Testing the Effects of a Virtual Reality Game for Aggressive Impulse Management (VR-GAIME): Study Protocol

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.

Pinpointing change in virtual reality assisted treatment for violent offenders: a pilot study of Virtual Reality Aggression Prevention Training (VRAPT)

Preventing relapse into violence and its destructive consequences among persistent re-offenders is a primary concern in forensic settings. The Risk-Need-Responsivity framework models the best current practice for offender treatment, focused on building skills and changing pro-criminal cognitions. However, treatment effects are often modest, and the forensic context can obstruct the delivery of interventions. Developing treatments for offenders should focus on the best method of delivery to make "what works work." Virtual reality (VR)-assisted treatments such as Virtual Reality Aggression Prevention Training (VRAPT) are a new and innovative approach to offender treatment. This pilot study followed 14 male violent offenders who participated in VRAPT in a Swedish prison context and measured changes from pre-treatment to post-treatment and 3-month follow-up in targeted aggression, emotion regulation, and anger. It also investigated potential impact factors (pro-criminal cognitions, externalizing behaviors, psychosocial background, and childhood adverse experiences). In Bayesian linear mixed effects models, participants showed a high probability of change from pre-treatment to post-treatment and to follow-up on all outcome measures. All outcome measures demonstrated a low probability of change from post-treatment to follow-up. Analysis of reliable change showed that participants' results ranged from recovery to deterioration. We discuss the implications of the study for VRAPT's impact on the target group, those who might benefit from the approach, and suggested foci for future studies in the field of VR-assisted offender treatment. The study was preregistered at the International Standard Randomized Controlled Trial Number registry (https://doi.org/10.1186/ISRCTN14916410).

Future developments in sociology in the age of the metaverse

The intent of this article is to shed light on the future challenges that sociology, in concert with other disciplines, will have to face from now on, starting with one of the possible hypotheses of research methodology. Indeed, as much as some of these issues in the last two decades have become the preserve of neuroscience, their origins, namely the conceptualizations of the classics of sociology, should not be forgotten. In this regard, it will be the task of researchers and sociology to investigate, through applied research attempts, phenomena such as empathy and emotions from innovative methodologies and research different from the current ones, capable of highlighting how emotions are modified by cultural context and spaces of interaction, moving away from a depersonalizing structuralism we were used to, refuting, for example, what neuroscientists have pointed out, according to which empathy and emotions belong to biological universalisms. Therefore, within this brief and informative article we intend to present a possibility of investigation, without any claim to truth or the only way to be able to do research in this field, moved only by the desire to open a fruitful discourse that can lead to the methodological approach toward applied sociology or laboratory research. The idea is to move beyond online netnography, not because the latter cannot provide satisfactory results, but because it will be necessary to broaden the range of choices, such as analysis in the metaverse, generating a viable alternative where this type of analysis cannot be pursued.

Exploring the effects of a wearable biocueing app (Sense-IT) as an addition to aggression regulation therapy in forensic psychiatric outpatients

Objective

Preventing and reducing violence is of high importance for both individuals and society. However, the overall efficacy of current treatment interventions aimed at reducing aggressive behavior is limited. New technological-based interventions may enhance treatment outcomes, for instance by facilitating out-of-session practice and providing just-in-time support. Therefore, the aim of this study was to assess the effects of the Sense-IT biocueing app as an addition to aggression regulation therapy (ART) on interoceptive awareness, emotion regulation, and aggressive behavior among forensic outpatients.

Methods

A combination of methods was used. Quantitatively, a pretest-posttest design was applied to explore group changes in aggression, emotion regulation, and anger bodily sensations associated with the combination of biocueing intervention and ART. Measures were assessed at pretest, after 4 weeks posttest, and after one-month follow-up. During the 4 weeks, a single-case experimental ABA design was applied for each participant. Biocueing was added in the intervention phase. During all phases anger, aggressive thoughts, aggressive behavior, behavioral control, and physical tension were assessed twice a day, and heart rate was measured continuously. Qualitative information regarding interoceptive awareness, coping, and aggression was collected at posttest. 25 forensic outpatients participated.

Results

A significant decrease in self-reported aggression was found between pre- and posttest. Furthermore, three-quarters of participants reported increased interoceptive awareness associated with the biocueing intervention. However, the repeated ambulatory measurements of the single-case experimental designs (SCEDs) did not indicate a clear effect favoring the addition of biocueing. On group level, no significant effects were found. On the individual level, effects favoring the intervention were only found for two participants. Overall, effect sizes were small.

