Mentalization as "the mental process by which an individual implicitly and explicitly interprets the actions of self and others as meaningful on the basis of intentional mental states such as personal wants, needs, feelings, beliefs, and reasons. Soft skills refer to a set of positive personal attributes and competences that improve relationships, work performance and market value. Social skills such as communication and cognition become part of soft skills when it comes to negotiation skills and the ability to interact positively with each other. The latter also refer to a set of skills that determine how we interact with others; this depends on the quality of mentalization processes. Virtual reality, also known as computer-simulated reality or videogenerated environments, is a computer technology that simulates imaginary or real environments such as classrooms. The power of this technique lies in the rapid construction of various realistic training and stimulus control environments. Several studies have demonstrated the efficiency of simulation using VR for knowledge acquisition but there is a lack of studies focused on mentalization and soft skills involvement. The aim of this study is to clarify the relationship between using VR and the improvement of mentalization through activities involving soft skills.
Mentalization as "the mental process by which an individual implicitly and explicitly interprets the actions of self and others as meaningful on the basis of intentional mental states such as personal wants, needs, feelings, beliefs, and reasons [1]. Authors define “Hypo-mentalization” as the inability to consider complex models of mental states, resulting in an impaired ability to understand others and the self [1].
Soft skills refer to a set of positive personal attributes and competences that improve relationships, work performance and market value [2]. Soft skills play a very important role in the workplace, job position as well as in the success of your career. These skills are applicable to each field of work and they are usually individual behavioral traits [3,4]. Several studies state that a combination of personal qualities and soft skills will certainly contribute to improving the employability of graduates [5,6], especially soft skills which are broadly applicable [3]. The latter also refers to a set of abilities that determine how we interact with others [1]. ‘Soft skills represent a dynamic combination of cognitive and meta-cognitive skills, interpersonal, intellectual and practical skills. Soft skills help people to adapt and behave positively so that they can deal effectively with the challenges of their professional and everyday life.’ In this instance, soft skills relate to a vast range of interpersonal and social qualities and competences, transferable across economic sectors and industries [7,8]. It's believed that students need to develop specific skills in order to adjust to the culture of their schools. This is because researchers claim that these traits help students better adapt to the school’s atmosphere and help them become more proactive. [9]. Additionally, emotional intelligence studies support the theory that students need to be clever at communicating with others. This is because it's believed that these skills will predict positive careers and lead to more teamwork in an era of rapid globalization. It's also believed that these skills are necessary for effective cross-cultural communication and retaining talent in organizations [10,11,12]. Several pieces of European Commission paperwork [13,14,15] and many HR specialists [16] stated that young graduates’ ‘soft skills’ are very important to their employability. These skills include the ability to work well with others, communicate clearly skills (such as the ability to work in teams, to communicate clearly and effectively, to adapt to different cultural contexts, to solve problems, to manage conflicts, to show endurance in complicated or stressful situations, etc.), adapt to new cultures and solve problems (i.e. the capacity to deal with a problem in a creative way). Social skills such as communication and cognition become part of soft skills when it comes to negotiation skills and the ability to interact positively with each other [17]. The latter also refer to a set of skills that determine how we interact with others [18]; this depends on the quality of mentalization processes.
We decided to clarify whether an intervention based on these skills would improve mentalization skills by using a virtual environment that allow a rapid construction of various life-like situations and a specific stimulus control. There are many studies in literature about using Virtual Reality in the rehabilitation of many disorders, but few studies focus on the use of VR in the development of soft skills and improvement of mentalization ability.
Virtual reality, also known as computer-simulated reality or video-generated environments, is a computer technology that simulates imaginary or real environments such as classrooms [19, 20].
Immersive VR, Tabletop VR, Projected VR and CAVE (C - Automated Virtual Environment) are the most commonly used types of VR. The power of this technique lies in the rapid construction of various realistic training and stimulus control environments [21-24]. The development of VR systems provides many advantages, such as create an environment that meets the needs of students, provides stability between users and stimuli, and fully records students' behaviors and functions, enables rapid feedback, saves time and money, and provides more interesting tools to motivate them to use this technique [21,22]. In the rehabilitation field, VR technologies enable people with impairments and disabilities due to brain damage to experience everything that is difficult or impossible for them in reality [24,27], however, it may be used as a educational tool to allow students to experience life-like events.
