A pilot study on treatment content in virtual reality-assisted aggression therapy at a maximum-security forensic psychiatric clinic

ABSTRACT Previous findings on results of treatment of aggression in violent offenders show inconsistent results, and implementations of such treatments have demonstrated varying success with

sometimes marginal gains in forensic settings. New methods, incorporating virtual reality as a tool for experiential learning, have been put forward yet require deepened investigations

concerning both treatment content and effects. The principal objective of this study is to examine the treatment content of the revised VRAPT intervention. Specifically, the study focuses on

understanding how the content of the VRAPT intervention is conceptualized from the perspectives of both patients and therapists. Inductive manifest content analysis was applied on content

of treatment workbooks (_N_ = 6 + 7), provided by both patients and therapists as part of seven concluded VRAPT treatments at a maximum-security forensic psychiatric clinic in Sweden. Three

manifest content categories were identified, relating to treatment content: Skills-training, Tailoring of the intervention, and Self-awareness. While generally quite similar, some

potentially important differences between patients’ and therapists’ perspectives on the VRAPT intervention were apparent. The findings suggest the necessity of further research into

optimizing VR-assisted treatments in forensic psychiatry. SIMILAR CONTENT BEING VIEWED BY OTHERS ONE-YEAR RANDOMIZED TRIAL COMPARING VIRTUAL REALITY-ASSISTED THERAPY TO COGNITIVE–BEHAVIORAL

THERAPY FOR PATIENTS WITH TREATMENT-RESISTANT SCHIZOPHRENIA Article Open access 12 February 2021 A RANDOMISED CONTROLLED TEST OF EMOTIONAL ATTRIBUTES OF A VIRTUAL COACH WITHIN A VIRTUAL

REALITY (VR) MENTAL HEALTH TREATMENT Article Open access 17 July 2023 LONGITUDINAL STUDIES SUPPORT THE SAFETY AND ETHICS OF VIRTUAL REALITY SUICIDE AS A RESEARCH METHOD Article Open access

06 May 2021 INTRODUCTION Given the diversity of aspects influencing aggressive behaviours and the inconclusiveness of current empirical findings, the quest for a comprehensive and

empirically supported model of aggression and its treatment continues1,2,3. Meanwhile, substantial knowledge on risk factors for general criminality, and violence specifically, is

available4,5,6. However, risk-based models for understanding aggression may be overly simplified, since each risk factor may constitute an indispensable part of an unnecessary (i.e., it

could just as well occur in its absence) yet collectively sufficient trigger of aggression7. When evaluated, structured risk assessments in general show a varying prediction of violence,

with assessment models used for prediction of imminent aggression showing better prediction than longer-term models8. However, while such models can provide crucial information on possible

risk factors, they do not provide direct guidance for the management of these risk factors that may be used in the treatment, or prevention, of aggression. Studies on treatment of aggression

show somewhat inconsistent yet promising results, favoring models applying cognitive behavioral treatment (CBT) in treatment of violent offenders9. When evaluating treatment interventions,

however, their feasibility in the clinical practice they are designed for must be considered, and implementations of aggression treatment interventions in forensic settings have demonstrated

varying success with sometimes only marginal gains3. Within the context of forensic psychiatry, where patients demonstrate complex clinical needs e.g., with a high comorbidity of mental

disorders, antisocial cognitions, substance use, impulsivity and/or lack of empathy10,11,12,13, an effective implementation of treatment interventions seems crucial since these persons

constitute a demanding but also vulnerable group, both in society and in clinical settings14,15,16. Aggression is a common problem in forensic psychiatric patients17,18 and is considered

central to patient management19,20. However, the evidence-base for interventions in general in forensic psychiatry is scarce21, stressing the need for more research into development and

evaluation of aggression treatments in forensic settings1,22,23,24. In a recent effort, immersive virtual reality (VR) has been put forward as a potentially viable method for both assessment

and treatment in general25,26,23, and of aggression in particular1,27. The argument advanced is that VR technologies, through potentially providing an ‘as-if’ experience, not merely

addresses the gap between real life and clinical and/or research settings, but in so doing also might improve the prognostic value of associated psychological research28,2930,31,32. This is

an important point, particularly in the context of forensic psychiatric populations, where cognitive deficits and paranoid ideations are common29. Such characteristics may limit the

effectiveness or appropriateness of VR-based interventions for certain individuals. These limitations should be acknowledged when considering the broader applicability of VRAPT and highlight

the importance of careful patient selection and adaptation of the intervention to individual needs. The ‘as-if’ experience of VR technology is thought to derive from what has been described

as the three core concepts of VR: immersion, presence, and embodiment33,34,35,36. Immersion means that the VR technology, admittedly to a varying degree37, provides an alternative

environment substituting physical reality38. Presence is described as the user’s acceptance of, and physical, social as well as emotional engagement with, the virtual environment39,40.

