Title: Reducing violence by forensic inpatients with psychosis: First stages of the development of a virtual reality treatment based on cognitive inhibitory learning theory
Funder: Department of Health and Social Care

Abstract: Background Forensic secure units provide care to offenders with a psychiatric diagnosis who pose a risk to others. There are 7,700 forensic beds in England and Wales, accounting for 19% of the NHS mental health budget. Secure units reduce risk by taking people out of provoking situations. This works in the short term. However, when discharged, 83% go on to commit a violent act; 11% are grave offences. Most offences are committed in the two years post-discharge. Patients need to be better prepared for real-world situations. This presents a clinical dilemma: patients need to go into everyday situations to learn to respond non-aggressively but the public also needs to be protected. One solution is to use virtual reality (VR). Virtual environments elicit similar responses to their real-world counterparts. Importantly, the learning made in VR translates into the real world. To make use of the simulations, patients also have to be coached with the right psychological techniques. Inhibitory learning theory, based on developments in neuroscience, outlines how the brain establishes emotional and behavioural responses to stimuli and how to optimise new response learning. We will use three VR simulations that trigger aggression (e.g. someone getting in the way). Patients will be actively coached by a therapist to develop new ways of thinking and responding to triggers. This will involve identifying triggers and distorted cognitions, inhibiting aggressive responses, processing disconfirmatory information, developing new cognitions and behavioural responses, and consolidating new memories. Research aimThe aim is to lay the groundwork for a treatment that reduces violence by forensic inpatients with psychosis. Methods Phase 1. Translation of theory to practice Study 1: A qualitative investigation of the key aggression triggers, distorted cognitions, and potentially helpful blocking cognitions. This study aims to ground the translation of the theoretical understanding in the patient experience and to identify any neglected factors that need to be included. Semi-structured interviews with forensic inpatients with psychosis (N=15) will be analysed using thematic analysis. Study 2: Development of a measure of distorted cognitions that mediate aggression. Patients with psychosis (N=1,000) will be recruited by the Clinical Research Network from mental health and forensic services. Classical test theory and item response theory will be used to develop a psychometrically robust measure. Phase 2. Socially-inclusive treatment design Three immersive VR scenarios that trigger aggression and an accompanying therapy manual will be designed. Several workshops with at least 10 patients and 8 staff will be held to ensure designs reflect the needs of forensic inpatients and staff, whilst also incorporating the psychological principles. Phase 3: Experimental test This proof of concept study will test the impact of the treatment on state aggression and the putative mediators. It is hypothesised that the VR therapy will reduce state aggression and that this will be mediated by changes in distorted cognitions and inhibitory control. Fifty forensic inpatients with schizophrenia will be randomised to receive either 90 minutes of VR therapy or 90 minutes of VR without therapy. Effects will be analysed using mixed effects models.

Lay abstract: The problem Although most people with psychosis are never violent, for a proportion of patients aggression is an important clinical issue. Forensic hospitals provide mental health care to offenders with a psychiatric diagnosis who pose a risk to others. These patients often react aggressively to other people. Forensic hospitals reduce risk to the public by taking patients out of provoking situations and providing treatment. This works in the short term. But when discharged, patients go back into provoking situations and most reoffend. Patients need to be better prepared to manage real world situations successfully.This presents a clinical dilemma: patients need to go back into situations so they can learn new non-aggressive ways of responding but the public needs to be protected. The solution One solution is to use immersive simulations. Like pilots use simulations to learn how to fly, patients can use virtual reality (VR) to learn how to manage successfully everyday situations. Putting on a headset allows patients to move around a virtual situation and interact with computer-generated characters. By combining this technology with the right psychological science, patients can develop new ways of thinking and behaving in situations where they feel provoked or threatened. Three VR simulations, chosen by patients, will be created that trigger aggression (e.g. someone on the street staring). The psychological techniques will come from 'inhibitory learning theory', which outlines how patterns of behaviour become established and how they can be changed. In VR the patient will be actively coached by a therapist to (i) become more aware of the triggers of aggression and unhelpful thoughts, (ii) to resist reacting aggressively, and instead (iii) take in new information about the situation and find an alternative way of thinking and responding. The project This project aims to lay the groundwork for the development of a VR therapy to reduce violence by forensic inpatients with psychosis (who make up the majority of forensic inpatients). There will be three phases: 1. Qualitative phase This phase will ensure that the scientific understanding of aggression, and the resulting treatment design, are well matched to the experience of patients. Fifteen forensic patients with schizophrenia will be interviewed about their experiences of aggression, including the main triggers, unhelpful thoughts that lead to aggression, and any helpful thoughts that reduce aggression (Study 1). A new questionnaire will also be developed to assess the thoughts that lead to aggression (Study 2).2. Socially-inclusive design phase The second phase will focus on the design of the three VR scenarios, with different levels of difficulty, and a therapy manual. Designs will be based on workshops with at least ten forensic patients and eight members of staff to ensure that the designs reflect the needs of patients. 3. Testing phase An experimental test will provide initial evidence that the therapy changes the key thoughts, increases resistance to aggressive behaviours, and reduces anger. Fifty forensic patients with schizophrenia will be randomly assigned to receive either 90mins of the VR therapy or 90mins in VR without the therapy. It is predicted that the VR therapy will lead to a reduction in aggression because of changes in thoughts and an increased ability to resist reacting aggressively. If effective, the VR therapy could then be developed into a full treatment to be tested in a clinical trial. PPI This project has been designed with input from people with lived experience. A lived experience advisory panel will contribute to all stages of this research. NHS benefits The project has the potential to create a step change in the treatment of aggression that has applicability across multiple mental health settings.

Research activity codes: 6.6 PSYCHOLOGICAL AND BEHAVIOURAL
Health categories: MENTAL HEALTH