Several studies have demonstrated the efficiency of simulation using VR for knowledge acquisition and for technical [27,28] and nontechnical [29,30] skills. Among the studies, the most frequently investigated soft skill is teamwork [31,32,33,40,38]; then, there is communication [31,34,37,40] followed by situation awareness, [31,37,38] decision-making [31, 35, 40] leadership [41, 44] and stress management [44, 45]. We referred to these skills mostly.
Virtual reality may be an innovative tool that may improve the educational system because of its efficiency and the capacity of data generation: VR simulators can track and record every action. The data are used to give learners feedback on their performance and progress over time through their profile, allowing them to verify their skills acquisition and become proactive in their learning.
The aim of this study is to clarify the relationship between using VR and the improvement of mentalization through activities involving soft skills.
In this study, we considered 40 subjects aged between 15 and 16. All the subjects had been recruited from the same city (Caserta, Italy) belonging to the same high school (scientific address) and they were homogeneous in terms of the socio‐cultural background of the parents. Therefore, the inclusion criteria were as follows: (a) a IQ between 95-105 through the WISC-IV [46,47] (b) absence of other psychiatric illness assessed by K-SADS [48] (c) medium‐high socio‐cultural class assessed through the SES scale [49].
After confirming the inclusion criteria of the sample, the subjects did not have different sociocultural factors. The sample was divided into two groups, 20 subjects each group.
In order to assess mentalization skills, The Reflective Functioning Questionnaire was assessed in two times: the first time (T0) after 4 months since the beginning of the school, and the second time (T1) at the end. The interventions lasted 5 months.
The data were collected at the FINDS Neuropsychiatry Outpatient Clinic by licensed psychologists in collaboration with the University of International Studies of Rome (UNINT).
The protocol used consists of the following tests:
SES: Self-administered questionnaire that allows collecting information about the level of education and professional of parents and indicates the position of the person or family within the social system [49];
WISC-IV: the IQ has been evaluated through the administration of Wechsler scales [46], multicomponent intelligence scales that allow to synthesize the intellectual ability of a subject through a global IQ index, the Verbal Comprehension Index (ICV, verbal reasoning ability on the basis of previously learned information), the Visuo-Perceptive Reasoning Index (IRP), the Index of Working Memory (IML, ability to maintain information and use it within seconds) and the Processing Speed Index (IVE, ability to process information efficiently).
YRFQ – 8: to provide an easy to administer self-report measure of mentalizing. It is composed of 8 item on the ability to infer mental states [50];
K-SADS: a diagnostic interview for the evaluation of psychopathological disorders (past and present) in children and adolescents aged 6 to 17 years according to the criteria of DSM-5. It consists of: an introductory unstructured interview, a diagnostic screening interview, a checklist for the administration of diagnostic supplements, five diagnostic supplements (mood disorders, psychotic disorders, anxiety disorders, attention deficit disorders and disruptive behavior, substance abuse) for each of which the criteria required by the DSM are provided, a comprehensive checklist of the patient’s clinical history and a scale for the overall assessment of the current functioning of the child (VGF) [48].
We administered the Y-RFQ 8 after 4 months from the beginning of school. After that we provided two types of interventions: in the experimental group it was used the Virtual Reality, while in the control group it was administered the intervention without using it. It was composed of a training course (frontal lessons and laboratory activities) organized by the University of International Studies of Rome (UNINT). It is structured as follows: an overall of 15 hours divided into 5 modules (3 hours each). Three theoretical modules that provide lectures with final debate among students. The first one was a theoretical lesson on the emotional regulation and affective development; the second one was on the awareness of themselves and the other one focusing on know our and the others’ mind; the third one was on our relationships and the differences between each other. Moreover, the practical modules were respectively on the exploration of our emotions and telling our life history to the class as an instrument of self and the other-knowledge. In the Virtual Reality sessions they had to view a video on the topics above mentioned. After that the played with a game in which they should interact actively in specific life-like situations. The intervention lasted 5 months. Finally, we assessed Y-RFQ 8 and we measured the mentalization skills after the intervention.
