Virtual Reality Aggression Prevention Training for People with Mild Intellectual Disabilities: A Feasibility Study

Figures & data

Figure 1. a) VR emotion recognition task and b) the VR set-up.

Table 1. Session overview.

Session 1	Introduction session during which information was given about the training and two short, neutral VR exercises were performed to get familiar with the VR system and equipment. During exercise 1 participants could choose and watch their favorite avatar (i.e., virtual character), and during exercise 2 participants walked through an empty virtual shopping street.
Sessions 2–4	Focussed on recognizing and differentiating between emotions. Participants were shown pictures of the basic emotions (scared, angry, happy, sad) in their workbook and discussed and mimicked the emotions. Further, participants practiced with facial emotion recognition of avatars in the VR street. In addition, the Relax step of the Stop-Relax-Think-Act strategy was introduced. Situations in which the participant has difficulties were discussed, to be able to create a personalized VR scenario for the following sessions.
Sessions 5–6	Focussed on experiencing and handling provocation by other people in VR and further developing the personal scenario. In VR, participants experienced provocative situations and were instructed to either react, or remain silent. During these sessions, the other Stop-Relax-Think-Act steps were introduced and practiced.
Sessions 7–12	Focussed on practicing with the personalized provocative interactive social scenarios. The main goal of the interactive scenarios was to let participants practice and learn to cope with their aggression adequately (using the Stop-Relax-Think-Act strategy). During the interactive scenarios, the therapist took the role of the avatar using a microphone with voice distortion for speech, and manually controlled the facial emotional expressions, and body movements of the avatar.

Table 2. Participant characteristics.

	n = 9
Age in years	30.0	(13.8)
Male	6	66.7%
Mild intellectual disability (IQ: 50–69)	6	66.7%
Borderline intellectual functioning (IQ: 70–85)	3	33.3%
Level of education
Primary education	4	44.4%
Pre-vocational education	2	22.2%
Secondary vocational education	2	22.2%
Secondary special needs education	1	11.1%
DSM-5 comorbid disorders
ADHD	3	33.3%
Autism spectrum disorder	2	22.2%
PTSD	1	11.1%
Bipolar disorder	1	11.1%

Note: Data are presented with M (SD) or n and percentage.

Figure 2. Mean session satisfaction ratings.

Table 3. Thematic analysis with illustrative quotes on experiences with the VR aggression prevention training of focus group participators and session forms. In total, information was obtained from all three therapists, five participants, and five mentors.