Conclusion

Biocueing seems a helpful addition to increase interoceptive awareness among forensic outpatients. However, not all patients benefit from the current intervention and, more specifically, from its behavioral support component aimed at enhancing emotion regulation. Future studies should therefore focus on increasing usability, tailoring the intervention to individual needs, and on integration into therapy. Individual characteristics associated with effective support by a biocueing intervention should be further investigated, as the use of personalized and technological-based treatment interventions is expected to increase in the coming years.

Assessing reactive violence using Immersive Virtual Reality

Assessing levels of aggression–specifically reactive violence–has been a challenge in the past, since individuals might be reluctant to self-report aggressive tendencies. Furthermore, experimental studies often lack ecological validity. Immersive Virtual Reality (IVR) offers a reliable, ethically safe environment, and is the most realistic virtual simulation method currently available. It allows researchers to test participants’ aggressive responses to realistic provocations from virtual humans. In the current study, 116 participants completed our IVR aggression task, in which they encountered avatars who would either approach them in a friendly or provocative fashion. Participants had the option either to shake hands or hit the virtual human, in congruent and incongruent trials. In congruent trials, the response required of the participant matched the approach with the avatar (e.g., hitting the avatar after provocation). In incongruent trials there was a mismatch between the avatars approach and the participants required response. Congruent trials were designed to measure the immediate reaction towards the virtual human, and incongruent trials to assess response inhibition. Additionally, participants also completed traditional questionnaire-based measures of aggression, as well as reporting their past violent behaviour. We found that the immediate aggressive responses in the IVR task correlated with the established questionnaire measures (convergent validity), and we found that the IVR task was a stronger predictor of past violent behaviour than traditional measures (discriminant validity). This suggests that IVR might be an effective way to assess aggressive behaviour in a more indirect, but realistic manner, than current questionnaire assessment.

Development of a Wearable Biocueing App (Sense-IT) Among Forensic Psychiatric Outpatients With Aggressive Behavior: Design and Evaluation Study

Background

The ability to regulate anger is often impaired in forensic psychiatric patients, frequently resulting in aggressive behavior. Although some treatment programs are partially successful in enhancing aggression regulation and reducing recidivism among specific subgroups, generalizable conclusions on the effectiveness of these interventions cannot be drawn to date. In forensic outpatient care, low treatment adherence and a predominant focus on cognitive control in most treatment programs may entail some of the factors impeding treatment. Technology-based interventions may address some of these treatment challenges.

Objective

The aim of this study is to explore whether a new technology-based biocueing intervention, the Sense-IT app, can be a valuable addition to aggression regulation treatment programs in forensic outpatient care. The Sense-IT app, which provides the user with real-time physiological feedback and behavioral support, is developed to strengthen emotional awareness and facilitate real-life practice. In this study, we aim to develop and evaluate an updated version of the Sense-IT app that is suitable for forensic outpatients with aggressive behavior.

Methods

First, we conducted a design study to assess the attitudes of forensic professionals and patients toward biocueing and to collect requirements for a biocueing app for this specific population. On the basis of this information, we developed an updated version of the Sense-IT app. In an evaluation study, 10 forensic outpatients used the app for 2 weeks. The app’s acceptability, usability, and clinical outcomes (aggression, anger, and recognition of bodily signals related to anger) were measured before and after the intervention using both quantitative and qualitative measures.

Results

The design study revealed a cautiously positive attitude toward the use of biocueing as an addition to aggression regulation therapy. The evaluation study among forensic outpatients demonstrated moderate acceptability and adequate usability for the new version of the Sense-IT app. Exploratory analysis revealed a significant decrease in trait aggression postintervention; no significant changes were found in other anger-related clinical outcomes. To further increase acceptability and usability, a stable functioning app with self-adjustable settings, the use of smartwatches with a longer battery life, and the use of the patient’s own smartphone devices were recommended.

Conclusions

This study, which is one of the first attempts to enroll and evaluate the real-life use of a biocueing intervention among forensic outpatients, emphasized the importance of involving both patients and therapists throughout the development and implementation process. In the future, experimental studies, including single-case experimental designs using ecological momentary assessment, should be performed to evaluate the effectiveness of the Sense-IT intervention on clinical outcomes. An open attitude toward new technology, allowing exploration of the potential benefits of the Sense-IT app case-by-case, and training of therapists in using the app are expected to facilitate its integration in therapy.

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

Prior laboratory experiments among healthy samples found that training avoidance movements to angry faces may lower anger and aggression, especially people high in trait anger. To enrich this training and make it more suitable for clinical applications, the present researchers developed it into a Virtual Reality Game for Aggressive Impulse Management (VR-GAIME). The current study examined the effects of this training in a randomized controlled trial among forensic psychiatric outpatients with aggression regulation problems (N = 30). In addition to the aggression replacement training, patients played either the VR-GAIME or a control game. Aggressive behavior was measured pre-, half-way, and post-treatment via self-report and clinicians ratings. No difference was found between the VR-GAIME and the control game. However, the participants reported gaining more insight into their own behavior and that of others. Future VR intervention tools in clinical settings may capitalize more on their benefits for self-reflection within interpersonal settings.

