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.

Virtual reality-assisted assessment of paranoid ideation in forensic psychiatric inpatients: A mixed-methods pilot study.

Background: Reliable and valid assessment of paranoia is important in forensic psychiatry for providing adequate care. VR technology may add to current assessment procedures, as it enables observation within realistic (social) situations resembling the complexity of everyday life. VR constitutes a promising tool within forensics, due to the restricted nature of forensic psychiatric hospitals and ethical challenges arising from observing potentially dangerous behaviors in real life. Objective: To investigate the feasibility of VR assessment for paranoid ideation in forensic psychiatric inpatients qualitatively by assessing the experiences of patients and a clinician, and to explore how the VR measures relate to established clinical measures. Methods: One clinician (experienced psychiatrist) and 10 forensic psychiatric inpatients with a history or suspicion of paranoid ideation were included. Patients participated in two immersive VR scenarios (bus and supermarket) during which paranoia was assessed by the clinician. Qualitative interviews were performed with patients and the clinician performing the assessment to investigate experiences and feasibility. Further, measures of paranoia, social anxiety, and positive symptoms were obtained. Results: Nine out of 10 participants with varying levels of paranoid ideation completed the assessment. Manifest inductive content analyses of the interviews revealed general experiences, advantages such as enabling observing participants from a different perspective, and challenges of the VR assessment, such as a lack of objectivity and the laboriousness of the assessment for the clinician. Although more paranoia was experienced during the supermarket scenario, correlates with classical measures were only significant for the bus scenario. Discussion: The VR assessment was appreciated by most patients and the clinician. Based on our results short, standardized VR assessment scenarios are feasible, however, they do not appear reliable or objective for assessing paranoia. The clinical usefulness is most likely as a collaborative tool and add-on measure to existing methods.

Use of Virtual Reality in Psychiatric Diagnostic Assessments: A Systematic Review.

Background: Technological developments such as Virtual reality (VR) provide new opportunities to extend and innovate mental healthcare. VR as a tool for clinical assessment has been described as promising, as it can enable real-time assessment within real-like environments or contexts as opposed to self-report and behavioral tasks in laboratory settings. Objective: With this systematic review we aimed to provide an overview of recent studies using VR in the assessment of psychiatric disorders. Methods: A systematic search was performed using Pubmed, Embase, PsycInfo, and Web of Science between 2016 and 2020. Studies were included if they used immersive VR, concerned assessment of psychiatric symptoms/disorders, and included adult patients with psychiatric disorders. Results: The search resulted in 3,163 potentially eligible articles, from which a total of 27 studies fulfilled inclusion criteria. Most studies considered anxiety (n = 7), addictive, (n = 7), or psychotic disorders (n = 5). Regarding ADHD (n = 3), PTSD (n = 3), and pedophilic disorder (n = 1), a few studies had been performed since 2016. The majority of the included studies compared patient groups to healthy control groups. Discussion: Recent studies on VR-assisted psychiatric assessments have been conducted to validate VR environments, to assess symptoms for diagnostics or therapy goals, search for biomarkers, and to gain knowledge on psychiatric disorders. VR tasks were able to detect some difference between patient and healthy control groups, mainly with regard to self-report measures. Despite previous, promising prospects, the use of VR as a tool in clinical assessments must still be considered as a field in need of continued developments and evaluations. Systematic Review Registration: www.crd.york.ac.uk/prospero, identifier: CRD42021233772.

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.

The effect of gender on the outcome of forensic psychiatric assessment in Sweden: A case vignette study.

BACKGROUND: Previous research suggests that female violent offenders at risk of a prison sentence are more likely than their male counterparts to be assessed as having mental health problems of a nature or degree that would lead to a court requirement for hospital treatment. AIMS/HYPOTHESES: To test the hypothesis that there is bias towards hospital disposal of female compared with male violent offenders with mental disorder. METHODS: In Sweden, the National Board of Forensic Medicine oversees all assessments of mental disorder for the criminal courts. Twenty-six Board appointed forensic psychiatrists, psychologists and social workers each independently assessed six case vignettes for fit with criteria for 'severe mental disorder', a prerequisite for hospital disposal from court. Each gender neutral vignette described a person who had been convicted of serious assault and had a major mental disorder. A gender was then assigned to each offender randomly within a block design, thus varying between sets. Participants were blind to the main aim of the study and the gender variation. RESULTS: There was no significant association between gender of the person assessed and judgement that s/he had a 'severe mental disorder'. An offender depicted as having mental retardation was more likely to be assessed as at high risk of criminal recidivism if portrayed as female, regardless of the sex, place of work or level of experience of the assessor. CONCLUSION: We found no evidence of gender bias in determining appropriateness of a hospital disposal of an offender with mental disorder. The difference in assessment of recidivism according to sex of the patient was only in relation to mental retardation; further research would be needed to able to interpret this. As researchers in other countries have reported gender bias in disposals from court, our findings may provide support for a centralised forensic psychiatric assessment board and formal, on-going training. Copyright © 2015 John Wiley & Sons, Ltd.

A new interactive computer simulation system for violence risk assessment of mentally disordered violent offenders.

BACKGROUND: Assessment of risk of future violence has developed from reliance on static indicators towards a more dynamic approach. In the latter context, however, the offender is seldom confronted with real life situations. AIMS: The aim of this study is to evaluate a computer-based system--Reactions on Display, which presents human interactions based on real-life situations--for its effectiveness in distinguishing between potentially violent offenders with mental disorder and a healthy comparison group. METHODS: Male offenders with autism spectrum disorders or psychosis were recruited from specialist forensic psychiatric units in Sweden and healthy participants from the local communities. Each consenting participant was presented with film clips of a man in neutral and violent situations, which at critical moments stopped the story to ask him to predict the thoughts, feelings and actions of the actor. RESULTS: Offender patients, irrespective of diagnosis, detected fewer emotional reactions in the actor in the non-violent sequence compared with controls. When asked to choose one of four violent actions, the offender patients chose more violent actions than did the controls. They also reported fewer physical reactions in the actors when actors were being violent. There were also some examples of incongruent or deviant responses by some individual patients. CONCLUSIONS AND IMPLICATIONS FOR PRACTICE: The use of interactive computer simulation techniques is not only generally acceptable to offender patients, but it also helps to differentiate their current response style to particular circumstances from that of healthy controls in a way that does not rely on their verbal abilities and may tap more effectively into their emotional reactions than standard verbal questions and answer approaches. This may pave the way for Reactions on Display providing a useful complement to traditional risk assessment, and a training route with respect to learning more empathic responding, thus having a role in aiding risk management.