Walking in Their Shoes: Using Virtual Reality to Reduce Stigma and Foster Managerial Support for Return-to-Work.

Introduction Return-to-Work Return-to-Work (RTW) after sick leave is defined as “a multidimensional process influenced mainly by psychosocial determinants (e.g., RTW expectations and job strain) and macrosystem variables (e.g., the healthcare and workplace systems) and, to a much lesser extent, by traditional medical indicators (e.g., symptom severity and prognosis; Gragnano et al., 2021, p. 492)”. Return-to-Work is seen as both a process and an outcome (Kärkkäinen, 2018; Young et al, 2005). The RTW process encompasses a series of phases, states, events and interactions with other individuals that begins on the first day of sick leave and continues until a goal set the individual in relation to his or her professional career is reached. Resuming work as such is an outcome, in the same vein as other subsequent outcomes in the RTW process, such as productivity, job satisfaction, career advancement, promotion, etc. Various models have proposed that returning to work consists of different phases (Corbière et al., 2020; Kärkkäinen, 2018; Kärkkäinen et al., 2018; Marois et al., 2020; Young et al., 2005). Generally, the first stage is an off-work phase, in which the person is at a standstill, trying to cope with the situation he or she is going through and recover physically and psychologically. A second RTW preparation phase involves developing skills and competencies to prepare for returning to work, in line with the goal set, by identifying challenges and obstacles and overcoming them on both the worker's and the organization's or company's side. On the worker's side. Finally, the third phase involves a gradual RTW, with a gradual increase in tasks and missions, as well as responsibilities and, over time, the pursuit and achievement of career goals. Through the various phases, both individuals and organizational factors contribute to the RTW. On the individual level, self-efficacy, work ability and expectation are key facilitators (Corbière et al., 2017; Etuknwa et al., 2019; Gragnano et al., 2021; Kärkkäinen et al., 2018; Lagerveld et al., 2010; Volker et al., 2015). RTW self-efficacy is the individual’s belief in their capacity to complete the process of returning to work (from the first day of sick leave to resuming work and thereafter) successfully and to overcome obstacles they are likely to encounter during the RTW process. Work ability refers to one’s evaluation of work capability in accordance with the work demands and their state of health. RTW expectations determined by the perceived duration and difficulties of the work resumption process. The more workers show high self-efficacy, work ability and positive RTW expectations, the greater the likelihood of resuming to work (Gragnano et al., 2018; Selander et al., 2021; Volker et al., 2015). On the organizational level, stakeholders of the work system as the employer/HR, the manager, co-worker and union play a key role in the RTW process, as well as healthcare professionals (e.g., general practitioner, psychologist), occupational physician, rehabilitation professional (e.g., RTW coordinator) and insurer (for a scoping review, see Corbière et al., 2020). Throughout the RTW process, the manager is at the center of interactions between stakeholders in the RTW process (Corbière at al., 2020; Kärkkäinen et al., 2018; Nielsen et al., 2018; Selander et al., 2021) and plays a key role by ensuring alignment with organizational policies, addressing workplace issues, facilitating job accommodations in collaboration with occupational health, supporting team dynamics, and preparing colleagues with appropriate resources to aid reintegration. Particularly, during the off phase, the manager plays a critical role by redistributing the absent employee's workload or arranging a replacement to protect team well-being, maintaining empathetic and non-pressuring contact with the absent employee to support recovery and reinforce a sense of belonging (Karkkainen et al., 2018; Corbière et al., 2017). During the RTW preparation phase, the manager plays a pivotal role in planning and coordinating the reintegration process. This includes engaging in joint discussions with the employee and occupational health professionals to define feasible job accommodations and offer social support, thereby enhancing the employee’s self-efficacy (Karkkainen et al., 2018). The manager should follow organizational RTW protocols, address the employee’s concerns, assess needs, limitations and obstacles, and ensure that previous psychosocial risk factors are not reinstated (Corbière et al., 2017). Additionally, the manager, in collaboration with the employee and occupational health services, must assess the feasibility of job accommodations and subsequently develop the RTW plan, considering legal, medical, and organizational considerations and coordinating with all relevant stakeholders (Corbière et al., 2020; Nielsen et al., 