoff, M. Die Deutsche Version des
Community-Attitudes-toward-the-Mentally-III(CAMI)-Inventars. Psychiatr. Prax. 2003,30, 202–206. [CrossRef] [PubMed]
Vorderer, P.; Wirth, W.; Gouveia, F.R.; Biocca, F.; Saari, T.; Jäncke, L.; Böcking, S.; Schramm, H.; Gysbers, A.; Hartmann, T.; Klimmt,
C.; Ravaja, N.; Sacau, A.; Baumgartner, T.; Jäncke, P. MEC Spatial Presence Questionnaire (MEC-SPQ). Short Documentation and
Instructions for Application. Report to the European Community, Project Presence: MEC (IST-2001-37661). Retrieved Sept
Wright, S.C.; Aron, A.; McLaughlin-Volpe, T.; Ropp, S.A. The Extended Contact Effect: Knowledge of Cross-Group Friendships
and Prejudice. J. Personal. Soc. Psychol. 1997,73, 73–90. [CrossRef]
57. R Core Team. R: A Language and Environment for Statistical Computing, Vienna, Austria; 2020.
58. Rosseel, Y.; Jorgensen, T.D.; Rockwood, N. Lavaan: Latent Variable Analysis; 2021.
59. Wickham, H. tidyverse: Easily Install and Load the Tidyverse; 2021.
Petty, R.E.; Cacioppo, J.T. The Elaboration Likelihood Model of Persuasion. In Communication and Persuasion; Springer: New York,
NY, USA, 1986; pp. 1–24. [CrossRef]
Hill, K.J.; Howarth, P.A. Habituation to the side effects of immersion in a virtual environment. Displays
,21, 25–30. [CrossRef]
J. Clin. Med. 2021,10, 2961 11 of 11
Shin, D. Empathy and embodied experience in virtual environment: To what extent can virtual reality stimulate empathy and
embodied experience? Comput. Hum. Behav. 2018,78, 64–73. doi:10.1016/j.chb.2017.09.012. [CrossRef]
Takayama, L.; Pantofaru, C. Inﬂuences on proxemic behaviors in human-robot interaction. In Proceedings of the 2009 IEEE/RSJ
International Conference on Intelligent Robots and Systems, 11–15 October 2009, St. Louis, MO, USA; pp. 5495–5502.
Naqvi, S.A.A.; Badruddin, N.; Malik, A.S.; Hazabbah, W.; Abdullah, B. Does 3D produce more symptoms of visually induced
motion sickness? In Proceedings of the 2013 35th Annual International Conference of the IEEE Engineering in Medicine and
Biology Society (EMBC), 3–7 July 2013, Osaka, Japan; pp. 6405–6408.
Narciso, D.; Bessa, M.; Melo, M.; Coelho, A.; Vasconcelos-Raposo, J. Immersive 360
video user experience: impact of different
variables in the sense of presence and cybersickness. Univers. Access Inf. Soc. 2019,18, 77–87. [CrossRef]
Pettigrew, T.F.; Tropp, L.R. A meta-analytic test of intergroup contact theory. J. Personal. Soc. Psychol.
,90, 751–783. [CrossRef]
Joyce, N.; Harwood, J. Improving Intergroup Attitudes through Televised Vicarious Intergroup Contact: Social Cognitive
Processing of Ingroup and Outgroup Information. Commun. Res. 2014,41, 627–643. [CrossRef]
Asan, O.; Yu, Z.; Crotty, B.H. How clinician-patient communication affects trust in health information sources: Temporal trends
from a national cross-sectional survey. PLoS ONE 2021,16, e0247583. [CrossRef]
Peterson, R.A. On the Use of College Students in Social Science Research: Insights from a Second-Order Meta-analysis. J.
Consum. Res. 2001,28, 450–461. [CrossRef]
Mond, J.M.; Robertson-Smith, G.; Vetere, A. Stigma and eating disorders: Is there evidence of negative attitudes towards anorexia
nervosa among women in the community? Null 2006,15, 519–532. [CrossRef]
Oliffe, J.L.; Ogrodniczuk, J.S.; Gordon, S.J.; Creighton, G.; Kelly, M.T.; Black, N.; Mackenzie, C. Stigma in Male Depression and
Suicide: A Canadian Sex Comparison Study. Community Ment. Health J. 2016,52, 302–310. [CrossRef]
Rodgers, R.F.; Paxton, S.J.; McLean, S.A.; Massey, R.; Mond, J.M.; Hay, P.J.; Rodgers, B. Stigmatizing Attitudes and Beliefs
Toward Bulimia Nervosa The Importance of Knowledge and Eating Disorder Symptoms. J. Nerv. Ment. Dis. 2015,203, 259–263.
73. Schiappa, E.; Gregg, P.B.; Hewes, D.E. The Parasocial Contact Hypothesis. Commun. Monogr. 2005,72, 92–115. [CrossRef]
World Medical Association. WMA Declaration of Helsinki—Ethical Principles For Medical Research Involving Human Subjects.
Available online: https://www.wma.net/policies-post/wma-declaration-of-helsinki-ethical-principles-for-medical-research-
involving-human-subjects/ (accessed on 29 May 2021).