Finally, embodiment might be understood as emerging through the previous two: the incorporation of experiencing, acceptance of, and engagement with an immersive virtual environment that to a

high enough degree shuts out physical reality. Subsequently, a sense of being in such an environment, of having agency and ownership constitute components of embodiment41, and are thus

important parts in establishing a sense of “being” in a virtual environment42. However, much remains to be investigated regarding VR-assisted treatment of aggression before any firmer

conclusions on its feasibility and effectiveness can be drawn17,43,44. The first randomized controlled trial of the VR Game for Aggressive Impulse Management (VR-GAIME)45 failed to show any

difference between VR-GAIME relative to the control condition46. Similarly, a randomized controlled trial investigating the Virtual Reality Aggression Prevention Training (VRAPT)47, although

finding positive effects post-treatment on self-reported hostility, anger control and non-planning impulsiveness, did not demonstrate effects at follow-up17. Recently, a revised version of

VRAPT1, in a small pilot study on imprisoned violent offenders, demonstrated positive effects on self-reported emotion regulation and aggression both post-intervention and at a 3-month

follow-up48. When the same VRAPT version was evaluated within forensic psychiatric care, patients described foremostly positive experiences from VR-assisted role-plays, and less positive

experiences in relation to motivation for aggression-focused treatment and technological limitations27. However, these initial studies do not in their own provide “evidence of absence” but

should rather be interpreted as “absence of evidence” in this specific field, why continued research into the specific components of VR-assisted aggression treatments is needed. The

principal objective of this study is to examine the treatment content (e.g., treatment goals, session tasks, observations during sessions, homework activities) of the revised VRAPT

intervention. Specifically, the study focuses on understanding how the content of the VRAPT intervention is conceptualized from the perspectives of both patients and therapists. It was

expected that patients and therapists would conceptualize the content of the revised VRAPT intervention in ways that reflect distinct and identifiable themes. These themes were anticipated

to relate to how the intervention supports emotional regulation, enhances self-awareness, and promotes behavioral change. The study aimed to explore and describe these thematic categories

in-depth, based on treatment workbooks and participant perspectives. MATERIALS & METHODS This study was conducted at a maximum-security forensic psychiatric clinic in Sweden.

Participants were recruited through clinical referrals, and only those meeting inclusion criteria (ongoing forensic psychiatric care, established pattern of violence, fluency in Swedish)

were considered. Data were analyzed manually using inductive manifest content analysis without software support. All coding was initially conducted by the author (FS). However, the final

categories and subcategories were refined and determined in consensus with last author MW. Subsequently, categories were interpreted, leading to a final narrative synthesis. The current

study applies inductive manifest content analysis49 on data from treatment workbooks, retrieved from a case-series pilot study including a diverse sample of forensic psychiatric patients

with predominantly reactive aggression problems; exploring the content of virtual reality-assisted aggression treatment as defined in the manualized and recently revised VRAPT intervention1.

PARTICIPANTS PATIENTS Seven patients from a maximum-security forensic psychiatric clinic (6 males, 1 female; mean age 36 years old) were recruited as per the following inclusion criteria:

(1) ongoing forensic psychiatric care, (2) established pattern of violence and current issues with reactive aggression, (3) having undergone VRAPT treatment. Criteria for exclusion consisted

of (1) inability to speak and read Swedish, (2) epilepsy, (3) IQ < 70, (4) severe autism spectrum disorder, (5) acute psychotic state, (6) security considerations that prohibited

participation. The composition of the sample was determined primarily by the willingness and availability of patients to participate in the study, rather than by a predetermined gender

distribution. In high-security forensic psychiatric settings, participation in research is often limited due to clinical, legal, and motivational factors. The inclusion of one female

participant reflects the actual population distribution at the clinic during the recruitment period and her expressed interest in participating. Regarding sample size, the decision to work

with seven participants aligns with qualitative research guidelines suggesting that data saturation can be achieved with small, information-rich samples, particularly when working with a

relatively homogeneous group and a focused research question. Nevertheless, we acknowledge the limitations of this sample size and encourage future studies with larger and more diverse

