Roundtable: Raising Empathy through Virtual Reality

*Sara Ventura and Alison Jane Martingano*

### **Abstract**

Virtual reality (VR) has been described as the ultimate empathy machine; but does it deserve this reputation? Thanks to its features of embodied technology, VR can let users virtually walk in someone else's shoes. In addition, multi-sensory VR experiences can present evocative and heart-wrenching stimuli. For these reasons, VR seems to be a likely candidate to foster empathy. However, the published literature indicates that the impact of VR on empathy is complex and depends both on the type of VR and also the type of empathy being evaluated. The present chapter compares two meta-analyses which suggest that VR can elicit empathy, but the theoretical factors on which the technology has more efficacies are in contrast. In this chapter, these discordant meta-analyses are discussed, and the reasons why they find different results are theorized. We attempt to answer when and how VR could be an empathy machine. We conclude that low-tech but evocative storytelling is most likely to yield emotional empathy, and embodied experiences that encourage perspective-taking will improve cognitive empathy. Although we attempt to present the latest empirical evidence about empathy and VR, we are aware that the scientific consensus around this topic is likely to evolve in the future.

**Keywords:** empathy, virtual reality, meta-analysis review, body cognition

### **1. Introduction**

Empathy plays a key role in preserving human social relationships. Empathic people are more likely to engage in prosocial behavior, and less likely to engage in aggressive behaviors. Moreover, even temporary arousal of empathy can have positive impacts on behavior in the moment [1, 2]. Empathy is composed of both emotional and cognitive factors whose integration contributes to share and understand another person's perspective. Importantly, scholars have described empathy as a muscle, and as such it should be capable of growth and even regeneration with sufficient effort [3]. Following this logic, a variety of empathy training programs have been designed to explicitly teach empathy (e.g., [3]), and in fields such as medicine, where such programs are used regularly, they generally have sizable positive effects (g = 0.63, [4] for meta-analysis). These programs are generally based on taking the perspective of someone else with the aim to feel the others emotions, to understand them, and to regulate one's own feelings [5]. Yet as most people are unlikely to enroll in explicit empathy training without incentive, psychologists have begun to explore how engaging in other activities may improve empathy. Recent research has shown that written fiction [6], drama [7], and of course virtual reality [8, 9] show promise as empathy generators.

The most ardent supporters of Virtual reality (VR) claim it is "the ultimate empathy machine" [10]. In brief, VR is an advanced technology that allow users to be present and to interact with a three-dimensional environment [11]. There are a wide variety of VR experiences with different degrees of interaction currently available that are designed to promote social good. For example, 1000 Cut Journey allows viewers to become Michael Sterling, a Black man, and encounter racism as they try to complete everyday activities [12]. Users can interact with the experience by opening doors and picking-up objects using a controller. Other experiences, such as Clouds over Sidra, are less interactive but immerse the user in 360-video as they follow a day in the life of 12-year-old Sidra who lives in a refugee camp [13]. New VR experiences continue to be created by innovative designers the world over. In 2016, VR giant Oculus released their "VR for Good" initiative to incentivize designers to create prosocial content [14]. Not to be outdone by their leading competitor, HTC VIVE announced their \$10 million "VR for Impact" program in 2017 [15]. VR has also been embraced by various charitable organizations as part of their fundraising campaigns (e.g., [13, 16–18]).

### **2. Conflicting literature on VR and empathy**

Despite its popularity, experimental evidence for the empathy-building efficacy of VR generally, and 360-degree video specifically, is inconsistent. For example, although some VR experiences have led to increases in empathy [8, 19, 20], these positive effects do always exceed more traditional and low cost experiences, such as reading [9], asking people to imagine what it would be like to be in someone else's situation [21] or taking part in real world role play [22].

These conflicting results from individual research studies are compounded by two recent conflicting meta-analyses authored by ourselves. Meta-analyses normally serve to reduce confusion by reducing the impact of random errors and providing a more precise estimate of the average effect size. They even allow researchers to explore potential moderators that may explain why a result is true in some cases but not in others. However, for VR and empathy, even using meta-analysis we did not find a consensus. Using data from 43 studies Martingano et al. found that VR led to approximately a third of a standard deviation more emotional empathy (d = 0.325) but no significant increase in cognitive empathy [23]. However, using a more constrained definition of VR, Ventura et al. found that in 7 studies VR led to approximately half a standard deviation more cognitive empathy (d = 0.513) but had no significant effect on emotional empathy [24] the reversed results (see **Figure 1**). The reason, we argue, is because the impact of VR on empathy depends not just on one thing, but two interacting moderators, namely, the type of empathy and the type of VR.