Strengths
Subthemes	Explanation	Quote
Theme 1. Learning outcomes
Using the Stop-Relax-Think-Action strategy	Participators reported the Stop-Relax-Think-Action strategy as the main learning point and mentioned using it during and after the training. The extent to which the strategy was learned differed, some only mastered “Stop” and “Relax.”	“Well, what you saw right away was also a bit of self-correction, the more client W practiced, the more he corrected himself. Like, oh no, I have to do something else, or I have to stop for a while.” (Mentor 1)
(2) Awareness of emotions	Participants reported learning to be more aware of their emotions, both cognitively and by noticing physical signs corresponding with aggression.	“ … he learned what tension feels like for him. He also learned how to talk about this and to set his limits.” (Mentor 3)
(3) Insights into triggers of aggression	Through the VR experiences, participants and therapists gained insights into specific personal triggers of aggression.	“We were involved in a roleplay and then I noticed that at a certain point, that there were certain gestures that really triggered him, certain words that triggered him and because I noticed that in him and could stop him and say: hey, what’s happening now, tell me, at a certain point he learned to recognize that better himself, so he knew much better what made him angry.” (Therapist 1)
(4) Decrease aggression	Participants, mentors, and therapists reported improved aggression regulation and self-correction resulting in reduced aggression.	“I notice that I am much calmer and I also think a lot more before I speak. Because before, I sometimes said things before thinking, so I’m much more thoughtful in my actions now, I notice that, that’s mainly, yes, especially with getting angry indeed, that’s where I actually came for, because I also notice that I am much calmer, I have become less aggressive, also, in general, I am less likely to get angry.” (Participant 1) “But the really big change is that he had several female friends, who actually didn’t even want to hang out with him anymore because he could react quite aggressively. And that’s just gone, those friends no longer say to him we are afraid of you.” (Mentor 1)
(5) Stop-Relax-Think-Action strategy	Participators reported the Stop-Relax-Think-Action strategy and individual tailoring (e.g., implementing “Stop” by saying it or using gestures) of the strategy as a strength.	“Recently I had a problem with the taxi. I held back. I stuck to SODA (Dutch mnemonic for Stop-Relax-Think-Action strategy) and relaxed in between. Breathe in breathe out. Also applied it at work. I know what STOP stands for. You are not rejected.” (Participant 1)
Strengths
Subthemes	Explanation	Quote
(6) Emotion recognition tasks	Emotion recognition tasks helped practice emotion recognition, to get used to VR, and it was mentioned to be fun for some.	“My clients especially found emotion recognition in the shopping streets very nice and pleasant and we used that a lot to get back into the VR world, well, to once again get used to it. Client X asked for going to the shopping street again to recognize emotions, because he liked that so much and he also really liked to notice that he was getting a little better at that because he found that quite difficult. He also said: I find that pretty hard in real life too, so if I can get better at this, maybe I can get a little better at that in the real world too.” (Therapist 1) “Dolls, indicate who is angry” [Answer concerns choosing the avatar that looks angry out of three avatars] [answer on: what did you learn most from] (Participant 3)
Theme 2. VR-specific advantages
(1) Interactive VR scenarios	Interactive VR scenarios triggered emotions and physical arousal enabling on the spot “recognizing physical signs,” “learning what emotions feel like and how one can talk about this,” “naming felt emotions,” “experiencing how reactions influence others,” and practicing new strategies to deal with anger-provoking situations. Scenarios were repeated with different responses, to enhance learning and generalization. The combination of experiencing in VR and reflecting/discussing afterward was mentioned as a strength.	“I had a client who sometimes got very angry around a mentor, and I think we did the same situation 15× with a different response and then see, what does that do to the avatar, in that case the mentor, if you react differently. She got very angry about behavior of her mentor, but did not dare to say anything about it … So, by being able to practice in a safe environment saying to the mentor, I don’t like this or hey, I’d like it if you could just look at me now. … Practicing things like that over and over again and noticing that it does something different for her, that she goes home differently, yields the necessary effect in aggression regulation at home as well, as she went home less angry.” (Therapist 1)
(2) VR is attractive & fun	Participators reported that VR is an exciting and fun method that made participants curious and motivated and made it feel less like therapy than interventions where they only talk.	“They offered to participate because they thought it was so cool. It’s something new … and the attraction is permanent, so those clients come into that room and their head doesn’t go to me first, … but their head goes to that device and they can’t wait for it, to put those glasses on.” (Therapist 3)
Strengths
Subthemes	Explanation	Quote
(3) VR forms a safe environment	VR was mentioned to feel like a safe environment to practice in for participants as well as therapists to engage in aggression-provoking behavior.	“I think it helps a lot that it’s kind of a safe environment where you can practice, where you can also practice different reactions, for example.” (Therapist 1)
Theme 3. Engagement of social network
(1) During the training: Involving mentors & other healthcare workers	Healthcare workers provided input for scenarios, helped with new skills in between sessions, and participated in roleplays. This gave them information on strategies for how they could help participants in provoking situations, and they made others aware of what the participant was working on and how they could help (e.g., help remember the Stop-Relax-Think-Action strategy or how to relax).	“Yes, what I found all in all very positive was actually the visit. We were invited [to the sessions], and I tried a few more times to let a colleague come along as well, then it lives more at the residence as well.” (Mentor 2) “You knew exactly which buttons to press [to trigger him in VR].” (Therapist 3 to Mentor 2)