0 1 0 1 1 2 1 2 1 2 1 2
Data analysis was conducted using SPSS 26.0 (2019) statistical data collection software. Significance at the 1% level (α < 0.001) was accepted. We compared the two groups (variable between =Gr1, group with VR and Gr2, group without VR) with T0 and T1 (variable within - time) to see if there was any normalization in the two subscales of Y-RFQ8 after the educational intervention. We want to check if there is an improvement between T0 and T1, but also between the two groups because one group used VR. Therefore, we performed ANOVA 2x2 mixed with repeated measurements: within (time) and between (group) factor.
This analysis showed the following results: Interaction time*group is significant [F (1,39) = 2.98, p<0.001]. This data indicates that there is a significant interaction between time and the group. More specifically, between the pre and post educational intervention and between groups there is a significant normalization of both subscales, more significant in Gr1 that had carried out a training through VR (table 1, table 2, figure 1, figure 2).
Interaction scale*time is significant [F (1.39) = 53,79, p<0.001]. This data indicates that there is a significant interaction between the two subscales and time.
13.53 13.48 10.61 11.92
7.56 7.63 9.68 8.22
SD 1.67 1.52 1.29 1.21 SD 1.50 1.61 1.32 1.33
F
F
More specifically, there is a significant improvement in mentalization skills after the intervention; at T0 the RFQ_U was low while the RFQ_C was high, while at T1 both tend to normalize (table 3).
Interaction scale*group is significant [F (1.39) = 52,58, p<0.001]. This data indicates that there is a significant interaction between the two subscales and groups.
More specifically, there is a significant improvement in mentalization skills after the intervention in both groups; the RFQ_U was lower in the Gr1 than Gr2, while the RFQ_C was higher in the Gr1 than Gr2 (table 4).
Learning has an 'affective component', described as one of four key criteria for simulation-based learning, which aligns with learners' needs, with motivation and self-efficacy being key concepts [51]. Also, note that many VR simulators enable participants to repeat their sessions, which helps them recognize and analyze their interactions and emotions [52]. Trainees emphasized and valued the emotional impact of VR simulations on self-efficacy,[53] as did the opportunities they provided to communicate with other disciplines or experience some scenarios of human interaction in problematic settings prior to any clinical practice [54]. In terms of motivation, VR simulations seem to be of particular interest, as it has been described as a very valuable learning experience, [55] superior to traditional taught lectures, [56] and seen as excellent preparation for clinical situations [57].
Another interest in VR simulation is data generation, since VR simulators track and record every movement. This data is used to provide learners with feedback on their performance and progress through their profiles, allowing them to review their skill acquisition and be proactive about their learning. However, they can also help educators better understand student learning processes by allowing them to customize inputs and complement their traditional teaching methods with appropriate simulations [58].
The most commonly studied soft skills are interpersonal and social skills, such as teamwork and communication. As a cognitive ability, it is also known as mentalizing ability. In fact, it's a vital personal skill, especially in a dynamic environment. Virtual reality can be used to render these environments very realistically.
In our research, where we tried to do this through virtual reality, we found that mentalizing skills tended to normalize in the experimental group. The control group showed improvements in mentalizing skills, but less than the experimental group.
These results suggest that VR may be involved in these processes due to its ability to reproduce more realistic and dynamic environments for student interaction and learning.
In conclusion, virtual reality simulation system is the latest development in education. The use of VR simulators for technical skills training has increased, but non-technical skills are less used than soft skills (i.e., cognitive and interprofessional social skills).
Evaluation of VR systems as training tools is essential, but little systematic research has been done so far. Most studies assessed the usability and acceptability of VR simulations, and few studies measured the impact of VR simulations on soft skills and mentalization development.
Nevertheless, the development of VR technologies and the portability of VR systems offer a very promising outlook for the future training. The wide range of possible scenarios that can be simulated, especially for soft skills training, will undoubtedly contribute to the progress of educational system.