Immersive Virtual Reality Simulation in Forensic Psychiatry and Adjacent Clinical Fields: A Review of Current Assessment and Treatment Methods for Practitioners

Background: Research has indicated that interactive, computerized case simulations using immersive virtual reality (VR) technology may be beneficial in the augmentation of conventional methods of assessment and treatment in forensic psychiatry, primarily through providing an engaging and safe environment in which the user can practice and learn skills and behaviors. However, there does not appear to be an overview of current developments available in the field, which may be an obstacle to clinicians considering the use of VR in their clinical practice. Objectives: Current, clinically relevant assessment and treatment methods applying immersive VR in forensic or adjacent clinical settings, were analyzed. Methods: This review surveyed the practical use of immersive VR in forensic psychiatry and relevant adjacent psychiatric and forensic fields from 2016 to 2020 and was performed in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Results: Out of the 1,105 journal articles screened, 14 met criteria for inclusion. Four articles described VR interventions directly addressing forensic psychiatric settings (treatment of general aggression and assessment of sexual offenders against children). The majority of the remaining articles were in the clinical domain of psychosis treatment. Several interventions were designed as part of comprehensive treatment programs, and others were intended as one-off assessments or paired with pre-existing psychological treatment. The degree to which the VR simulations were individualized to the user appeared to be largely dependent upon the extent of provider input. A variety of research methodologies were used in the included articles and the majority had limitations common to small-scale, non-randomized studies. None of the studies reported serious adverse effects. Discussion: There is a lack of large randomized controlled trials of current assessments or treatments using VR simulation in forensic psychiatry, let alone those with long-term follow-up, showing clear advantages of VR over standard practice. The evidence thus far is insufficient to recommend immediate and large-scale implementation of any one VR intervention, however, several have been shown to be feasible and acceptable to the participants and to provide insights and inspiration for future research and development.

A Perspective on the Integration of eHealth in Treatment of Offenders: Combining Technology and the Risk-Need-Responsivity Model

While there are multiple ways in which eHealth interventions such as online modules, apps and virtual reality can improve forensic psychiatry, uptake in practice is low. To overcome this problem, better integration of eHealth in treatment is necessary. In this perspective paper, we describe how the possibilities of eHealth can be connected to the risk-need-responsivity (RNR) model. To account for the risk-principle, stand-alone eHealth interventions might be used to offer more intensive treatment to high-risk offenders. The need-principle can be addressed by connecting novel experience-based interventions such as VR and apps to stable and acute dynamic risk factors. Finally, using and combining personalized interventions is in line with the responsivity-principle. Based on research inside and outside of forensic psychiatry, we conclude that there are many possibilities for eHealth to improve treatment-not just based on RNR, but also on other models. However, there is a pressing need for more development, implementation and evaluation research.

Welches Potenzial haben virtuelle Realitäten in der klinischen und forensischen Psychiatrie? Ein Überblick über aktuelle Verfahren und Einsatzmöglichkeiten

Virtuelle Realitäten (VR) werden in der Diagnose und Behandlung von Patienten im klinischen Feld bereits seit 20 Jahren erfolgreich eingesetzt und weiterentwickelt. Seit etwas mehr als 5 Jahren gibt es nun auch erste Beispiele über die Anwendung von VR in psychiatrisch-forensischen Kontexten. Für die forensische Psychiatrie ist die Möglichkeit, realistische, sichere und kontrollierbare Diagnostik- und Lernumgebungen zu schaffen, der ausschlaggebende Vorteil der VR-Technologie. So können z. B. Straftäter in Szenarien behandelt oder begutachtet werden, welche im echten Leben risikoreich, unethisch oder ökologisch invalide wären. In diesem Artikel werden unterschiedliche aktuelle Studienbeispiele zu klinischer Behandlung und Diagnose von Patienten sowie der forensischen Prognose und Therapie von Straftätern vorgestellt. Damit zeigt der Überblick, dass VR mittlerweile auch in der forensischen Psychiatrie ein vielversprechendes Werkzeug sein kann, welches bereits etablierte Instrumente ergänzen oder erweitern kann. Auch in der Ausbildung von forensisch-psychiatrischem Fachpersonal können VR-Anwendungen eine Hilfe sein. Hier gibt es bereits erste vielversprechende Einsätze durch das Training mithilfe von virtuellen Patienten, jedoch benötigt es noch umfangreiche Forschungsarbeit auf diesem Feld, um sie im professionellen Alltag einsetzen zu können. Vor dem Einsatz von VR-Anwendungen sollten sich Forscher und Praktiker neben den Vorteilen auch mit den Nachteilen von VR auseinandersetzen und ein besonderes Augenmerk auf die ethischen Richtlinien werfen, welche in den letzten Jahren dazu erarbeitet wurden. Die stetige Weiterentwicklung und der immer breitere Einsatz von VR im klinischen und forensisch-psychiatrischen Feld zeigen, dass VR auch hier das Potenzial hat, ein etabliertes Forschungs- sowie Therapieinstrument zu werden.

