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Klein Haneveld L, Kip H, Bouman YHA, Weerdmeester J, Scholten H, Kelders SM. Exploring the added value of virtual reality biofeedback game DEEP in forensic psychiatric inpatient care-A qualitative study. Front Psychol 2023; 14:1201485. [PMID: 38023054 PMCID: PMC10666827 DOI: 10.3389/fpsyg.2023.1201485] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2023] [Accepted: 09/25/2023] [Indexed: 12/01/2023] Open
Abstract
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.
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Affiliation(s)
- Lisa Klein Haneveld
- Department of Research, Transfore, Deventer, Netherlands
- Centre for eHealth and Wellbeing Research, Department of Psychology, Health and Technology, University of Twente, Enschede, Netherlands
| | - Hanneke Kip
- Centre for eHealth and Wellbeing Research, Department of Psychology, Health and Technology, University of Twente, Enschede, Netherlands
| | | | - Joanneke Weerdmeester
- HKU University of the Arts, Centre for Educational Research and Innovation, Utrecht, Netherlands
- Games for Emotional and Mental Health (GEMH) Lab, Enschede, Netherlands
| | - Hanneke Scholten
- Games for Emotional and Mental Health (GEMH) Lab, Enschede, Netherlands
- Communication Science, Department of Technology, Human and Institutional Behavior, University of Twente, Enschede, Netherlands
| | - Saskia M. Kelders
- Centre for eHealth and Wellbeing Research, Department of Psychology, Health and Technology, University of Twente, Enschede, Netherlands
- Opentia Research Unit, North-West University, Vanderbijlpark, South Africa
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Weerdmeester J, van Rooij MMJW, Granic I. Visualization, Self-Efficacy, and Locus of Control in a Virtual Reality Biofeedback Video Game for Anxiety Regulation. Cyberpsychol Behav Soc Netw 2022; 25:360-368. [PMID: 35612469 DOI: 10.1089/cyber.2022.0030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
The current study aimed to identify specific feedback mechanics and psychological processes that may contribute to positive outcomes in biofeedback applications for anxiety regulation. Specifically, using a dismantling study design, the unique impact of visualizations that directly mirror users' breathing was examined in relation to anxiety regulation as well as locus of control and self-efficacy. Following an anxiety induction, participants (N = 67) were randomly assigned to play one of two variations of a biofeedback video game. In both versions, players' in-game movement was contingent on their breathing; however, the experimental condition additionally included visualizations that directly mirrored players' breathing. Changes in self-reported state anxiety and physiological arousal were measured as well as the level of internal control and self-efficacy participants experienced while playing the game. Results showed that all participants were able to effectively reduce their anxiety and arousal, but no condition differences were found. Implementing mirroring visualizations did not contribute to individuals' ability to self-regulate nor their self-efficacy or locus of control above and beyond receiving feedback based on their in-game movement. Overall, individuals who experienced higher self-efficacy and a stronger internal locus of control were better able to regulate their anxiety, but no clear links were found with changes in self-reported physiological arousal. In light of these results, we recommend the continued exploration of the role of specific design choices and intervention components as well as underlying mechanisms of change in biofeedback interventions, especially pertaining to how individuals perceive themselves and their ability to change.