[1] Bateman A, Fonagy P (2004): Psychotherapy for Borderline Personality Disorder: Mentalization
Based Treatment. Oxford, UK, Oxford University Press. [2] Sejzi, A. A., Aris, B., & Yuh, C. P. (2013, April). Important soft skills for university students in 21th century. In Conference: 4th International Graduate Conference on Engineering, Science, and Humanities (IGCESH 2013) at, Universiti Teknologi Malaysia (UTM), Johor. [3] Attakorn, K., Tayut, T., Pisitthawat, K., & Kanokorn, S. (2014). Soft skills of new teachers in the secondary schools of Khon Kaen Secondary Educational Service Area 25, Thailand. ProcediaSocial and Behavioral Sciences, 112, 1010-1013. [4] Gruzdev, M. V., Kuznetsova, I. V., Tarkhanova, I. Y., & Kazakova, E. I. (2018). University Graduates' Soft Skills: The Employers' Opinion. European journal of contemporary education, 7(4), 690-698. [5] Karpov, 2011 – Karpov, A.V. (2011). Professionalism of the modern teacher. Methodology for assessing the level of qualifications of pedagogical workers. Karpov, I.V. Kuznetsova, M.D.
Kuznetsova, V.D. Shadrikov. Moscow: Logos. 168 p. [6] Wye, C. K., & Lim, Y. M. (2009). Perception Differential between Employers and Undergraduates on the Importance of Employability Skills. International education studies, 2(1), 95-105. [7] Hurrell, S. A. 2016. “Rethinking the Soft Skills Deficit Blame Game: Employers, Skills
Withdrawal and the Reporting of Soft Skills Gaps.” Human Relations 69 (3): 605–628 [8] Deloitte Access Economics. 2017. Soft Skills for Business Success. https://www2.deloitte.com/content/dam/Deloitte/au/ Documents/Economics/deloitte-aueconomics-deakin-soft-skills-business-success-170517.pdf. [9] Harvey, L. 2000. “New Realities: The Relationship Between Higher Education and
Employment.” Tertiary Education & Management 6 (1): 3–17 [10] Goleman, D. 1995. Emotional Intelligence. New York: Bantam. [11] Goleman, D., and R. Boyatzis. 2008. “Social Intelligence and the Biology of Leadership.”
Harvard Business Review September: 74–81 [12] Claxton, G., A. L. Costa, and B. Kallick. 2016. “Hard Thinking About Soft Skills.” Educational
Leadership 73 (6): 60–64 [13] EC (European Commission). 2012a. An agenda for new skills and new jobs in Europe: Pathways towards full employment. http://ec.europa.eu/research/social-sciences/pdf/new-skils-and-jobsin-europe_en.pdf. [14] EC (European Commission). 2012b. Rethinking education strategy: Investing in skills for better socio-economic outcomes. http://ec.europa.eu/education/news/rethinking/com669_en.pdf. [15] EC (European Commission). 2013. Modernisation of Higher Education. Report on Improving the quality of teaching and learning in Europe’s higher education institutions. http://ec.europa.eu/education/library/reports/modernisation_en. pdf. [16] Grugulis, I., and S. Vincent. 2009. “Whose Skill Is It Anyway? ‘Soft Skills and Polarization.”
