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].

The effectiveness of Forensic Outpatient Systemic Therapy in the treatment of juvenile antisocial behavior: A study protocol of a Multiple Case Experimental Design.

BACKGROUND: Juvenile antisocial behavior can have long-lasting and devastating effects for juveniles themselves, victims, and society. Evidence-based treatment is vital. Forensic Outpatient Systemic Therapy (Forensische Ambulante Systeem Therapie; FAST) is a promising treatment for juveniles showing severe antisocial behavior including aggression, (domestic) violence, and delinquent behavior. FAST has a flexible intensity and length, addresses individual and systemic risk and protective factors, and is responsive to the abilities of the client (system), intervention characteristics all considered crucial for effective treatment. The current study will investigate whether FAST is effective in reducing aggression of the juvenile, reaching client formulated subgoals, and improving family functioning. Processes of change will be examined, as well as mediation by reaching client formulated subgoals and improved family functioning. METHODS: A Multiple Case Experimental Design (MCED) with an ABC design will be performed (A = baseline, B = intervention, and C = follow-up). Juveniles with primary aggression and/or anger problems (N = 15) and their caregiver(s) will be recruited. Data collection will consist of self-report questionnaires and case file analysis. Participants fill out frequent short self-report questionnaires (twice a week during phase A, every other week during phase B, and every week during phase C) and two main questionnaires at the start of the intervention and immediately after intervention end, thereby covering a period of 5 to 11 months. Both visual and statistical analyses will be performed. DISCUSSION: This study will generate robust knowledge and inform clinical practice on the effectiveness, processes of change, and mediating mechanisms of FAST, aiming to improve the treatment of future families within youth forensic care. TRIAL REGISTRATION: This trial was registered at ClinicalTrials.gov on 28/08/2023, protocol ID 60-63600-98-1138a.

A pilot study regarding the feasibility and efficacy of an outpatient treatment program for young adult high-risk offenders (YAHOP).

This pilot study examines whether the Young Adult Habitual Offender Program (YAHOP), an intensive and outpatient program, is related to a reduction in the general risk of recidivism, common forensic symptomology as well as cognitive distortions. The program integrity (PI) was assessed, with the intent to explore the relationship between the level of PI and any changes in several outcome variables. Additionally, the study examines whether participants with a migration background benefitted equally from YAHOP compared to participants with a native Dutch background. The sample comprised n = 90 high-risk young adult offenders. Results show a decrease in general risk of recidivism. The dynamic risk factors delinquent social network, insufficient impulse control, and dysfunctional problem-solving skills also show a decrease, as well as the forensic symptoms of aggression and anger. Effect sizes are small, except for anger, which has a medium effect size. We found no change in cognitive distortions and problematic substance use. YAHOP shows to be responsive and culturally sensitive, as the participants with a migration background show a significant decrease in general risk of recidivism. No moderator analysis was conducted due to an overall low level of program integrity. After improving program integrity, full-scale quantitative research is needed as YAHOP has the potential as a promising desistance program for high-risk offenders, as in this study the 56 non-completers were also included.

Factor Analysis With Unusual Sexual Interests: A Replication Study in a Representative Population Sample.

A previous study found a variety of unusual sexual interests to cluster in a five-factor structure, namely submission/masochism, forbidden sexual activities, dominance/sadism, mysophilia, and fetishism (Schippers et al., 2021). The current study was an empirical replication to examine whether these findings generalized to a representative population sample. An online, anonymous sample (N = 256) representative of the Dutch adult male population rated 32 unusual sexual interests on a scale from 1 (very unappealing) to 7 (very appealing). An exploratory factor analysis assessed whether similar factors would emerge as in the original study. A subsequent confirmatory factor analysis served to confirm the factor structure. Four slightly different factors of sexual interest were found: extreme, illegal and mysophilic sexual activities; light BDSM without real pain or suffering; heavy BDSM that may include pain or suffering; and illegal but lower-sentenced and fetishistic sexual activities. The model fit was acceptable. The representative replication sample was more sexually conservative and showed less sexual engagement than the original convenience sample. On a fundamental level, sexual interest in light BDSM activities and extreme, forbidden, and mysophilic activities seem to be relatively separate constructs.

Effectiveness of Moral Developmental Interventions for Youth Engaged in Delinquent Behavior: A Meta-Analysis.

There is vast empirical evidence showing that juvenile delinquency is associated with delays in moral development, including moral judgment, empathy, and self-conscious emotions (guilt and shame). Consequently, interventions have been developed that target moral development of juvenile delinquents to reduce criminal offense recidivism. However, a comprehensive synthesis of studies examining the effectiveness of these interventions was not yet available. The present meta-analysis of (quasi-)experimental research therefore examined the effects of interventions that target moral development of youth engaged in delinquent behavior. Interventions that targeted moral judgment (11 studies and 17 effect sizes) showed a significant and small-to-medium effect on moral judgment (d = 0.39), with intervention type as a significant moderator, but no significant effect on recidivism (d = 0.03; 11 studies and 40 effect sizes). No (quasi-)experimental studies were found that targeted guilt and shame in juvenile offenders, and an insufficient number of studies (i.e., only two) were found to conduct a meta-analysis of interventions that target empathy. The discussion focuses on potential ways to improve moral development interventions for youth engaged in delinquent behavior, and provides suggestions for future research.