cohorts. THERAPISTS Therapists conducting VRAPT treatments were all, except one who at the time of the study was completing the final resident year, licensed psychologists or CBT therapists

experienced in forensic psychiatry. Additionally, all underwent 16 h of specific training in the VRAPT methodology prior to treatment delivery. VRAPT INTERVENTION This version of the VRAPT

intervention is theoretically based in CBT and the General Aggression Model (GAM)50,51,52. Spanning over 16 sessions divided into four phases1, VRAPT begins with a general introduction to

both the intervention in itself and the virtual environment. The second phase concentrates on skills training in assessing and discerning emotions – portrayed by the facial expressions of

avatars within the virtual environment – together with practicing self-management of physiological reactions (as measured by e.g., variations in heart rate and skin conductance). In phase

three, the patient practices interpersonal and problem-solving skills through therapist-led role plays in VR; the therapist actively participates in the virtual environment through voice

distortion and triggers behavioural responses of the avatar as a response to the patient’s actions. Finally, VRAPT concludes with an evaluation of patients’ experiences, with particular

emphasis on learning outcomes. The virtual environment used throughout all phases was rendered by the software Social Worlds (©CleVR). Patients and therapists each have a workbook throughout

the treatment, where they keep notes before and after each session. Both patients and therapists are expected to make notes on what to include in the next session and to evaluate the

completed session. Thus, the workbooks become both a summary of, but also a tool for the treatment as a whole1. ETHICAL CONSIDERATIONS The present study, as part of a VRAPT pilot study, was

approved by the Swedish Ethical Review Authority (Dnr: 2019–02337; 2020–06317). In such a population as the current sample, ethical considerations are of specific importance since forensic

psychiatric patients are considered a particularly vulnerable group, showing wide-ranging needs of healthcare and societal interventions12. The inherent coerciveness of forensic settings53

accentuates the need for specific ethical considerations regarding, e.g., autonomy, deception, informed consent, mental liberty, moral agency and dignity53,54,55. Additional considerations

should also be given to the risk of therapeutic misconception1,56, referring to misinterpretations or confusion regarding the difference between clinical research and ordinary treatment that

may arise, potentially making participants feeling pressured to participate to progress in their care. Since the present study only analyzed pseudonymized data, some of the above-mentioned

concerns might be seen as alleviated. Written informed consent was obtained from all participants following verbal and written explanations of both purpose and procedures involved as part of

the pilot study. Likewise, information was given concerning the voluntary nature of participation and possibility of withdrawal of consent without the need for any explanation. DATA SOURCES

The study was conducted in accordance with guidelines for data saturation in qualitative studies57. Data from seven individual VRAPT treatments, reported in therapists’ and patients’

treatment workbooks (_N_ = 7 + 6), at a maximum-security forensic psychiatric clinic were analyzed within this study, portraying how virtual reality-assisted aggression treatment was

conducted in a clinical forensic psychiatric setting. This study follows the proposed saturation guidelines, which suggest 9–12 texts57. Even though not all treatment workbooks were

returned, one patient declined to do so, the total data amounted to 13 texts. Thus, it would seem reasonable that data saturation was achieved. Overall, the treatment workbooks were

structured session by session, the participant version spanning 126 pages and the therapist version 160 pages. Both versions described the ongoing and remaining work within the intervention,

with space for participants’ own written reflections. Patients’ workbooks additionally included a section where each patient wrote down the homework for each session. PROCEDURE AND DATA

ANALYSIS All treatment workbooks were read several times by the main author (FS), a master’s student in clinical psychology with experience working in maximum-security forensic psychiatry,

to facilitate an overall comprehension of the data. Thereafter, preliminary codes were assigned, and the data was further organized into content categories and subcategories. A content

category describes the content at a manifest level, with a low degree of interpretation and a varying degree of abstraction58. The decision was made not to separately first read either

patients’ or therapists’ workbooks, but rather to simultaneously read both, treatment by treatment. It was felt that this better facilitated a comprehensive understanding of each and every

individual treatment, as well as of what, generally, had been the content of all seven treatments. All coding was initially conducted by the author (FS). However, final categories and

subcategories were refined and determined in consensus with last author MW. Subsequently, these categories were interpreted, resulting in a concluding narrative synthesis. No software was

used in the analysis process. RESULTS The following content categories were identified in the workbooks: Skills training, Tailoring of the intervention, and Self-awareness. An overview of

the content categories and associated subcategories of patients’ and therapists’ perspectives on the revised VRAPT intervention is provided in Table 1, followed below by descriptions of each