#### **2.1 The impact of Virtual Reality depends upon the type of empathy**

Scholars and laypeople alike hold a variety of diverse and competing definitions of empathy [25]. In an influential paper on the topic, Daniel Batson listed eight definitions of empathy with the hope of reducing confusion by recognizing the term's complexity [26]. One of the reasons it is so difficult to define empathy

#### **Figure 1.**

*Overall standardized mean differences and 95% confidence intervals for published meta-analyses on the impact of VR on empathy.*

is because it is a multifaceted concept. It is not simply that researchers have not agreed on a single definition of empathy, but that empathy is not a single thing to begin with.

Although there is disagreement in the literature regarding exactly what counts as empathy, many scholars make a distinction between cognitive and emotional empathy. Emotional empathy (sometimes called affective empathy) involves experiencing emotions in response to others' emotions or expressions of emotions. On the other hand, cognitive empathy involves understanding others' thoughts and feelings without necessarily reacting emotionally [2]. This understanding is most often achieved via perspective-taking, so much so that perspective-taking is often used as a synonym for cognitive empathy. Given the definitional confusion surrounding the term empathy, in this chapter, we will discuss research and theory on empathy that is styled under many different names. Overall, cognitive and emotional empathy are best thought of as broad categories that each encompass a variety of different empathy types. Despite disagreement over which concepts are classified under each category, the distinction between emotional and cognitive empathy remains common [26, 27].

Despite our conflicting results, Martingano et al. [23] and Ventura et al. [24] both find the distinction between cognitive and emotional empathy is critical when discussing the impact of VR on empathy.

So why might VR impact emotional and cognitive empathy differently? Media scholars have argued that one of the strengths of VR is that it removes the cognitive burden normally associated with empathizing [28]. By virtually taking someone else's perspective on behalf of users, VR is doing the work of cognitive empathy for them. VR designers have made use of powerful graphics, motion-sensing technologies, and surround sound systems to place viewers in realistic environments and situations that they might find hard to imagine, such as refugee camps, homeless shelters, or the experience of racial discrimination. By doing the perspective-taking on behalf of users, it is hoped that VR can enhance empathy in people who are not otherwise motivated or able to empathize [29].

Perspective-taking is a difficult skill that requires attention and sufficient cognitive resources. Cognitive load hinders both emotion recognition [28, 30] and perspective-taking [31]. Moreover, neuroscientists have shown that the more difficult it is to predict another person's intentions, the more active the brain areas involved in cognitive empathy become. Therefore, it seems likely that cognitive empathy, like many other skills, benefits from the practice and that practice should occur within the zone of proximal development [32]. The zone of proximal development is defined as the space between what someone can do without assistance and what they can do with assistance. In other words, optimal skill development occurs a practice activity is not too difficult, but also not too easy. Practice activities known to enhance cognitive empathy include acting and creative writing, which require some little effort to recreate the mental states of fictional characters [33, 34]. The question is, does VR provide a suitable opportunity for users to practice cognitive empathy skills? In some cases, VR may be making it too easy for users by doing the perspective-taking work for them, alternatively, VR may overwhelm the senses making it too difficult for users to focus on understanding others' emotions. But importantly, in some cases, VR may provide the optimum level of support needed for users to practice and improve their perspective-taking, emotion recognition, and other cognitive empathy skills. We will discuss what features were used in the 7 studies included in Ventura and colleagues [24] meta-analysis that seemed to make them so effective at enhancing cognitive empathy in the next section and why the majority of studies included in Martingano and colleagues [23] meta-analysis were not, but first we ought to consider why VR might increase emotional empathy.

