Testing the Effects of a Virtual Reality Game for Aggressive Impulse Management: A Preliminary Randomized Controlled Trial among Forensic Psychiatric Outpatients

VR-assisted aggression treatment in forensic psychiatry: a qualitative study in patients with severe mental disorders

Introduction

Improvements in virtual reality (VR) have made it possible to create realistic, virtual settings for behavioral assessment and skills training that cannot otherwise be accessed in a safe way in forensic psychiatric settings. VR interventions are under development but little is known how forensic psychiatric patients with severe mental disorders experience VR-assisted assessments or treatments.

Methods

The present study aimed to help fill this knowledge gap via qualitative interviews with seven patients with severe mental disorders at a high-security forensic psychiatric clinic who had completed the newly revised Virtual Reality Aggression Prevention Training (VRAPT). All participants were interviewed 12 weeks after the VRAPT intervention, and interview data analyzed with manifest inductive content analysis.

Results

Six manifest content categories were identified: 1. Therapeutic process, 2. VRAPT method, 3. VR technology, 4. Previous treatment experiences, 5. Challenges to treatment of aggression, and 6. Unexpected experiences. The participants had diverse experiences related to both the VRAPT intervention and forensic psychiatric care. Participants described a mixture of positive experiences in relation to VR-assisted role-plays, and less positive in relation to motivation for aggression-focused treatment and technological limitations.

Discussion

The present findings suggest further studies are needed on how to best implement VR-assisted treatments for aggression in forensic settings, and potentially further modification of treatment content in interventions like VRAPT.

Treatment of aggression regulation problems with virtual reality: study protocol for a randomized controlled trial

Background

Aggressive conduct among delinquents presents a pervasive issue, bearing substantial implications for not only society at large but also for the victims and the individuals displaying the aggression. Traditional approaches to treating aggression regulation deficiencies generally employ Cognitive Behavioral Therapy (CBT) in conjunction with analog role-playing exercises. A body of research supports the efficacy of various therapeutic models for aggression regulation, including Responsive Aggression Regulation Therapy (Re-ART). Role-playing within a therapeutic context has been shown to contribute significantly to reductions in violent reoffending. However, the practical application of these skills in real-world settings remains challenging due to the inherent risk of aggressive outbreaks. Additionally, the conventional role-playing scenarios, often conducted in a therapy room, lack contextual realism and may induce role confusion between the patient and the therapist. Virtual Reality (VR) technology could offer a viable solution to these limitations by allowing for skill training in both behavioral and cognitive domains within a realistic yet safe and controlled setting. The technology also facilitates real-time awareness of emotional states and tension levels in the patient. This paper describes the study protocol of a randomized controlled trial in which Re-ART offered in a virtual environment (Re-ART VR) is compared to Re-ART offered as treatment as usual.

Methods and analysis

Adult forensic outpatients with aggression regulation problems are randomly assigned to either Re-ART VR or Re-ART. The Controlling Skills, Influence of Thinking and Handling Conflicts modules will be offered to both groups during 3-6 months. Pre- and post-intervention measurements are performed. The primary outcome measurement is the degree of aggression regulation, while secondary outcome measurements include impulsivity and cognitive biases. Additionally, patient motivation and therapist motivation are expected to act as moderating factors.

Discussion

To date, scarcely previous research has been done on the effectiveness of VR in treatment of aggression regulation problems in forensic outpatients. Forensic outpatients who do not benefit sufficiently from mainly CBT-based interventions may benefit more from experiential learning. The unique capabilities of VR in this regard have the potential to enhance the treatment effect.Clinical trial registration: [https://clinicaltrials.gov/], identifier [NL78265.018.21].

Exploring the added value of virtual reality biofeedback game DEEP in forensic psychiatric inpatient care-A qualitative study

Background

Low motivation and suboptimal cognitive skills are common among forensic psychiatric patients. By focusing on doing and experiencing, innovative technologies could offer an alternative to existing treatment for this patient group. One promising technology is DEEP, a VR biofeedback game that teaches diaphragmatic breathing, which has shown its potential in reducing stress in other populations. This exploratory study aimed at identifying if, how and for whom DEEP can be of added value in forensic mental healthcare.

Methods

This study used a qualitative approach. Six focus groups with 24 healthcare providers and 13 semi-structured interviews with forensic psychiatric inpatients were conducted in two Dutch forensic mental healthcare organizations. All healthcare providers and patients experienced DEEP before participating. The data were coded inductively, using the method of constant comparison.

Results

The data revealed six themes with accompanying (sub)codes, including (1) the possible advantages and (2) disadvantages of DEEP, (3) patient characteristics that could make DEEP more or (4) less suitable and beneficial, (5) ways DEEP could be used in current treatment, and (6) conditions that need to be met to successfully implement DEEP in forensic mental healthcare. The results showed that DEEP can offer novel ways to support forensic psychiatric patients in coping with negative emotions by practicing diaphragmatic breathing. Its appealing design might be suitable to motivate a broad range of forensic psychiatric patient groups. However, DEEP cannot be personalized, which might decrease engagement and uptake of DEEP long-term. Regarding its place in current care, DEEP could be structurally integrated in existing treatment programs or used ad hoc when the need arises. Finally, this study showed that both healthcare providers and patients would need practical support and information to use DEEP.

Conclusion

With its experience-based and gamified design, DEEP could be useful for forensic mental healthcare. It is recommended that patients and healthcare providers are included in the evaluation and implementation from the start. Besides, a multilevel approach should be used for formulating implementation strategies. If implemented well, DEEP can offer new ways to provide forensic psychiatric patients with coping strategies to better control their anger.

Management of Aggression in Young Male Adults Using the Virtual Reality-Based Communication Modification Program

High aggression is common and costly for mental health problems in young adults. Because communication is a universal part of social relationships, including conflicts with others, it could be a possible target for mediating aggression. This study aimed to evaluate whether the virtual reality (VR)-based communication modification program can be utilized for aggression management. Fifty-eight individuals with high aggression (n = 30) and with low aggression (n = 28) completed psychological assessments associated with aggression and functional communication, and they participated in the program, consisting of the three tasks: exploring the communication style, practicing functional communication, and expressing empathy. The participants’ selections and their visual analog scale scores, in response to questions in the tasks, were collected as behavioral data. Results indicated that the high aggression group selected blaming dysfunctional communication style more frequently than the low aggression group. VR-based parameters, expected to reflect dysfunctional communication-related characteristics, showed significantly different correlations with aggression-related traits between the two groups. These findings show that our program may accurately represent an individual’s aggressive traits and elicit the appropriate reaction.