category and subcategory. Citations are followed by either P (Patient) or T (Therapist), together with the treatment number, within parentheses. SKILLS TRAINING This content category stems

from both patients’ and therapists’ perspectives on the acquisition of abilities to calm oneself, awareness and recognition of emotions, taking the perspectives of others, handling of

conflicts and self-assertion, and finally training of different scenarios and role-play both in and outside of the VR environment. The following subcategories were identified: Relaxation

techniques, Cognitive empathy, and Interpersonal communication. RELAXATION TECHNIQUES Evident from the treatment workbooks was how different ways of calming oneself were perceived as an

integral and helpful part of the intervention. The value of being able to, in various ways, gain a sense of control over the situation, thus attaining perspective and reducing emotional

arousal, was described as related to a lessening of aggressive impulses. “_It was harder to be aggressive… used the breathing technique and then walked away_” (P2). “_The breathing exercise

worked fine_,_ also being much appreciated by the participant_” (T5). The mental act of considering the consequences of acting in one way or another, comparing anticipated results with one’s

own internal goals was also perceived as a helpful part of the intervention. “_I consider the consequences. Also_,_ how to handle the situation in the best possible manner_” (P4). “_Working

on finding techniques that calms. Identifies “to consider the consequences” and “to consider my own goals_”” (T7). One patient offered a slightly different perspective, highlighting the

importance of learning from one’s mistakes. “_Continue to know my own mistakes_,_ and not repeating them even in difficult situations_” (P6). COGNITIVE EMPATHY Patients described

difficulties in awareness and recognition of emotions when confronted by the facial expressions of virtual avatars during the second phase of VRAPT. Taking the perspectives of others, and

recognizing especially emotions of disgust and surprised/confused, was described as difficult. “_The ability to discern the signals of others_,_ I feel it’s more difficult with women but do

not know why_” (P2). “_When joking with another person I do not know when they feel ‘enough is enough’_” (P5). To a substantial degree, these were seen to resonate with the perspective of

therapists. The latter, however, while in agreement regarding disgust rather emphasized difficulties recognizing anger as opposed to surprised/confused. Furthermore, therapists also stressed

how skills training in emotion recognition enabled the patient to better understand both him-/herself as well as those he/she interacted with. “_Says that “recognizing emotions” has been

rewarding It has made him think about how he is perceived. Realizes that there could be a difference in how one looks and how one feels and that there in between is a process called

“interpretation”_” (T6). INTERPERSONAL COMMUNICATION From the perspective of patients, the importance of attaining a sound self-assertiveness based on a sense of self-respect was clear.

This, in turn, influenced aggressive impulses and was tied with the ability to verbally, as opposed to physically, tackle challenging situations. “_Try and talk to the individual_,_ like

saying I understand that you are upset but you don’t need to be angry with me_” (P3). “_-self-assertion even confronting through speaking your hearts intent not getting into an argument…

also it’s not about getting people to adapt to what one feels it’s about self-respect_” (P4). One patient elaborated on how the tackling of a difficult interpersonal situation was coupled

with the ability to sometimes stay and speak one’s mind as opposed to withdraw from the situation. In that sense, interpersonal events could be described as a continuous negotiation of

“space”. “_To claim_,_ or to give space_” (P4). Therapists’ perspectives centered somewhat more towards establishing a joint understanding of the situation, exploring the other’s perspective

and on different modes of communication. “_Validate the other_,_ formulate a shared problem_,_ ask for help_” (T4). “_I role-play different sides and ask him to sort these based on

different modes of communication also how different goals are achieved through different styles. Pros and cons_” (T4). “_To develop an alliance: ask questions_,_ get the other to elaborate

on what he/she is saying_,_ let the other finish and remember “that they want what’s best for me”_” (T6). TAILORING OF THE INTERVENTION As with the previous content category, this category

stemmed from both patients’ and therapists’ perspectives, depicting their perception of identifying risk scenarios, on finding a basis for skills training, the appraisal of whether

techniques and strategies actually were useful, goal-attainment, and finally on the adaptation of the intervention to the specific patient. The following subcategories were identified:

Determining treatment goals, Adapting to participants’ needs and limitations, and Application in everyday life. DETERMINING TREATMENT GOAL Therapists’ perspectives accentuated the time and

collaborative effort needed in defining risk scenarios and arriving at valid treatment goals. In most cases, ongoing dialogue was necessary throughout the intervention. “_determining

treatment goals and defining risk scenarios takes a long time. It felt to me and the participant that some things / questions were repetitive_” (T1). From the perspective of therapists, it

was clear how patients often had a hard time identifying what was difficult, and thus what should be the focus / goals of the treatment. Risk scenarios were often not merely being used as a

foundation for role-play, but also in determining and reviewing overarching goals of the intervention. “_“It’s hard to answer” (regarding what is difficult) even with follow-up questions the

participant was unable to come up with anything_” (T3). “_– the participant has a hard time coming up with new triggers_,_ he says that he didn’t know before that he was sick but has now

realized this_,_ but doesn’t feel that there is all that much to practice on and that I am welcome to come up with scenarios and exercises of my own_” (T3). Therapists could vary scenarios

to gain new perspectives. “_A surprise-scenario instead of the participant knowing in advance what was about to happen_” (T2). “_Used certain scenarios as a surprise in order to get more of

a response from the participant_” (T3). Patients’ perceptions, on the other hand, seemed more to do with the ability to act constructively in challenging situations, a forward-looking

perspective on furthering the attainment of life goals. Determining of treatment goals, for patients, thus seemed more focused on finding new ways of acting, with less focus on defining

risks. “_The ability to interpret one’s surroundings and not misconstrue situations. A lessening of suspicion towards unknown people_,_ an outlook affected by the life I’ve lived_” (P2). “_…

to realize that the situation isn’t worth acting out or to wind up_,_ suppress emotions that doesn’t lead to anything good for me or my future life_” (P2). “_… being able to walk away from

situations… to speak one’s mind in an acceptable manner… to explain to ward staff not to patronise me_,_ rather talk to me in a pedagogic way_” (P3). ADAPTING TO PATIENTS’ NEEDS AND

LIMITATIONS At the heart of therapists’ perspectives was the need to adapt to patients’ limitations, sometimes repeat and/or change scenarios multiple times and to role-play outside of the

VR environment. “_same scenario 3 times_,_ not as strong reaction as the first time regardless of strategy_” (T2). “_The participant says that these scenarios are what he needs and that they

are much more realistic than previous ones…_” (T2). However, role-playing realistic and, for the patient, triggering scenarios could become overwhelming why the focus of scenario enactment

had to change. “_The participant gets emotionally affected_,_ tears up. Talking about his brother stirs anger and sadness. Focus a lot on behaviour… I role-play for him Works well!_” (T5).

Some patients described a preference for real-life role-plays instead of VR-assisted role-plays, as they experienced difficulties perceiving the VR milieu as authentic. Here, therapists

adapted to patients’ preferences. “_Experience VR as fake_,_ and that it feels unnatural. Asks for role-play IRL_,_ which we also do_” (T7). Patients reported the need to feel a sense of

familiarity with the situation at large, both in terms of the treatment and the therapist. One patient stated, in relation to both the overall treatment and the just concluded VR scenario,

that time was needed in order to feel at ease. “_After having gone through the same situation 2 times before_,_ there was a familiarity to the situation and thus the 3 time it felt easier

and less strenuous_” (P2). APPLICATION IN EVERYDAY LIFE Perspectives on the usefulness of techniques and strategies were mixed: on the one hand helpful in tackling situations reminiscent of

the risk scenario, on the other hand sometimes hard to apply more generally. “_– helpful in situations similar to the risk scenario_” (P3). “_no situations on the ward where I could use the

strategies_” (P3). “_when angry and having to calm down and when tiered but having trouble sleeping_” (P5). In contrast, one patient described the viewpoint of the techniques / strategies as

altogether unhelpful. “_Don’t feel it leads to any change_” (P7). Nonetheless, therapists’ outlook on goal-attainment portrayed enhanced communicative capabilities, an insight into the

effectiveness of relaxation techniques and emotional awareness. “_– the participant realized the usefulness of communication- and relaxation strategies… generally much better at conversing

where he previously had kept silent… learned it’s possible to mirror emotional states_” (T3). On a similar note, one patient’s perspective also pointed to a better understanding of self and

others, an awareness of own limitations and challenges. “_–VRAPT has opened my eyes as to when I faulter in communicating and socialising with fellow humans –more knowledgeable of my

shortcomings_,_ wishing to better implement these methods in everyday life –has taught me being self-assertive is tough_,_ since I never was previously in life_” (P4). SELF-AWARENESS This

content category, as perceived by patients, has to do with how the intervention clarified the meaning of physiological reactions, was illustrative of own limitations, together with what

might be helpful. The following subcategories were discerned: Early reactions to heightened aggression, Awareness of own limitations, and What calms and helps. EARLY REACTIONS TO HEIGHTENED