2018). Finally, during the resumption phase, the manager plays a central role in supporting the employee’s reintegration. This includes informing colleagues – while respecting confidentiality – about the RTW process and necessary accommodations to foster empathy and support (Karkkainen et al., 2018) and implementing work adjustments and follow RTW plan agreed by employee, healthcare providers, and the organization (Corbière et al., 2020). In their scoping review, Corbière et al. (2020) also emphasized the crucial role of managers in creating a supportive RTW environment by normalizing mental health issues, reducing stigma, and encouraging team engagement in the reintegration process. Indeed, one significant barrier to employment for individuals with a current or a past mental illness or mental health issues is the persistence of negative employer attitudes, which can adversely influence hiring decisions and supervisory practices. Employers often hold stereotypical beliefs that individuals with mental illness or mental health issues lack the competence to meet the job demands, require supervision, or that employment may be detrimental to their own health (Brouwers, 2020). A recent study has shown that managers’ stigma toward employees with mental health problems are associated with less accommodation and social support actions to prevent sickness absence (Schuller et al., 2024). To reduce stigma and foster prosocial behaviors, empathy, and specifically perspective-taking, has been identified as a particularly effective mechanism in intergroup context (Vanman, 2016). Empathy refers to the ability to put oneself in another person’s place and comprises both a cognitive component (i.e., the ability to understand another person’s thoughts and feelings by adopting their perspective) and an affective component (i.e., the ability to share and resonate with another’s emotional state; see Hakansson Eklund & Summer Meranius, 2021, for a review). Perspective-taking, defined as the capacity to adopt another person’s viewpoint and to imaginatively "walk in their shoes," plays a central role in promoting empathic responses (Trevena et al., 2024). In this context, Virtual Reality (VR), considered as the “ultimate empathy machine” (Milk, 2015) has proven to be a particularly effective intervention for enhancing empathy, as it facilitates perspective-taking, presence, immersion, engagement, and interactivity (for a review, see Trevena et al., 2024). Virtual Reality (VR) is a computer-based technology that creates immersive artificial environments simulating real-world settings and sensory experiences, where a user interacts with the computer-generated environment, typically requiring specialized headsets to immerse users in three-dimensional virtual worlds (Fuchs et al., 2007; Steen et al., 2024). By perceptually replacing the external environment with a virtual one, VR has become a valuable tool in psychology for training, education, assessment, and intervention (Rizzo & Koening, 2017; Tusher et al., 2024). In the context of training, VR offers the advantage of allowing individuals to practice skills in a controlled and safe environment (Oliveira et al., 2021). It also enables observation, evaluation, and feedback on the performance of the trained skills (Chang et al., 2023), which are often transferable to real-life situations (for reviews, see Chang et al., 2023; Oliveira et al., 2021). Gerry et al. (2022) have proposed a classification of VR solutions for empathy training into three categories: simulation, perspective-taking, and biofeedback. Simulation involves practicing empathic behaviors and learning to communicate empathically with a target—for example, medical students learning to deliver bad news to patients. VR-based training has shown to enhance soft skills such as knowledge of mental illness and screening abilities in healthcare professionals (for a systematic review, see Steen et al., 2024). Perspective-taking places individuals in the embodied experience of the target and presents elements of their subjective perception. Biofeedback, on the other hand, incorporates real-time physiological data (e.g., heart rate, respiration) during interactions, fostering awareness of physiological arousal linked to empathic experiences. In the present study, we are interested in managers’ perspective-taking toward individuals returning to work after a long-term absence. Specifically, we aim to examine whether embodying the experience of an employee on their first day back at work through virtual reality (VR) increases managers’ empathy and fosters more positive attitudes toward returning workers. For instance, Peck et al. (2013) demonstrated that white participants embodied in dark-skinned avatars via visuomotor synchrony showed a significant reduction in implicit racial bias, highlighting the potential of VR-based perspective-taking to influence attitudes. Similarly, Herrera et al. (2018) compared the effects of a traditional perspective-taking task (imagining becoming homeless)