ABSTRACT
Background: Treating violent behavior in prisons comes with challenges, such as the inability to practice safely with triggering situations and motivational issues. A solution may be the use of Virtual Reality (VR). With VR, specific conditions or needs can be tailored for individual practice, it can enhance motivation and VR has proven to be a safe and effective tool in mental health treatment. Objective: A pilot study was conducted to test the acceptability, feasibility, and preliminary effects of VR Aggression Prevention Treatment (VRAPT) in a prison-based population. Methods: In total 17 detainees with aggressive behavior were included in this single-group pilot study. Acceptability and feasibility were assessed using qualitative measures for participants and therapists. Preliminary treatment effects were measured with self-report and observational measures on aggression, anger, emotion regulation, and impulsiveness. Results: Participants and therapists were predominantly positive about VRAPT. Participants rated the sessions with an average satisfaction score of 9.2 out of 10 (SD = 0.3). Qualitative data showed that participants reported having learned to respond more adequately to aggressive behavior and gained insights into their own and others' triggers and tension. The combination of VR and theory was experienced as a strength of the treatment, as well as the ability to trigger aggression in VR which provided insights into aggression. However, the theoretical framework was found to be too complex, and more aggressive and personal scenarios should be incorporated into the sessions. Self-reported aggression, anger, provocation, emotion regulation, and observed verbal aggression decreased and seemed to stabilize after the treatment ended, with small to medium effect sizes. Conclusion: VRAPT proved feasible and acceptable for most participants and therapists. An adapted treatment protocol called Virtual Reality Treatment for Aggression Control (VR-TrAC), will be used in a future RCT to investigate the effects of the treatment in a prison-based population.
ABSTRACT
Emotion regulation has been specifically linked to both non-suicidal self-injury (NSSI) and attempted suicide. It is also known that self-harm is disproportionally higher (30-68.4%) in forensic samples than in the general population, yet knowledge about the association between emotion regulation and self-harm in forensic settings is scarce. The purpose of this study was to describe emotion regulation in a sample of forensic psychiatric patients, to explore dimensions and levels of emotion regulation between forensic psychiatric patients with and without self-harm, and to explore associations between forensic psychiatric patients' self-reported emotion regulation and self-reported functions of NSSI. A cohort of forensic psychiatric inpatients (N=98) was consecutively recruited during 2016-2020 from a high-security forensic psychiatric clinic in Sweden. Data were collected through the self-report measures Difficulties in Emotion Regulation Scale (DERS) and Inventory of Statements About Self-injury (ISAS). In relation to the first aim, median total and subscales scores for DERS were reported. Results showed a statistically significant difference in emotion regulation between participants with and without self-harm (p=0.004), with a medium effect size (Cohen's d=0.65) for the DERS total scale. The DERS subscales returned large differences for Impulse (p=0.001, d=0.86), Goals (p=0.014, d=0.58), and Strategies (p=0.012, d=0.54) between participants with and without self-harm. Finally, DERS scores were correlated with both the interpersonal (rs =0.531, p<0.001, n=43) and intrapersonal factors (rs =0.503, p<0.001, n=43) of NSSI as reported on the ISAS. Participants with self-harm (NSSI and/or suicide attempts) demonstrated significantly more difficulties with emotion regulation than those without self-harm. Emotion dysregulation was associated with both interpersonal and intrapersonal functions of NSSI in the participants. We suggest further studies on forensic psychiatric patients' maladaptive behaviors that focus on substance abuse, self-harm, and aggressive behaviors in relation to the regulation and expression of emotion.
ABSTRACT
Structured assessment of aggressive behavior in forensic psychiatry is needed. This study investigated staff-observed and self-reported measures to map prevalence and characteristics of aggressive behavior in forensic inpatients and aimed to identify early signs of aggressive outbursts. In this longitudinal study, 120 forensic psychiatric inpatients with a history of aggression were included. Staff monitored aggressive behavior for 30 weeks using the Social Dysfunction and Aggression Scale (SDAS). Patients completed baseline self-report measures on aggression, anger, and impulsivity. Staff monitoring showed that most inpatients displayed moderate (86%) or severe (65%) aggressive behavior at least once, and 37.5% showed physical aggression. Inpatients with a least one physical aggression incident differed from others in self-reported anger, (reactive) aggression, non-planning impulsivity, and sociodemographic and clinical characteristics (e.g., higher prevalence of cluster B personality disorders, and lower intelligence). Two-thirds of the physical aggression incidents were preceded by observations of increased non-physical aggression (SDAS). In forensic psychiatric inpatients with a history of aggression, more than a third of the patients demonstrated at least one occasion of physical aggression during 30 weeks of observation.
Subject(s)
Aggression , Inpatients , Forensic Psychiatry , Humans , Longitudinal Studies , Self ReportABSTRACT
Early childhood adversity can cause an imbalance in the autonomic function, which may in turn lead to the development of trauma-spectrum disorders and aggressive behavior later in life. In the present study, we investigated the complex associations between early adversity, heart rate variability (HRV), cluster B personality disorders, and self-reported aggressive behavior in a group of 50 male forensic inpatients (M age = 41.16; SD = 10.72). Structural Equation Modeling analysis revealed that patients with cluster B personality disorders were more likely to have adverse early childhood experiences and reduced sympathetic dominance in response to a threat than patients without cluster B personality disorders. In addition, HRV and cluster B personality disorders did not significantly mediate the association between early childhood adversity and self-reported aggressive behavior. These findings are important for clinical practice to facilitate specific treatment programs for those affected.
Subject(s)
Adverse Childhood Experiences , Aggression , Adult , Child, Preschool , Heart Rate , Humans , Inpatients , Male , Personality Disorders/epidemiologyABSTRACT
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.
ABSTRACT
BACKGROUND: Many patients residing in forensic psychiatric centers have difficulties regulating their aggression in an adequate manner. Therefore, they are frequently involved in conflicts. Evidenced-based aggression therapies in forensic psychiatry are scarce, and due to the highly secured environment, it is hard to practice real-life provocations. We have developed a Virtual Reality aggression prevention training (VRAPT), providing safe virtual environments, in which patients can practice controlling their aggressive behaviors in an adequate way. The main objective of this study is to examine whether VRAPT is effective in reducing aggression among forensic psychiatric inpatients. METHODS: Four forensic psychiatric centers in the Netherlands are participating in this study. Participants will be randomly assigned to either VRAPT or a waiting list. The two groups will be compared at several different time points: baseline (12 weeks before intervention), pre-intervention, post-intervention and at 12 weeks follow-up. After follow-up measurements are completed, participants from the waiting list will also receive VRAPT. The primary outcome is level of aggressive behavior, consisting of staff-reported and self-reported measures. Secondary outcomes are self-report questionnaires on e.g., anger, impulsivity and aggression. DISCUSSION: To the best of our knowledge this is the first study to examine the effectiveness of a VR aggression prevention training in forensic psychiatric centers. Further details on the methodological issues are discussed in this paper. TRIAL REGISTRATION: Dutch Trial Register ( NTR, TC = 6340 ). Retrospectively registered 14-04-2017.
