Regular Re-ART versus Virtual Reality Re-ART: an RCT study

Delinquent aggressive behavior is a common problem, with significant
consequences for society, victims and perpetrators. Several studies provide
evidence of the effect of various aggression regulation treatments on
aggressive behavior and overall recidivism, as well as on factors that are
believed to influence recidivism risk. An example of a treatment method is
Responsive Aggression Regulation Therapy (Re-ART).
Studies show that role-playing is a working element in aggression regulation
therapy, and VR role-playing is more effective than analog role-playing.
Virtual Reality (VR) offers the opportunity to train skills in a realistic
context, and to make the patient aware of tension and emotions. This is done in
a safe, controlled environment.
Research on the use of VR in the treatment of mental disorders has shown that
VR interventions are effective across a variety of disorders, syndromes, and
behaviors and may be a promising addition to existing treatments.
Little research has been done on the effectiveness of VR in the forensic
setting. Although VR is seen as a promising supporting e-health treatment
application, research will need to show to what extent, and in what way, VR can
add value to treatments in forensic mental health care.
We investigate whether adding VR to three modules of the Re-ART treatment leads
to a greater improvement in degree of aggression regulation compared to the
three modules of the Re-ART treatment without VR.

Our study at 'de Waag' (an outpatient forensic mental health institution) would
provide a first impression of the added value of adding VR to the treatment of
aggression regulation problems.
Results from the study are also useful for forensic treatment in general, as
the outcome measures (degree of aggression regulation, cognitive biases,
patient motivation and therapist motivation) are also (partly) applicable to
other care programs, such as the treatment of Acquisition Offenses, Intimate
Partner Violence and Sexual Offenses.
This study will primarily examine whether offering three modules of the Re-ART
treatment with VR leads to a greater improvement in degree of aggression
regulation compared to the three Re-ART modules without VR.
An improvement in cognitive biases is also examined, this is included as a
secondary outcome measure. Since it is expected that patients treated with VR
have greater treatment motivation and working with VR can also increase
treatment motivation among therapists, it is examined whether these two
variables have a moderating effect.

A Randomised Controlled Trial (RCT) will be performed at two outpatient clinics
at *de Waag*. Adult male patients who are indicated for the treatment Re-ART
outpatient for adults on the basis of the indication criteria in the
Theoretical Manual are asked to participate. When patient consents to
participate in the study, written informed consent is obtained. The researcher
randomly assigns participants to condition (Treatment as Usual or Treatment as
Usual with VR).
The number of sessions required to complete a module according to the
guidelines varies. The estimated number of sessions for research purposes (the
three modules combined) is 15 to 20. This equates to a treatment duration of
approximately 3 to 6 months.
Prior to the study, patient complete the intake and risk assessment phase, as
well as follows a part of the Re-ART treatment, plus other interventions if
indicated. After completion of the study intervention period, all participants
will continue with the treatment according to the treatment plan, or will stop
treatment if the treatment goals are achieved.
The primary outcome measure degree of aggression regulation is measured with
the Aggression, Anger and Impulsivity subscales of the Forensic Symptoms
Inventory - Revised (FSI-R). The secondary outcome measure cognitive biases is
measured with the Brief Irrational Thoughts Inventory (BITI), patient
motivation is measured with the Treatment Motivational Scales for forensic
outpatient treatment (TMS-F) and the motivation of therapists will be measured
with the Motivation Therapist Questionnaire (a (short) questionnaire drafted
for this study).
Participants will fill out the FSI-R, BITI and TMS-F prior to the start and
after the study intervention period.

In the Treatment as usual condition (TAU), the regular Re-ART treatment is
offered to patients. For the study, this concerns the modules Controlling
skills, Infuence of Thinking and Handling Conflicts. Prior to the study,
patients have already followed one or more modules of the Re-ART treatment.
After the study intervention period, clients will follow further modules, if
indicated.
In the experimental condition (EXP), various experiential exercises and role
plays from the modules Controlling skills, Infuence of Thinking and Handling
Conflicts are offered with Virtual Reality. The treatment otherwise remain the
same.

Since the treatment in this study is (almost) identical to the regular
treatment there will be hardly any additional burden for study participants.
Patients in both conditions will fill out a number of questionnaires at the
beginning and after the study (estimated time 40 minutes). Some of the
questionnaires are part of the regular treatment as part of Routine Outcome
Monitoring (ROM).
Patients may experience symptoms of cyber sickness (nausea, dizziness,
sweating) during a VR session.