Work, Employment and Society 23 (4): 597–615. [17] Touloumakos A. K. (2020). Expanded Yet Restricted: A Mini Review of the Soft Skills
Literature. Frontiers in psychology, 11, 2207. [18] Sejzi, A. A., Aris, B., & Yuh, C. P. (2013). Important soft skills for university students in 21th century. In Conference: 4th International Graduate Conference on Engineering, Science, and Humanities (IGCESH 2013) at, Universiti Teknologi Malaysia (UTM), Johor. [19] Schwebel DC, Gaines J, Severson J. (2008) Validation of virtual reality as a tool to understand and prevent child pedestrian injury. Accid Anal Prev; 40:1394-400. [20] Reid D. (2002) Virtual reality and the person-environment experience. Cyberpsychol Behav; 5:559-64. [21] Yeh SC, Tsai CF, Fan YC, Liu PC, Rizzo A, editors. (2012). An innovative ADHD assessment system using virtual reality. In: 2012 IEEE EMBS International Conference on Biomedical Engineering and Sciences;; Langkawi, Malaysia. [22] Parsons TD, Bowerly T, Buckwalter JG, Rizzo AA. (2007) A controlled clinical comparison of attention performance in children with ADHD in a virtual reality classroom compared to standard neuropsychological methods. Child Neuropsychol;13:363-81. [23] Rizzo AA, Buckwalter JG. (1997) Virtual reality and cognitive assessment and rehabilitation: the state of the art. Stud Health Technol Inform;44:123-45. [24] Rose FD, Attree EA, Brooks BM, Andrews TK. (2001) Learning and memory in virtual environments: A role in neurorehabilitation? Questions (and occasional answers) from the University of East London. Presence: Teleoper Virtual Environ;10:345-58. [25] Gongsook P, (2012) editor. Time simulator in virtual reality for children with attention deficit hyperactivity disorder. In: Herrlich M, Malaka R, Masuch M, editors. Entertainment Computing - ICEC 2012. ICEC 2012. Lecture Notes in Computer Science, vol 7522. Berlin; Springer. [26] Agha RA, Fowler AJ. The role and validity of surgical simulation. Int Surg 2015;100(2):350– 357. [27] Harder BN. Use of simulation in teaching and learning in health sciences: a systematic review. J
Nurs Educ 2010;49(1):23–28. [28] McGaghie WC, Issenberg SB, Cohen ER, Barsuk JH, Wayne DB. Does simulation-based medical education with deliberate practice yield better results than traditional clinical education? A metaanalytic comparative review of the evidence. Acad Med 2011;86(6):706–711. [29] Cumin D, Boyd MJ, Webster CS, Weller JM. A systematic review of simulation for multidisciplinary team training in operating rooms. Simul Healthc 2013;8(3):171–179. [30] von Wendt CEA, Niemi-Murola L. Simulation in interprofessional clinical education: exploring validated nontechnical skills measurement tools. Simul Healthc J Soc Simul Healthc 2017;1. [31] Cohen D, Sevdalis N, Patel V, Taylor M, Lee H, Vokes M, et al. Tactical and operational response to major incidents: feasibility and reliability of skills assessment using novel virtual environments. Resuscitation 2013;84(7):992–998. [32] Heinrichs WL, Youngblood P, Harter P, Kusumoto L, Dev P. Training healthcare personnel for mass-casualty incidents in a virtual emergency department: VED II. Prehosp Disaster Med 2010;25(5):424–432. [33] Khan R, Scaffidi MA, Walsh CM, Lin P, Al-Mazroui A, Chana B, et al. Simulation-based training of non-technical skills in colonoscopy: protocol for a randomized controlled trial. JMIR Res Protoc 2017;6(8):e153 [34] Brewin J, Tang J, Dasgupta P, Khan MS, Ahmed K, Bello F, et al. Full immersion simulation: validation of a distributed simulation environment for technical and non-technical skills training in Urology. BJU Int 2015;116(1):156–162. [35] Brunckhorst O, Shahid S, Aydin A, McIlhenny C, Khan S, Raza SJ, et al. Simulation-based ureteroscopy skills training curriculum with integration of technical and non-technical skills: a randomised controlled trial. Surg Endosc 2015;29(9):2728–2735. [36] Greci LS, Ramloll R, Hurst S, Garman K, Beedasy J, Pieper EB, et al. vTrain: a novel curriculumfor patient surge training in amulti-user virtual environment (MUVE). Prehosp Disaster Med 2013;28(3):215–222. [37] Khan R, Scaffidi MA, Walsh CM, Lin P, Al-Mazroui A, Chana B, et al. Simulation-based training of non-technical skills in colonoscopy: protocol for a randomized controlled trial. JMIR Res Protoc 2017;6(8):e153. [38] WillaertW, Aggarwal R, Harvey K, Cochennec F, Nestel D, Darzi A, et al. Efficient implementation of patient-specific simulated rehearsal for the carotid artery stenting procedure: part-task rehearsal. Eur J Vasc Endovasc Surg 2011;42(2):158–166. [39] Dorozhkin D, Olasky J, Jones DB, Schwaitzberg SD, Jones SB, Cao CGL, et al. OR fire virtual training simulator: design and face validity. Surgical Endoscopy. 