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Affiliation(s)
- Joanneke Weerdmeester
- Orthopedagogics: Family and Behaviour, Faculty of Social Sciences, Radboud University, Nijmegen, Netherlands
| | - Marieke M J W van Rooij
- Research Support Office, Faculty of Behavioural, Management and Social Sciences, University of Twente, Enschede, Netherlands
| | - Isabela Granic
- Health, Aging & Society, Faculty of Social Sciences, McMaster University, Hamilton, Ontario, Canada
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Weerdmeester J, van Rooij MM, Engels RC, Granic I. An Integrative Model for the Effectiveness of Biofeedback Interventions for Anxiety Regulation: Viewpoint. J Med Internet Res 2020; 22:e14958. [PMID: 32706654 PMCID: PMC7413290 DOI: 10.2196/14958] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2019] [Revised: 01/03/2020] [Accepted: 01/22/2020] [Indexed: 12/22/2022] Open
Abstract
Biofeedback has shown to be a promising tool for the treatment of anxiety; however, several theoretical as well as practical limitations have prevented widespread adaptation until now. With current technological advances and the increasing interest in the use of self-monitoring technology to improve mental health, we argue that this is an ideal time to launch a new wave of biofeedback training. In this viewpoint paper, we reflect on the current state of biofeedback training, including the more traditional techniques and mechanisms that have been thought to explain the effectiveness of biofeedback such as the integration of operant learning and meditation techniques, and the changes in interoceptive awareness and physiology. Subsequently, we propose an integrative model that includes a set of cognitive appraisals as potential determinants of adaptive trajectories within biofeedback training such as growth mindset, self-efficacy, locus of control, and threat-challenge appraisals. Finally, we present a set of detailed guidelines based on the integration of our model with the mechanics and mechanisms offered by emerging interactive technology to encourage a new phase of research and implementation using biofeedback. There is a great deal of promise for future biofeedback interventions that harness the power of wearables and video games, and that adopt a user-centered approach to help people regulate their anxiety in a way that feels engaging, personal, and meaningful.
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Affiliation(s)
| | | | | | - Isabela Granic
- Behavioural Science Institute, Radboud University, Nijmegen, Netherlands
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Bossenbroek R, Wols A, Weerdmeester J, Lichtwarck-Aschoff A, Granic I, van Rooij MMJW. Efficacy of a Virtual Reality Biofeedback Game (DEEP) to Reduce Anxiety and Disruptive Classroom Behavior: Single-Case Study. JMIR Ment Health 2020; 7:e16066. [PMID: 32207697 PMCID: PMC7139423 DOI: 10.2196/16066] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2019] [Revised: 11/21/2019] [Accepted: 12/16/2019] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND Many adolescents in special education are affected by anxiety in addition to their behavioral problems. Anxiety leads to substantial long-term problems and may underlie disruptive behaviors in the classroom as a result of the individual's inability to tolerate anxiety-provoking situations. Thus, interventions in special needs schools that help adolescents cope with anxiety and, in turn, diminish disruptive classroom behaviors are needed. OBJECTIVE This study aimed to evaluate the effect of a virtual reality biofeedback game, DEEP, on daily levels of state-anxiety and disruptive classroom behavior in a clinical sample. In addition, the study also aimed to examine the duration of the calm or relaxed state after playing DEEP. METHODS A total of 8 adolescents attending a special secondary school for students with behavioral and psychiatric problems participated in a single-case experimental ABAB study. Over a 4-week period, participants completed 6 DEEP sessions. In addition, momentary assessments (ie, 3 times a day) of self-reported state-anxiety and teacher-reported classroom behavior were collected throughout all A and B phases. RESULTS From analyzing the individual profiles, it was found that 6 participants showed reductions in anxiety, and 5 participants showed reductions in disruptive classroom behaviors after the introduction of DEEP. On a group level, results showed a small but significant reduction of anxiety (d=-0.29) and a small, nonsignificant reduction of disruptive classroom behavior (d=-0.16) on days when participants played DEEP. Moreover, it was found that the calm or relaxed state of participants after playing DEEP lasted for about 2 hours on average. CONCLUSIONS This study demonstrates the potential of the game, DEEP, as an intervention for anxiety and disruptive classroom behavior in a special school setting. Future research is needed to fully optimize and personalize DEEP as an intervention for the heterogeneous special school population.