The effectiveness of blended versus regular Forensic Outpatient Systemic Therapy in the treatment of juvenile antisocial behavior: a study protocol of a randomized controlled trial.

BACKGROUND: Antisocial behavior during adolescence can have long-lasting negative effects and leads to high societal costs. Forensic Outpatient Systemic Therapy (Forensische Ambulante Systeem Therapie; FAST) is a promising treatment for juveniles aged 12-21 showing severe antisocial behavior. The intensity, content and duration of FAST can be adjusted to the needs of the juvenile and their caregiver(s), which is considered crucial for effective treatment. Next to the regular version of FAST (FASTr), a blended version (FASTb) in which face-to-face contacts are replaced by minimally 50% online contacts over the duration of intervention was developed during the Covid-19 pandemic. The current study will investigate whether FASTb is equally effective as FASTr, and through which mechanisms of change, for whom, and under which conditions FASTr and FASTb work. METHODS: A randomized controlled trial (RCT) will be carried out. Participants (N = 200) will be randomly assigned to FASTb (n = 100) or FASTr (n = 100). Data collection will consist of self-report questionnaires and case file analysis, and include a pre-test at the start of the intervention, a post-test immediately after the intervention, and a six month follow-up. Mechanisms of change will be investigated using monthly questionnaires of key variables during treatment. Official recidivism data will be collected at two-year follow-up. DISCUSSION: This study aims to improve the effectiveness and quality of forensic mental health care for juveniles with antisocial behavior by studying the effectiveness of blended care, which has not been studied before in treatment of externalizing behavior. If found to be at least as effective as face-to-face treatment, blended treatment can help meet the urgent need for more flexible and efficient interventions in this field. In addition, the proposed study aims to unravel what works for whom, knowledge urgently needed in mental health care for juveniles with severe antisocial behavior. TRIAL REGISTRATION: This trial was registered at ClinicalTrials.gov on 07/11/2022, registration number NCT05606978.

A Meta-Analysis of the Effectiveness of EMDR and TF-CBT in Reducing Trauma Symptoms and Externalizing Behavior Problems in Adolescents.

This multi-level meta-analysis tested if evidence-based trauma treatment was effective in reducing trauma symptoms and externalizing behavior problems in adolescents. Based on eight independent samples and 75 effect sizes, results indicated that Trauma Focused-Cognitive Behavioral Therapy (TF-CBT) and Eye Movement Desensitization Reprocessing (EMDR) had a large and significant overall effect (d = 0.909) on reducing trauma symptoms and externalizing behavior problems. Trauma treatment significantly decreased trauma symptoms (large effect) and externalizing behavior problems (medium effect). Age and type of control group moderated treatment effects. Treatment was more effective in older adolescents. Trauma treatment for adolescents with externalizing behavior problems had a larger effect compared to no treatment, but not compared to treatment as usual. It seems important to provide a broad treatment offer for adolescents with severe externalizing behavior problems, in which, besides trauma treatment, attention is paid to reducing relevant individual risk factors for behavior problems.

Exploratory Factor Analysis of Unusual Sexual Interests.

BACKGROUND: Unusual sexual interests are largely intercorrelated, yet not much is known about underlying patterns of clusters between various sexual interests. AIM: To identify underlying clusters of unusual sexual interests using exploratory factor analysis. METHODS: We conducted exploratory factor analysis with self-reported interest in a wide variety of unusual sexual acts for an online, international sample (N = 669; 61% female), and for women and men separately. Factor regression weights were correlated to self-reported sex life satisfaction, sexual outlet, and psychiatric symptoms. OUTCOMES: Participants rated the attractiveness of 50 unusual sexual activities, and reported on their sex life satisfaction (Arizona Sexual Experiences Scale), sexual outlet, and symptoms regarding ADHD (Adult ADHD Self-Report Screening Scale for DSM-5), depression, anxiety, and stress (Depression, Anxiety, and Stress Scale). RESULTS: We identified 5 factors of unusual sexual interests that were largely comparable for women and men: submission/masochism, forbidden sexual activities, dominance/sadism, mysophilia (attraction to dirtiness or soiled things), and fetishism. For women, unusual sexual interests related to more psychiatric symptoms and higher sexual outlet, whereas this relation was less explicit for men. CLINICAL IMPLICATIONS: Different factors of unusual sexual interests may serve different underlying functions or motivations, for instance related to sexual, and emotional regulation. A better understanding of the nature of unusual sexual interests is important to be able to influence sexual interests that are unwanted or cause damage to others. STRENGTHS & LIMITATIONS: Strength of this study include its anonymity, the avoidance of sexual orientation effects, and the possibility to indicate only a slight endorsement toward sexual items. Limitations include the sample's generalizability and the truthfulness of online responding. CONCLUSION: Unusual sexual interests could be clustered into 5 factors that were largely comparable for women and men: submission/masochism, forbidden sexual activities, dominance/sadism, mysophilia, and fetishism. Schippers EE, Smid WJ, Huckelba AL, et al. Exploratory Factor Analysis of Unusual Sexual Interests. J Sex Med 2021;18:1615-1631.

