Virtual Reality Aggression Prevention Training in a Dutch prison-based population * a pilot study

Violent crimes (violence directed against a person or matters) are still one of
the most common crimes in a Dutch prison-based population. Violent crimes alone
take up to 29% of all offenses. If property crimes with violence and sexual
assaults are also included, this number can increase up to half of all
offenses. When looking at the recidivism rates of these types of crimes, it has
been estimated that 22% of these offenders will return to prison within two
years after they have been released (*DJI in getal 2013-2017,* 2018). Research
also shows that individuals with violent crimes during their incarceration,
recidivate more often and even sooner than inmates without violent crimes
(Mooney & Daffern, 2015), which indicates the importance on treating
individuals with aggression problems in detention.

Many forms of aggression-based therapies have been developed, mostly consisting
of cognitive or behavioural methods, or a combination of the two (Shelton,
Sampl, Kesten, Zhang, & Trestman, 2009). The focus is mostly on reshaping
cognitions, improve problem solving, exposure and skill training (Shelton et
al., 2009). Research has shown that treatment for aggression in generally works
in reducing the recidivism rates (McGuire, 2008) However, results in
prison-based populations the results are still inconclusive, mostly due to the
low quality of the studies (Auty et al., 2017; McGuire, 2008).

For therapy to be successful, a couple of factors are of importance: firstly,
the motivation or the willingness of the offenders to change their behaviour
(Jochems et al., 2012; McGuire, 2008; Smeijers, Bulten, Buitelaar, & Verkes,
2018). Individuals may be convinced that they have no problem or may have
followed therapy earlier without success, demotivating them to follow therapy
again. Secondly, most therapies are very theoretically, which may not be
successful for some specific populations. It is recommended, for example in
individuals with low intellectual disabilities, to use less language-dependent
therapies (Simpson, Mizen, & Cooper, 2016). Lastly, a known difficulty in
imprisoned individuals is the inability to practice learned behaviour in real
life situations (McGuire, 2008).

A solution to the above encountered problems may lay in the use of Virtual
Reality (VR). VR uses artificial computer-generated environments to imitate
real-world situations. VR makes it possible to practice situations in an
interactive computer-generated environment and therefore combines theoretical
information with practical learning situations. Situations can be altered as
much as needed to fit the precise conditions in which the individual wants to
practice the problematic behaviour (Freeman et al., 2017). This technique may
also trigger the motivation of individuals, as it is new and interesting, and
may also be attractive to the younger generation since they grew up with
technology and innovation.

The primary objective of this pilot study is to adjust the VRAPT protocol to
make it applicable in a prison-based sample and to investigate if the protocol
of the pilot study is feasible for a larger effect study. Several
questionnaires will be filled in with the main goal to investigate if they are
suitable for the study and if any problems are encountered if participants or
staff will fill them in.
The goal is to resolve any issues, before an effect study can be conducted.

The secondary objective of this study is to examine the effect of the VRAPT on
aggression in a prison-based population.
This will be evaluated with the same two methods that are used in the previous
VRAPT effect study in forensic inpatients (Klein Tuente et al 2018) and will be
applied in our upcoming randomized controlled trial: staff observation and
self-report measurements with additional physiological measurements.

This study will be an uncontrolled pilot study. As mentioned in the
introduction and rationale, the previous VRAPT study is being conducted in four
Dutch Forensic Psychiatric Centers (FPC*s), and will be used as the base for
the VRAPT study in a prison-based population (Klein Tuente et al 2018).

Procedure
1. All participants meeting the inclusion criteria, will be made aware of the
study through the psychologist, the case manager or the mentor on the ward.
Also, there will be flyers with information about the study, so participants
who want to join also can apply on one*s own initiative.
2. When participants are signed up, a researcher will pay the participant a
visit to give information about the study and check if they meet the inclusion
criteria. As screening with the Aggression Questionnaire is needed for
assessment of eligibility, informed consent for the study is obtained before
the AQ is administered.
3. The mentor of the participant will be instructed how to score the Social
Dysfunction and Aggression Scale (SDAS-9). They will be asked to fill out the
SDAS weekly, four weeks before the treatment will start, until four weeks after
the training is over. Research assistants will check if the scores are complete
and support the staff with filling out the questionnaire.
4. Self-report questionnaires are filled in by the participants for baseline
measurements (DERS NAS-PI, RPQ, BISS-11, ACE and MATE). The research assistant
will assist with filling in the questionnaires (explain the content of the
questionnaires and assist when participants don*t understand the questions).
5. Treatment consists of 16 twice-weekly individual sessions with a maximum
duration of 60 minutes per session. Physiological measurements will start in
the 6th session.
6. After every session, the SRS is filled in and additional evaluating
questions are asked.
7. At the end of treatment, baseline measures (only AQ, BIS-11, DERS, NAS-PI,
RPQ) are repeated in all participants. The research assistant will assist the
participants with filling in the questionnaires.
8. Two months after the end of the VRAPT sessions, measures are repeated again.

The VRAPT protocol that will be used in this study is the protocol that is
currently used in the study of Klein Tuente et al. (2018). This protocol is
based on the Social Information-Processing (SIP) model of Crick and Dodge
(1994). The first five sessions focus on the early stages of information
processing (what is happening and what does is mean). Session six through 16
focus on the late information processing stages (what goals am I trying to
achieve, what options do I have to react, what am I going to do and what is the
reaction or behaviour). To train the aforementioned stages, different
aggressive inducing situations are formed in VR.
During the VRAPT sessions, patients wear headsets with controllers and walk in
a simulated virtual environment. The virtual environment is adapted to the
specific needs of the patients, with different themes (for example a store, bar
or mall) and avatars (for example a security guard, a group of females or males
with different ethnic backgrounds) to choose from. The trainer takes the role
of the avatar by using a microphone with voice distortion, controlling the
facial expressions and bodily movements throughout the VRAPT session.
In the sessions, patients are able to train de-escalating behaviour in
interaction with the avatars. The VRAPT is a 16 -twice-weekly individual
training session of 60 minutes.

Participants will have a maximum of 16 sessions twice-weekly, with a maximum of
60 minutes per session. Participants will undergo two types of measurement
during the study. The first measurements will consist of questions about
experiences during the session (1 short questionnaire and additional questions
after each session) and physiological measurements during sessions. The
questions about the experience of the session will approximately take a half an
hour to complete after each session. The physiological measurements are part of
the intervention.
The second measurements consists of self-report measurements, filled in before
intervention starts (7 questionnaires about childhood trauma, substance abuse,
emotion regulation, anger, aggression and impulsiveness), after the
intervention ends (6 questionnaires about emotion regulation, anger,
aggression, impulsiveness, and the *real-life experience* in VR) and 2-months
follow-up (5 questionnaires about emotion, regulation, anger, aggression and
impulsiveness). It will take approximately three hours in total to fill in the
questionnaires before the treatment, after the treatment and at follow up.
Research assistants will be available to support when questionnaires are filled
in. We expect participants to benefit from the training as they will learn to
control their emotions and use de-escalating behaviour. It is also thought that
the burden en risk will be minimal, as no major adverse events have been
documented before with VR research.