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Affiliation(s)
- Rineke Bossenbroek
- Behavioural Science Institute, Radboud University, Nijmegen, Netherlands
| | - Aniek Wols
- Behavioural Science Institute, Radboud University, Nijmegen, Netherlands
| | | | | | - Isabela Granic
- Behavioural Science Institute, Radboud University, Nijmegen, Netherlands
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Weerdmeester J, Lange WG. Social Anxiety and Pro-social Behavior Following Varying Degrees of Rejection: Piloting a New Experimental Paradigm. Front Psychol 2019; 10:1325. [PMID: 31293469 PMCID: PMC6603339 DOI: 10.3389/fpsyg.2019.01325] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2018] [Accepted: 05/21/2019] [Indexed: 11/30/2022] Open
Abstract
In general, human beings tend to try and reconnect after they have been socially rejected. It is not clear, however, which role the number of rejecters and rejection sensitivity plays. In addition, it is unclear whether the supposed pro-social behaviors are aimed at the rejecters or at innocent individuals. By means of a new paradigm, the present pilot study investigated compensatory behavior of individuals with varying degrees of social anxiety, following varying degrees of rejection. In addition, it was explored toward whom their behavior was directed: rejecters or innocent individuals. Female students (N = 34) were assessed on their degree of social anxiety and then, based on a personal profile they wrote, they were either rejected by 1, 2, or 3 fictional other participants or completely accepted. Afterward, the participants had to explicitly rate the creativity of drawings made by the others and, in a pro-social reward paradigm, awarded the other participants money based on their creativity rating. In addition, implicit social approach tendencies toward photos of rejecters, acceptors, or innocent individuals were assessed by means of an approach-avoidance task. The results confirmed that people with a low degree of social anxiety respond to rejection in a compensatory pro-social manner explicitly as well as implicitly, but that people with a high degree of social anxiety fail to do so. With regard to sources of rejection, only implicit approach-avoidance tendencies reflected a distinction between rejecters and innocent individuals. Theoretical implications are discussed in the light of the small sample size and other limitations.
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Affiliation(s)
| | - Wolf-Gero Lange
- Behavioural Science Institute, Radboud University Nijmegen, Nijmegen, Netherlands
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Weerdmeester J, Cima M, Granic I, Hashemian Y, Gotsis M. A Feasibility Study on the Effectiveness of a Full-Body Videogame Intervention for Decreasing Attention Deficit Hyperactivity Disorder Symptoms. Games Health J 2016; 5:258-69. [PMID: 27304677 DOI: 10.1089/g4h.2015.0103] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
OBJECTIVE The current study assessed the feasibility and effectiveness of a full-body-driven intervention videogame targeted at decreasing attention deficit hyperactivity disorder (ADHD) symptoms, specifically inattention, hyperactivity, impulsivity, and motor deficiency. MATERIALS AND METHODS The game was tested in a Dutch sample (N = 73) of school-aged children with elevated ADHD symptoms. Children assigned to the intervention condition played "Adventurous Dreaming Highflying Dragon," and those in the control condition played a comparable full-body-driven game without ADHD-focused training components. Games were played during six 15-minute sessions. Outcomes were teacher-rated ADHD symptoms and scores on neuropsychological tasks assessing motor skills, impulsivity, and sustained attention. RESULTS There was some indication of greater improvement in the intervention group in comparison to the control group in terms of teacher-rated ADHD symptoms. Both groups showed equal indication of improvement in fine motor skills, but no change was found in gross motor skills. Additionally, both groups showed a deterioration in number of hits (assessing sustained attention) on the go/no-go task. Last, the intervention group showed a greater increase in false alarms (assessing impulsivity) than the control group. CONCLUSION Dragon seems promising as a game-based intervention for children with ADHD. Children who played Dragon improved in several areas with only a short amount of gameplay (1.5 hours in total), and their satisfaction with the game was high. For future research, it is recommended to further inspect Dragon's influence on impulsivity and gross motor skills. Furthermore, it is recommended to disentangle, examine, and evaluate specific properties of videogames that might lead to positive behavioral change.
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Affiliation(s)
| | - Maaike Cima
- 1 Behavioural Science Institute, Radboud University , Nijmegen, The Netherlands
| | - Isabela Granic
- 1 Behavioural Science Institute, Radboud University , Nijmegen, The Netherlands
| | - Yasaman Hashemian
- 2 School of Cinematic Arts, University of Southern California , Los Angeles, California
| | - Marientina Gotsis
- 2 School of Cinematic Arts, University of Southern California , Los Angeles, California
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