The idea that virtually taking another person's perspective would lead to emotional empathy is rooted in a long-standing assumption that perspective-taking is the mechanism by which emotional empathy occurs. This idea was borne from extensive research showing that if you ask someone to take someone else's perspective, they are more likely to feel emotional empathy towards them (e.g. [35]). However, researchers now know that people default to feeling emotional empathy for others who are suffering regardless of whether perspective taking instructions are given, and the apparent benefit of perspective-taking was actually from a dampening effect of control instructions [36, 37]. Indeed, neuroscientific evidence shows us that perspective-taking is not a required pathway to emotional empathy. Emotional empathic responses are fast, automatic, and occur spontaneously [38] even when participants are not consciously aware of what they are seeing [39]. In our daily lives, most of us are familiar with automatic emotional empathy, it's the sort that rushes over us when a refugee child is depicted on the news. VR may well arouse emotional empathy automatically if it depicts the suffering of another person, but this is unlikely to be due to the virtual perspective-taking feature and simply a result of displaying evocative stimuli. The differing results of our two meta-analyses found for emotional empathy, therefore, are likely due to the different emotionally arousing nature of the VR experiences included in each meta-analysis (see below).

#### **2.2 The impact on empathy depends on the type of virtual reality**

VR is an overarching term for a collection of computer hardware and software that immerses users in artificial environments. Both the hardware and the virtual content may impact whether a given VR experience is effective at arousing empathy. Commonly, VR experiences use a headset to display three-dimensional images and while wearing this system, a user's movements and orientation are tracked and fed

#### *Roundtable: Raising Empathy through Virtual Reality DOI: http://dx.doi.org/10.5772/intechopen.109835*

back into the system to adapt the presentation of the virtual environment. However, other hardware has been considered under the umbrella 'virtual reality'. Martingano et al. used a particularly all-encompassing definition of virtual reality that included "any computer technology that virtually simulates one or more senses (auditory, visual, olfactory, gustatory, and/or tactile simulations)". Within this definition desktop VR that plays on a normal computer screen is included as it stimulates vision and auditory senses, and so too are auditory-only simulations played on regular headphones (for example simulations of what it may be like to suffer from auditory hallucinations as a result of schizophrenia).

In contrast, the VR experiences included in Ventura et al.'s meta-analysis all used head-mounted display units making these experiences more immersive on average, benefiting from spatialized sound, stereoscopic visuals, greater image resolution, and a higher update rate. More immersive VR environments have been associated with creating a heightened feeling of presence in users [40]. Presence is the "perceptual illusion of non-mediation" [41], where a user fails to acknowledge the existence of the VR environment and responds as it were not there. More simply put, the user has a feeling of truly "being there" in the virtual environment [28]. Recent research suggests that the feeling of presence mediates the influence of VR on empathy [42]. This may be one reason why Ventura and colleagues found an overall positive impact of VR on cognitive empathy, but Martingano and colleagues did not.

In addition, to creating a sense of presence, immersive VR can also create feelings of embodiment. Developments in motion and voice detection have led to a tighter coupling of body and machine which may trigger feelings of body ownership in users [43]. VR allows users to see and hear as if they were experiencing someone else's point of view in the real world, in other words, to have an "embodied experience" [28]. In some cases, a VR experience is specifically designed to produce a "body ownership illusion" or "body-swap illusion" where users are deliberately given a virtual body that is different from their own. In Ventura's meta-analysis, 3 of the 7 studies used a body swap illusion (42.9%). However, in Martingano's meta-analysis only 7 of 43 studies (16.3%) used this illusion. Body swap illusions may be particularly effective at encouraging users to take the perspective of the person they are embodying [44], and provides another potential explanation for why Ventura found a positive impact on cognitive empathy. The utility of these illusions will be discussed more below.

