Factors related to employment across vocational levels in patients with schizophrenia: focus on subminimum wage non-competitive employment.

People living with a psychotic disorder can experience a broad range of symptoms including distressing anomalous sensory experiences such as auditory verbal hallucinations (hearing voices) or unusual (delusional) beliefs about themselves, others, or events []. These symptoms can adversely affect the style and quality of their communications with and behaviours towards others [, ] including informal carers, who are typically relatives and close others providing unpaid care and support []. The United Kingdom (UK) has an estimated 6.5 million informal carers, many of whom support individuals with a psychotic disorder [, ]. Their support plays a vital role in promoting recovery and wellbeing, including improving treatment engagement and life expectancy, and reducing levels of relapse, hospitalisation and overall care needs and costs [–] However, key aspects of the caregiving role can be challenging, confusing, and adversely impact carers’ own wellbeing. For instance, carers may be exposed to difficult communications and behaviours from care recipients (e.g., persecutory delusions) as well as other problematic behaviours such as verbal aggression [, ]. These experiences can, in turn, adversely affect the style and quality of the caregiving relationship, and the effectiveness of carers’ communications and responses to care recipients [, ]. For some carers, negative communication styles may reflect the limited understanding of psychosis and its presentations. It might also reflect gaps in illness specific communication skills and confidence in establishing and maintaining positive interactions when care recipients experience delusions and hallucinations []. Caregiving relationships characterised by negative communication styles are robust predictors of poorer patient outcomes in psychosis, particularly elevated relapse rates and a need for more intensive care [–]. Further, negative caregiving relationships are associated with an increased risk of an overall breakdown in the caregiving relationship and care arrangements, and deterioration in patient outcomes [] Thus, strategies to disrupt negative communication cycles in caregiving relationships and enhance carer management skills are important targets in treatment recommendations for carer interventions in psychosis [–]. However, we currently have a lack of evidence-based approaches to support carers in psychosis in developing, rehearsing, and implementing optimal communication styles with care recipients experiencing persistent delusions and/or hallucinations. Standard family-based interventions [] are not designed to directly target carers’ cognitions, affect and communications in real time. The last decade has seen growth and innovation in digital health technologies, including applications of virtual reality (VR) software in the assessment and treatment of mental health conditions [, ]. VR offers a unique opportunity to reproduce, control and manipulate ecologically valid environments and social interactions in real time through the use of avatars (virtual characters that individuals respond to as if they were social agents and in naturalistic settings) [] Unlike role-play, which relies on imagination, VR provides a common reference point where the therapist can see exactly what the participant sees, facilitating more precise clinical formulation. VR also creates a “plausible” yet safe environment where nothing the individual fears can actually happen, allowing carers to freely experiment with and rehearse new communication styles, without the risk of real-world interpersonal consequences.