Addiction in context.

People with low cognitive and adaptive abilities are more susceptible to 
develop a substance-related and addictive disorder (SAD). While adapted cognitive behavioural 
therapy (CBT) protocols, such as CBT+, have been developed to accommodate this 
vulnerable user group, these protocols still heavily rely on the capacity to 
reflect on and talk about behaviour and the generalization of skills that were 
discussed in the treatment room. This presents a significant challenge for 
individuals with mild to borderline intellectual disabilities (MBID). Virtual reality (VR) is a 
suitable tool to overcome these shortcomings, by offering an immersive 
environment in which patients can experience and learn to recognize risk 
situations and triggers in context, without having to rely on memory or 
verbalization. Although VR is already sparsely used in addiction treatment, 
little is known about how it can be integrated in existing treatment, if and 
how it is of added value for current SAD treatment programs, and during which 
phase of treatment VR should be offered.

To identify if, how and when VR is of added value in current treatment methods 
for people with SAD and MBID.

In this study, a multiple baseline SCED with two conditions will be deployed,
where participants will follow their regular CBT treatment (A phase) and
additionally will receive VR either in the beginning (assessment phase) or the
middle (practice phase) of their treatment (B phase). Both conditions start
with a baseline of two weeks where participants follow TAU (i.e. one treatment
session per week). After two weeks, participants in condition 1 will start
using VR in their regular treatment for three weeks (week 3-5) and follow their
TAU again after these three weeks (in week 6). Participants in condition 2 will
start using VR in their regular treatment after 6 weeks of TAU, receiving VR
sessions in week 7 to 9 of their treatment program. Each participant thus
receives a total of three VR sessions in their TAU.

By introducing VR at different times in TAU, it is possible to investigate when
VR is of most added value for the patients. At the same time, this study
investigates whether the added value of VR for people with ID lays in gaining
insight into triggers and risk situations and / or learning and practicing
coping skills. A mixed-method approach will be used in which both quantitative
as qualitative measures will help in answering the research questions. Because
a SCED requires repetitive measurements over time, participants will
continuously be monitored throughout the duration of their treatment of 12
weeks by using the experience sampling method (ESM) and questionnaires after
each treatment session.

The intervention consists of using VR scenarios in different parts of the 
treatment to support the patient in their understanding of- and coping with 
their SUD. For this purpose the hard- and software of CleVR will be used as an 
intervention tool. CleVR is CE-certified as a medical device and is specialised 
in developing evidence-based VR environments for the treatment of mental health 
disorders. CleVR offers several VR environments identified as possible risk 
situations for people with SUD, such as a supermarket, a living room or a pub.

In this SCED, participants in condition 1 will explore potential triggers and 
risk situations in VR. Together with the client and based on the individual 
needs of the client, the virtual environments will be personalised by the 
therapist to resemble risk situations recognizable by the client (e.g. adding 
specific triggers related to the substance used or the gambling behaviour by the client). The focus will 
be on identifying personalized risk factors that are relevant for an individual 
patient*s substance use or gambling behaviour (*triggers*, including e.g. situations and social 
interactions). To support the therapist flashcards will be available with 
guidelines on how to personalize VR environments together with their client. 
Also example questions are given on how the therapist can help the client in 
gaining more insight into their triggers and risk situations in VR. It is 
emphasized that the number of triggers and the degree of stress in risk 
situations for the client should be gradually increased, in order to let the 
client get used to being in VR (i.e. starting in a VR environment that is 
comfortable for the client with little to no triggers, and gradually adding 
triggers to the environment or switching to more exciting environments).
Participants in condition 2 will use the VR environments to practice coping 
strategies discussed in TAU, such as keeping distance or asking for help. VR 
templates (e.g. home environment where a party is given, buying alcohol in a 
supermarket, home environment with a computer) are available to the therapist in which a specific coping strategy can be practiced. Flashcards describing example exercises for each VR template 
are available to the therapist. Each flashcard offers an introductory and an 
advanced practice to be performed in VR, so the practice can be adapted to the 
needs and skills of the client.

Load of study participation
Participants follow treatment-as-usual (TAU) for their SAD, where VR is either 
integrated in the beginning (i.e. week 3-5) or middle (i.e. week 7-9) of their 
treatment. In each condition participants partake in three VR sessions in 
total. Existing CBT exercises are replaced with similar exercises in VR. Due to 
this integration, treatment sessions will have the same duration as before 
(between 30-45 minutes). For the purpose of this study, treatment session will 
be lengthened with 5 minutes to administer the after session questionnaires, 
which is done by the therapist to keep things efficient. The experience 
sampling questionnaires will substitute paper and pencil homework exercises in 
TAU. Hence, only participation in the intake and interviews will require some 
substantial additional time investment of participants, each lasting a maximum 
of 45 minutes. The study intake and interviews will focus mainly on the 
experiences of the participants during treatment. We do not expect discomfort 
or psychological burden from these study activities.

Risks associated with participation 
The VR intervention has the potential to incur some discomfort to the 
participants, including slight disorientation and motion sickness (i.e. 
cybersickness). However, these disadvantages are minimized by exclusion of 
participants with prior motion sickness, and continued monitoring of 
participants while experiencing VR and introducing them gently back into the 
real world after the VR session. Therapists are trained to recognize discomfort 
in participants, to intervene appropriately and if necessary withdraw the 
participant from the study.
Participants are exposed to potential triggers in VR related to their SAD, 
which could lead to an increase in craving. This is a normal experience in 
patients recovering from SAD (as increase in craving also appears during TAU 
while talking about SAD), and if done well, is beneficial for treatment since 
it allows them to gain insight in triggers and practice with coping strategies. 
Health care professionals are trained to notice this craving and offer coping 
strategies to the client when needed, as they do in TAU. 

Benefits of participation 
Possible benefits for participants could include more insight into their SAD 
and triggers and generalization of learned skills in VR to the real world. 
Additionally, VR integrated CBT+ potentially fits the needs of this vulnerable 
user group better than TAU, offering a more practical and pleasurable treatment 
experience.