### **3. When and how VR can increase empathy**

#### **3.1 Change the body to change the mind: the key role of body ownership**

Embodied technology may be a key feature of VR that allows users to practice and improve their cognitive empathy skills. The sense of embodiment refers to the set of sensations related to having (ownership), being located in (location), and controlling (agency) a body [45]. The body contributes to the representation of ourself and, as explain by the author Blanke [46], human adults experience a 'real me' that 'resides' in 'my' body and is the subject (or 'I') of experience and thought. The multisensory bodily signals and their integrated neural representation are of fundamental importance for self-consciousness and the body is also central to our understanding of others. In general, we become aware of our bodies through exteroceptive signals such as the touch, and through interoceptive such as the heart rate and proprioceptive signals arising from within the body [47]. Then, we use the feelings from the body to sense

both our physical condition and emotional state. The perception of our body can be manipulated generating what is called the "body ownership illusion" or "body-swap illusion". The usual example is the rubber-hand illusion, during which synchronous stroking of a seen fake rubber hand and one's own unseen hand causes the rubber hand to be attributed to one's body [46]. The successful manipulations demonstrated the malleability of the mental representation of one's body, identity, and the emotions we feel.

In the past decades, several studies have demonstrated the ability of VR to induce body-swap illusions by altering the sense of embodiment. Through the advanced VR technologies such as the opt-track suit it is possible to alter the neuropsychological basis of self-experience and experiment a different "ontological self" by owning a virtual body of different race, size, and gender groups. According to Riva [48] there are three possible strategies that can be used to alter bodily self-consciousness using VR: (i) mindful embodiment, which consists in the modification of the bodily experience by facilitating the availability of its content in the working memory; (ii) augmented embodiment, which is based on the enhancement of bodily self-consciousness by altering/extending its boundaries; and (iii) synthetic embodiment, which aims to replace own body with synthetic self-consciousness (incarnation). Thanks to these characteristics, VR could facilitate cognitive empathy, specifically perspective taking, in challenging situations by offering compelling experience of what it feels like to walk in someone else's shoes [28].

### **3.2 Evocative stimuli to arouse emotions: creating a transformative emotional experience**

Many charitable organizations and philanthropic groups interested in using VR to increase empathy are largely turning to cheaper and less technological advanced VR experiences (that are not capable of producing the body-swap illusion) such as 360-degree video [13–15]. This choice is likely financially driven: 360-degree videos are much less expensive than computer generated environments, possibly costing as low as \$10 k/minute to create, whereas the same computer generated (CG) environment could cost nearly double that [49]. However, importantly, these experiences may be sufficient for their purposes of arousing emotional empathy and creating a transformative emotional experience.

A transformative experience is defined as an event in which a person's worldview is reconstructed, resulting in a shifted perspective of the world, or in the change on values and beliefs [50]. The transformative experiences induced in VR could facilitate social interaction by helping people to establish common ground and infer shared knowledge and beliefs between interactants [51]. Potentially even low-tech VR can generate high sense of engagement and social connectedness in people that naturally belong to the outgroup and therefore increase emotional empathy [23].

To do this, VR technology can be used to show emotionally evocative imagery. Particularly of children, animals, or other targets whom users can relate to, engage with, and feel connected to. This can be achieved by showing real-world footage of suffering individuals, with close-ups of emotion-laden faces, crescendo-ing music, and an invested narrator. A good example of this is, 'Clouds over Sidra', which is a documentary-style 360-video of a refugee camp depicting a young girl called Sidra who talks about her life in the camp and hopes for the future [13]. Another example is a 360-video showing female sexual harassment that has been shown to increase emotional empathy in a male sample (**Figure 2**) [52].

*Roundtable: Raising Empathy through Virtual Reality DOI: http://dx.doi.org/10.5772/intechopen.109835*

#### **Figure 2.**

*A participant watching the 360-degree video about sexual harassment into the female perspective.*

Charitable organizations have been aware of these techniques for years. Fundraising campaigns often feature vivid photographs and describe personal details about an individual and their plight. Social scientists have tested the effectiveness of such individuated appeals experimentally, with the phenomena earning itself the name *The Identifiable Victim Effect*. Identified victims have been found to evoke stronger feelings of empathic compassion than statistical victims [53] and this increased arousal mediates increased charitable giving [54]. In an important recent research study [55] demonstrated that regardless of the technology used, telling engaging narratives is key to the success of VR. This study helps to explain why more immersive VR experiences do not necessarily lead to more emotional empathy. People can engage in a narrative without surround sound or high-resolution graphics. In the same way a low-budget play can still transport us to another world, and a novel can lead us into another's psyche, a cardboard VR headset playing the right content can also generate emotional empathy. Understanding that narrative engagement is key to enhancing emotional empathy with VR also helps to explain why in some cases VR is not outperforming more low-tech solutions such as reading or watching a video [23].

