Virtual Reality Aggression Prevention Therapy (VRAPT) versus Waiting List Control for Forensic Psychiatric Inpatients: A Multicenter Randomized Controlled Trial

Stéphanie Klein Tuente,Chris N W Geraets,Erik Bulten,Stefan Bogaerts,Marije Keulen-De Vos,Hein Bokern,Wim Veling,Maarten Vos,Sarah Van Ijzendoorn

doi:10.3390/jcm9072258

Abstract

Many forensic psychiatric inpatients have difficulties regulating aggressive behavior. Evidence of effective aggression treatments is limited. We designed and investigated the effectiveness of a transdiagnostic application of a virtual reality aggression prevention training (VRAPT). In this randomized controlled trial at four Dutch forensic psychiatric centers, 128 inpatients with aggressive behavior were randomly assigned to VRAPT (N = 64) or waiting list control group (N = 64). VRAPT consisted of 16 one-hour individual treatment sessions twice a week. Assessments were done at baseline, post-treatment and at 3-month follow-up. Primary outcome measures were aggressive behavior observed by staff and self-reported aggressive behavior. Analysis was by intention to treat. This trial was registered in the Dutch Trial Register (NTR, TC = 6340). Participants were included between 1 March 2017, and 31 December 2018. Compared to waiting list, VRAPT did not significantly decrease in self-reported or observed aggressive behavior (primary outcomes). Hostility, anger control, and non-planning impulsiveness improved significantly in the VRAPT group compared to the control group at post-treatment. Improvements were not maintained at 3-month follow-up. Results suggest that VRAPT does not decrease aggressive behavior in forensic inpatients. However, there are indications that VRAPT temporarily influences anger control skills, impulsivity and hostility.

Highlights

Aggression of forensic psychiatric inpatients is highly prevalent, with recent estimates between 31% and 59% of at least one violent assault during hospitalization [1,2]
Reasons for discontinuation of the virtual reality aggression prevention therapy (VRAPT) were: drug use, cardiac arrhythmia, security restrictions, feeling uncomfortable during role-playing, moved to another clinic that was not participating in this study
The present study investigated the effect of a novel virtual reality aggression prevention therapy (VRAPT) in forensic psychiatric inpatients

Summary

Introduction

Aggression of forensic psychiatric inpatients is highly prevalent, with recent estimates between 31% and 59% of at least one violent assault during hospitalization [1,2]. A systematic review of psychological therapies designed for violent behavior in clinical and forensic settings found ten studies, providing tentative support for the effectiveness on aggressive behavior. The review included only two randomized controlled trials, both of cognitive behavioral therapy, one of which had negative outcomes [5]. Another more recent systematic review included 16 studies on the effect of Aggression Replacement Training (ART) on antisocial behavior in young people and adults [6]. Results indicated positive effects of ART on recidivism rates and secondary outcomes (e.g., social skills), only four studies involved adult samples, and the majority of the included studies were of average quality because of non-randomized designs, selection bias, and small sample sizes

Methods

Results

Conclusion