Integrating People, Context, and Technology in the Implementation of a Web-Based Intervention in Forensic Mental Health Care: Mixed-Methods Study

Background

While eMental health interventions can have many potential benefits for mental health care, implementation outcomes are often disappointing. In order to improve these outcomes, there is a need for a better understanding of complex, dynamic interactions between a broad range of implementation-related factors. These interactions and processes should be studied holistically, paying attention to factors related to context, technology, and people.

Objective

The main objective of this mixed-method study was to holistically evaluate the implementation strategies and outcomes of an eMental health intervention in an organization for forensic mental health care.

Methods

First, desk research was performed on 18 documents on the implementation process. Second, the intervention’s use by 721 patients and 172 therapists was analyzed via log data. Third, semistructured interviews were conducted with all 18 therapists of one outpatient clinic to identify broad factors that influence implementation outcomes. The interviews were analyzed via a combination of deductive analysis using the nonadoption, abandonment, scale-up, spread, and sustainability framework and inductive, open coding.

Results

The timeline generated via desk research showed that implementation strategies focused on technical skills training of therapists. Log data analyses demonstrated that 1019 modules were started, and 18.65% (721/3865) of patients of the forensic hospital started at least one module. Of these patients, 18.0% (130/721) completed at least one module. Of the therapists using the module, 54.1% (93/172 sent at least one feedback message to a patient. The median number of feedback messages sent per therapist was 1, with a minimum of 0 and a maximum of 460. Interviews showed that therapists did not always introduce the intervention to patients and using the intervention was not part of their daily routine. Also, therapists indicated patients often did not have the required conscientiousness and literacy levels. Furthermore, they had mixed opinions about the design of the intervention. Important organization-related factors were the need for more support and better integration in organizational structures. Finally, therapists stated that despite its current low use, the intervention had the potential to improve the quality of treatment.

Conclusions

Synthesis of different types of data showed that implementation outcomes were mostly disappointing. Implementation strategies focused on technical training of therapists, while little attention was paid to changes in the organization, design of the technology, and patient awareness. A more holistic approach toward implementation strategies—with more attention to the organization, patients, technology, and training therapists—might have resulted in better implementation outcomes. Overall, adaptivity appears to be an important concept in eHealth implementation: a technology should be easily adaptable to an individual patient, therapists should be trained to deal flexibly with an eMental health intervention in their treatment, and organizations should adapt their implementation strategies and structures to embed a new eHealth intervention.

Validation of a mobile game-based assessment of cognitive control among children and adolescents

Cognitive control is the most fundamental psychological function that underlies the execution of many other psychological functions. A mobile game application could be a useful strategy to evaluate cognitive control in the groups of children and adolescents. Although a serious game that is based on gamification would be an optimal platform for the administration of behavioral and clinical assessments of children and adolescents, most studies on gamification have been conducted among adults and older adults than among children and adolescents. This study aimed to assess cognitive control using a mobile game that used gamification and compared the results to those from traditional neuropsychological tests for children and adolescents. In order to address this objective, this study used a serious game, namely, “CoCon,” which was developed to assess cognitive control in children and adolescents. This study included 100 participants from a community sample (mean age = 11.75 years, ranged from 9 to 16 years, SD = 1.40 years; Male = 59(59%), Female = 41(41%)). The analyses interrogated the relationships among various game behaviors scores of CoCon, the standardized neuropsychological tests (K-WISC-IV, CTT, and Stroop), and self-reporting executive function difficulty questionnaire. As results, a mobile game application-based assessment proved to be a reliable and valid measure of the cognitive control in children and adolescents. The index scores from the CoCon were significantly related to various cognitive control functions and differentiated between the high and low cognitive control groups. Specifically, even though the participants completed the mobile game ‘CoCon’ in their natural habitats, the CoCon scores were comparable to the measures from standard neuropsychological tests. In conclusion, the present findings suggest that mobile games that use advanced technology and sophisticated psychological strategies can serve as a new and expanded platform for the administration of psychological assessments.