### **4. Discussion**

Science grows continuously: answers provided by previous research leads to new research questions, and so on. The present chapter represents another turn in this cycle, as we attempt to understand when and how VR increases empathy. Our discussion arises from two published meta-analysis authored by ourself that present contrasting findings on which empathy factors are better fostered by VR: emotional empathy in Martingano and colleagues [23], and cognitive empathy in Ventura and colleagues [24]. We conclude that our results are a product of two interacting moderators: the type of empathy and the type of VR in question. Emotional empathy appears to be aroused most effectively by evocative stimuli and immersive storytelling, whereas cognitive empathy appears to benefit from embodied experiences which require more technological advanced VR experiences.

However, there are limitations to the confidence in which we can make these conclusions. First of all, like all meta-analyses, the quality and precision of our estimated effects was dictated by the nature of the studies available for inclusion. Although we feel it is unlikely, it is possible that the different results obtained in Martingano and colleagues and Ventura and colleagues are simply statistical artifacts. As can be seen from **Figure 1**, the 95% confidence intervals from both meta-analyses overlap, and so it is possible that the true size of this effect is captured within these bounds. More research, as always, would help tighten these estimations and we encourage other researchers to update our work as appropriate.

Second, content matters. In much the same way that not all television shows have the same effect, not all VR experiences do. Some television shows are educational, some are funny, and some are unsuitable for minors. Therefore, in the same way it is foolish to ask whether TV in general is educational, it is also mistaken to ask whether VR in general increases empathy. Although neither of our meta-analyses deliberately selected for content, both were restricted to VR experiences that had content that was more likely to elicit empathy because articles had to measure empathy to be included. Researchers who had gone to the effort to measure empathy generally did so because they expected their VR experience would impact it. It is not very likely that researchers are going to put users in a first-person shooter VR game and then measure empathy – at least we have not seen that done! Psychological research finds that the type of media content matters for whether outcomes are aggressive or prosocial [56]. Similarly, violent VR content is unlikely to have a positive effect on empathy and may even lead to more aggressive outcomes.

Third, the users of VR matter. The personal characteristics and demographics of VR users may influence their experiences within VR [57]. For example, users' perceptions of presence can vary dramatically in similar or even identical virtual environments [58, 59]. It is therefore likely that user characteristics will also influence the utility of VR for increasing empathy. In Martingano et al.'s meta-analysis they found, for example, that the positive impact of VR on empathy was three times larger for children with Autism. Recent research also indicates that the utility of the body ownership illusion depends on user psychological traits. For example, lower scores on the traits of machismo and alexithymia were demonstrated to be facilitators for male participants to embody a female victim of sexual harassment [60].

Finally, given the interaction between the type of VR and the type of empathy aroused there is no simple "one size fits all" answer to the most empathy-enhancing VR experiences. Unfortunately, our advice on how to promote emotional empathy using VR (evocative imagery and immersive storytelling) is in almost direct contradiction to our advice on how to use VR to increase cognitive empathy (subtle, ambiguous stimuli that challenge people to tell their own story). Clinicians, parents, charities, and educators should select VR experiences with care based on the empathic outcomes they wish to evoke. In the future, it may be possible to design VR experiences that are emotionally evocative while still leaving room for users to build upon the experience using their own imagination. Indeed, we hope that the insights provided in this chapter may help take a small step in that direction, and prompt further research into this area.

### **Acknowledgements**

This work was funded by a Margarita Sala postdoctoral fellowship for the requalification of the Spanish university system from the Ministry of Universities of the

Government of Spain and financed by the European Union NextGeneration EU (grant UP2021-044).

This work was supported by the Intramural Research program of the National Genome Research Institute.

## **Author details**

Sara Ventura1,2\* and Alison Jane Martingano3

1 Department of Psychology, University of Bologna, Bologna, Italy

2 Institute Polibienestar, University of Valencia, Valencia, Spain

3 Department of Psychology, University of Wisconsin, Green Bay, United States

\*Address all correspondence to: sara.ventura@uv.es

© 2023 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

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### **Chapter 4**