A quasi-experimental pilot study to the effects of Responsive Aggression Regulation Therapy (Re-ART) Outpatient for young adults.

It is important to provide treatment for juvenile and young adult violent offenders, since no or (too) late treatment increases the risk of recidivism and persistent aggressive behavior in adulthood. In this study, we investigated the efficacy of the intervention Responsive Aggression Regulation Therapy (Re-ART) Outpatient, which has been developed for adolescents and young adults between 16 and 24 years old with severe aggression problems. This quasi-experimental (pilot) study compared the effects of Re-ART Outpatient (n = 47) with a control group (n = 29) receiving treatment as usual on measures regarding risk of violent recidivism, impulsivity, emotional/personal functioning, family functioning, motivation, handling anger, self-reported problem behavior, coping skills, and cognitive distortions. Re-ART showed significantly better results than the control group on risk of violent recidivism, impulsivity, emotional/personal functioning, motivation, handling anger, certain coping skills, and certain cognitive distortions. Family functioning and self-reported rule-breaking behavior did not differ significantly between the groups. The results implicate that Re-ART is a promising outpatient intervention for young adults with severe aggressive behavior. The results can be explained by the fact that Re-ART treats both systemically and individually and pays specific attention to stress reduction and the improvement of executive functions.

Responsive Aggression Regulation Therapy (Re-ART) Improves Executive Functioning in Adolescents and Young Adults with Severe Aggression Problems: A Pilot Study.

This pilot study (N = 25) compared the effects of a short, four-month version of Responsive Aggression Regulation Therapy Outpatient (Re-ART Compact) and the entire, ten-month intervention (Re-ART Complete) on specific executive functioning (EF) and the risk of violent recidivism in adolescents and young adults (13-23 years). Re-ART is a cognitive behavioral-based intervention for adolescents and young adults with severe aggression problems. The Re-ART Compact and Re-ART Complete groups were comparable on the EF measures inhibition, flexibility, emotion regulation, self-evaluation, and self-control, but the Re-ART Complete group showed more improved risk of violent recidivism. We conclude that Re-ART Compact can be used as a compact, short intervention for EF, which is a valuable addition to the field of forensic mental health care where many problem behaviors relate to poor EF.

Responsive Aggression Regulation Therapy (Re-ART): An Evaluation Study in a Dutch Juvenile Justice Institution in Terms of Recidivism.

This article describes a quasi-experimental study of the effectiveness of Responsive Aggression Regulation Therapy (Re-ART) in terms of recidivism for 16- to 21-year-old juveniles with aggression problems and high risk of recidivism. In a Dutch juvenile justice institution, an experimental group received Re-ART ( n = 63, Re-ART group) and a waitlist control group received Treatment as Usual ( n = 28, TAU group). Results indicated that Re-ART is significantly more effective than TAU in reducing the juveniles' recidivism risk for violent offending. Compared with the TAU group, the Re-ART group showed significantly less violent crimes after 2 and 3 years, less property crimes after 2 years, and less general recidivism after 2 and 3 years. There was no significant difference between groups in recidivism of property crimes with violence. Ethnicity, mild intellectual disabilities, substance abuse, and age did not moderate the effects on recidivism outcome, which indicates that Re-ART was equally effective for various groups.

The Relationship Between the Level of Program Integrity and Pre- and Post-Test Changes of Responsive-Aggression Regulation Therapy (Re-ART) Outpatient: A Pilot Study.

Responsive-Aggression Regulation Therapy (Re-ART) Outpatient is a cognitive behavioral-based intervention for adolescents and young adults (16-24 years) with severe aggressive behavioral problems. This pilot study (N = 26) examined the level of program integrity (PI; that is, the delivery of the intervention as it is originally intended) of Re-ART. We also investigated the pre- and post-test changes in several outcome variables, and the relation between the level of PI and these changes. Participants were recruited from three different outpatient forensic settings. Results showed that the PI of half of the treatments was not sufficient (e.g., the intensity of the program was too low and some standard modules were not offered). In addition, this pilot study demonstrated that sufficient PI was related to positive changes in aggression, cognitive distortions, social support, coping (reported by therapist), and distrust (responsiveness to treatment).