(2) During the training: Involving family & friends	Involving friends and family resulted in more detailed descriptions of situations where aggression occurred. Significant others to whom aggression was directed were also involved sometimes and were helped by practicing in VR how to react. Finally, learned skills were discussed with significant others.	“Client X, he also practiced with his girlfriend and with his mother, which was really important, network. We also phoned the mother a few times at the end of a session, to discuss what did you learn today, because he found that translation difficult.” (Therapist 2)
(3) After the training: support in daily life	Involving others in the training resulted in beneficial effects. Participators reported that the social network became more aware of triggers, and could help participants cope better, make changes in their own behavior/surroundings, and helped participants remember what they had learned.	“What I heard later from mentors at the residential locations, was that … if something happened on location, that they recognized triggers and could keep a closer eye on him, and could stop him much sooner, if he couldn’t do that himself at that moment.” (Therapist 1) “Client Y who always has the same jokes, so others don’t like that … coincidentally last week that happened again, and then I said to Y, you went to that course then and stop, that applies also for others, eh, if they tell you to stop, then you should do that too. And that was very funny, because then he picks it up immediately, that he is like oh yes, I was taught that then.” (Mentor 2)
Strengths
Subthemes	Explanation	Quote
(4) Visiting environment of participant	Visiting the working, daytime, or living environment by the therapist was reported to be informative. Visits provided input for sessions, were experienced as fun by participants, and created awareness of what the participant was working on e.g., healthcare workers at the locations.	“I’ve been on location with clients to see, where do they live, where do they work, who do they deal with? At one point another client came, who was very irritating for my participant … he talked very quickly and mixed up all kinds of things, and he wanted to know everything about you, very curious. … So, you take that with you in the treatment, and then you dare to do what such a client did back, … . that link with the actual situation is absolutely necessary.” (Therapist 3)
Points of improvement
Subtheme	Explanation	Quote
Theme 1. Content-related
More focus & time on practicing in VR	Therapists and mentors reported that more time should be invested in practicing and learning in VR. Herewith the training will become less verbal, which was seen as an advantage. As therapists became more experienced throughout the pilot, more time was invested in practicing.	“The idea was getting stronger that we need to practice more and less cognitively, so I’ve started doing that more and more, so the clients who came last got the most out of it. … that roleplaying of hard situations … . not going in-depth, but more of just practicing.” (Therapist 2)
(2) Physical arousal exercises are not helpful	Exercises were done to experience the physical arousal that accompanies anger and for practicing indicating when to stop. Participators agreed that the physical exercises did not relate enough to feelings of anger and aggression, and that arousal could also be induced in VR.	“Of climbing the stairs, I also think, what connection does it actually have with the training and with being angry?” (Participant 2) “Exercises that required me to do physical activity doesn’t seem like getting angry to me.” (Participant 4)
(3) More participation of family/friends/healthcare workers	Participation of healthcare workers, family, and friends was found to be extremely beneficial by all participators. But participators expected effects to be bigger if the network is included even more often.	“Other people should accompany participants more often during sessions” (Answer on the question what would you like to see changed most) (Mentor 4)
Theme 2. Personalization
7(4) Personalize session number & frequency	Participators reported that the session frequency and number should be fitted to the client. Some participants needed more sessions, and follow-up booster sessions should be offered for repetition and consolidation.	“What I got back from the participants is that they, what they would really like, are a kind of comeback sessions. So, for example, after 3 or 6 months you have another repeat session, to practice, especially because they also notice that it is quite difficult to keep doing it well and that it feels so safe to be able to practice it in such a VR world, occasionally being able to do it again repeat, because the power of repetition is really very important.” (Therapist 1)
Points of improvement
Subtheme	Explanation	Quote
(5) More personalization in VR software	Participators reported that it would be advantageous if the software offered more personalization in terms of surroundings (enabling practice in environments matching everyday life), appearance, and the voices of avatars.	“I’m going to practice with my husband, but my husband has glasses and the avatar has no glasses, that is not right” (Therapist 1 quoting participant 5) “Yes. Because I couldn’t find a voice at all.” [that sounded right] (Participant 2)
(6) More flexibility in the protocol in terms of VR exercises	Emotion recognition exercises were not suitable for all. Offering the training in a more modular form (in which e.g., the emotion recognition module can be shortened or skipped) and practicing with multiple situations can improve the training.	“Instead of increasing triggers, practicing skills in different situations leads to more generalization and prevents the participant from finding it boring.” (Mentor 3)
(7) Change relaxation exercises	The initial relaxation exercises did not fit with the participants’ needs. Personal exercises (with which they had positive experiences) or viewing relaxing nature scenes in VR did fit well.	“No, they (relaxation exercises) were really terrible! No, that did not really help. Those protocol exercises were, no.” (Therapist 1)

Figure 3. Mean well-being per session.