2017 Sep;31(9):3527–3533. [40] Shamim Khan M, Ahmed K, Gavazzi A, Gohil R, Thomas L, Poulsen J, et al. Development and implementation of centralized simulation training: evaluation of feasibility, acceptability and construct validity. BJU Int 2013;111(3):518–523. [41] Sweigart LI, Umoren RA, Scott PJ, Carlton KH, Jones JA, Truman B, et al. Virtual TeamSTEPPS(®) simulations produce teamwork attitude changes among health professions students. J Nurs Educ 2016;55(1):31–35. [42] Maschuw K, Osei-Agyemang T, Weyers P, Danila R, Bin Dayne K, RothmundM, et al. The impact of self-belief on laparoscopic performance of novices and experienced surgeons. World J Surg 2008;32(9):1911–1916. [43] Wucherer P, Stefan P, Abhari K, Fallavollita P, Weigl M, Lazarovici M, et al. Vertebroplasty performance on simulator for 19 surgeons using hierarchical task analysis. IEEE Trans Med Imaging 2015;34(8):1730–1737. [44] Youngblood P, Harter PM, Srivastava S, Moffett S, Heinrichs WL, Dev P. Design, development, and evaluation of an online virtual emergency department for training trauma teams. Simul Healthc 2008;3(3):146–153. [45] Dorozhkin D, Olasky J, Jones DB, Schwaitzberg SD, Jones SB, Cao CGL, et al. OR fire virtual training simulator: design and face validity. Surgical Endoscopy. 2017 Sep;31(9):3527–3533. [46] Wechsler, D. (2003). Wechsler Intelligence Scale for Children (4th ed.). San Antonio, TX:
Pearson. [47] Orsini, A., Pezzuti, L., Picone, L. WISC-IV. Contributo alla taratura italiana, Giunti
Organizzazioni Speciali, 2012. [48] Ambrosini PJ (2000). Historical development and present status of the schedule for affective disorders and schizophrenia for school-age children (K-SADS). J Am Acad Child Adolesc Psychiatry. Jan;39(1):49-58 [49] Rossi G. (1994). La rilevazione del SES in due contesti culturali italiani. Poster presentato alla Giornata di studio «Lo stile dell’interazione madre-bambino in differenti contesti culturali italiani», Potenza [50] RFQ-8 Fonagy P, Luyten P, Moulton-Perkins A, Lee YW, Warren F, Howard S, et al. (2016).
Development and validation of a self-report measure of mentalizing: The Reflective Functioning Questionnaire. PLOS ONE.;11(7): e0158678 [51] Kneebone R. Evaluating clinical simulations for learning procedural skills: a theory-based approach. Acad Med 2005;80(6):549–553. [52] Fertleman C, Aubugeau-Williams P, Sher C, Lim AN, Lumley S, Delacroix S, et al. A discussion of virtual reality as a new tool for training healthcare professionals. Front Public Health 2018;6:44. [53] Youngblood P, Harter PM, Srivastava S, Moffett S, Heinrichs WL, Dev P. Design, development, and evaluation of an online virtual emergency department for training trauma teams. Simul Healthc 2008;3(3):146–153 [54] Rogers L. Developing simulations in multi-user virtual environments to enhance healthcare education. Br J Educ Technol 2011;42(4):608–615. [55] Riesen E,MorleyM, Clendinneng D,Ogilvie S, AnnMurrayM. Improving interprofessional competence in undergraduate students using a novel blended learning approach. J Interprof Care 2012;26(4):312–318. [56] Dorozhkin D, Olasky J, Jones DB, Schwaitzberg SD, Jones SB, Cao CGL, et al. OR fire virtual training simulator: design and face validity. Surgical Endoscopy. 2017 Sep;31(9):3527–3533. [57] King S, Chodos D, Stroulia E, Carbonaro M, MacKenzie M, Reid A, et al. Developing interprofessional health competencies in a virtual world. Med Educ Online 2012;17:1–11. [58] Umoren RA, Poore JA, Sweigart L, Rybas N, Gossett E, Johnson M, et al. TeamSTEPPS virtual teams: interactive virtual team training and practice for health professional learners. Creat Nurs 2017;23(3): 184–191.