Reducing aggression of forensic inpatients with Virtual Reality Aggression Prevention Training - Intellectual Disability (VRAPT-ID)

Patients with (mild) intellectual disability (MID) are overrepresented in
forensic settings compared to the general population. This can be explained by
the fact that people with MID have more risk factors for risk behaviour and
psychiatric disorders than people without MID. Criminal risk factors include
e.g., increased impulsivity, limited coping skills, and problems with
metallization. Patients with MID have difficulties processing verbal
information and generalizing, making patients with MID in forensic psychiatric
centres less responsive for current treatments reducing aggression. Current
psychotherapies for reducing aggression in forensic patients with MID are
usually ineffective because it is not adapted to their limited cognitive
skills, specific needs, learning style, and IQ. Besides, patients in an FPC
often resist therapy and are less motivated because of the forced TBS order,
which makes them less responsive for therapy with greater risk of drop-out and
no-show.

The main objective of this study is to examine whether Virtual Reality
Aggression Training - Intellectual Disability (VRAPT-ID) is effective in
reducing ag gressive behavior over time among inpatient forensic psychiatric
patients, specifically those with MID. The second objective is to examine
whether VRAPT-ID improves therapy compliance in forensic psychiatric patients
in comparison to other therapies.

This is a protocol study to examine both the effect of the intervention ands
therapy compliance. It is a single case experimental design (SCED),
specifically a multiple baseline design (MBD). It is a non-concurrent multiple
baseline design across patients, in which 12 patients will be randomly assigned
to five different baseline lengths. There are three phases: baseline phase (A)
- experimental phase (B) - follow up phase

All patients in this study will receive aggression training using Virtual
Reality Aggression Prevention Training - Intellectual Disability (VRAPT-ID).
Treatment duration is 12 weeks with a bi-weekly VRAPT-ID session and patients
will be followed-up at four weeks and at 12 weeks after finishing the
intervention.

Patients are asked to participate in the 'VR catwalk' intervention at the
beginning of their training and during the follow-up at four and 12 weeks after
finishing the training. Besides, patients are asked to wear the Empatica 4
wristband during the VRAPT-ID sessions to measure the biomarkers (skin
sympathetic nerve activity and heart rhythm). Participants receive bi-weekly
VRAPT-ID which consists of 24 sessions in total, with a maximum session
duration of 60 minutes over a period of twelve weeks. VRAPT-ID treatment is not
yet part of the treatment of aggressive behaviour in an FPC. This treatment
will be indicated in addition to the regular treatment program. The main goal
of VRAPT-ID is to enable patients to deal with (upcoming) escalating (social)
situations more effectively. We expect patients to benefit from the training.
VRAPT-ID provides patients with tools that are intended to improve their
self-regulation in escalating situations. We expect VRAPT-ID to reduce
aggressive behaviour and stress in patients and to improve their
self-regulation. In this way, the main goal of admission to a high security
forensic psychiatric centre can be met, which is to reduce future recidivism in
violent behaviour. Besides, we expect that VR treatment improves therapy
compliance. Low treatment motivation and treatment dropout is common in
forensic settings (Dixon et al., 2016; Brunner et al., 2019). In a recent
research with VR treatment in forensic inpatients, patients reported enjoying
working with VR and looking forward to undergo more treatment with VR (Klein
Tuente, 2020). Besides, VR can be seen as a form of *''gamification'*' which
is a growing phenomenon in education to enhance motivation in learning
(Caponetto et al., 2014). Therefore we expect VR to reduce the number of
drop-outs and no-shows. VR is a safe and controlled way to expose forensic
inpatients to social stimuli (Klein Tuente, 2020). There is a small chance
that patients will experience transient *cyber sickness* (such as sweating and
dizziness) during the VR training, but no major side effects of VR are known
(La Viola, 2000) nor have been documented in previous studies. Therefore, no
major adverse events of VRAPT-ID are expected.