AGGRESSION Several patients described a heightened awareness of how physiological, cognitive as well as behavioural changes act as cues to emotional arousal and elevated risk of aggressive

behaviour. “_increased heartbeat_,_ sweating_,_ gets ready to fight_” (P2). “_Heart beats faster_,_ more energy throughout the body_,_ a sharpening of senses_” (P4). “_I become terser_”

(P6). AWARENESS OF OWN LIMITATIONS Patients described the importance of not getting caught up in old behavioural patterns; the difficulty of doing what one knows one should. One patient

reported such awareness in response to a direct question in the treatment workbook regarding needed abilities and treatment goals. “_to listen and not to argue_,_ to speak my thoughts and

feelings and recognize signs that I’m getting angry_” (P6). However, another patient summed up a general theme of although having gone through the intervention and being more aware of own

triggers and responses, it nonetheless could be difficult to act constructively in a challenging situation. “_When in conflict with somebody it can be hard to walk away_” (P5). WHAT CALMS

AND HELPS Patients’ perspectives considered attaining control of oneself and the situation, of finding ways of giving oneself time to pause and reflect, as well as how this was practiced

time and time again throughout the intervention. “_Breath in calmly through the nose and breath out through the mouth_” (P3). Specifically, the helpfulness of a physical distance to other

people, and the importance of being left alone, was emphasized. “_…having a distance to people_” (P3). However, some patients elaborated on that merely distance and control was not enough,

instead stressing the need for distraction. Distraction was reported as a prerequisite for the lessening of emotional arousal and therethrough the sense of being able to handle the

situation. “_Not merely controlling the anger_,_ but also deceiving myself with methods of distraction_” (P2). “_Do something relaxing… listen to music_,_ exercise_” (P7). DISCUSSION The

principal focus of this study was to highlight the perspectives of patients and therapists regarding the treatment content of the revised VRAPT intervention, and therethrough implicitly also

addressing how VRAPT was clinically implemented in a high-security forensic psychiatric setting. Of particular interest for present purposes was how the perspectives of patients and

therapists on the actual treatment content of VRAPT were seen to not merely converge but occasionally also differ in potentially important ways, e.g. as pertains to the determination of

treatment goals, interpersonal communication, and the underlying reasons for the need for adaptations of the intervention. In sum, three content categories were manifest in the data: Skills

training, Tailoring of the intervention, and Self-awareness. SKILLS TRAINING Overall, the present findings suggest that skills training during VRAPT principally comprised three separate

parts: the awareness and recognition of emotions depicted in the VR environment, techniques to calm oneself, and finally the enactment of scenarios and role-play both within and without of

the virtual milieu. However, combining patients’ and therapists’ perspectives, it became evident how these, albeit being separate parts, nonetheless were perceived as a coherent treatment in

large focused on interpersonal communication. Accordingly, patients’ perspectives seemed to a substantial degree to resonate towards how awareness and recognition, as well as the

communication of emotional states, enabled them to establish and maintain a sense of self-respect. One patient even pointed out that it is not so much to get others to change according to

how one feels, but rather that being able to recognize emotions in oneself and others is a piece of the puzzle that enables a sound self-assertiveness. Here, the inherent coerciveness in

forensic psychiatry53,54,55. Patients also emphasized difficulties in discerning emotional signals from others. However, patients and therapists reported different emotions as the most

difficult for patients to recognize; patients described disgust, together with surprised / confused, as the most difficult whereas therapists aligned with patients on disgust but also

stressed difficulties recognizing anger. The current study is insufficient for conclusions as to whether this may signal a genuine lack of ability, as has been proposed in previous research

on forensic psychiatric patients59,60 or conversely be better appropriated to issues with the rendering of the facial expressions in the virtual environment. Returning to the focus of

interpersonal communication, therapists offered a slightly different perspective in accentuating the establishment of a shared understanding of any given interpersonal event, to formulate a

mutual problem and to invite the other to elaborate on his/her view. Thus, it would seem that therapists to a higher degree forwarded working on different modes of communication, to consider

the wishes of others as well as the need to adapt to one’s surroundings as central aspects of the intervention. Emergent from both perspectives was how the attainment of ways to calm

oneself was at the heart of VRAPT, but also how a collaborative effort was both needed and helpful in arriving at the precise techniques that were suitable for the specific patient.

Moreover, how the intervention not merely provided suggestions for new ways to remain calm in challenging situations, but how it also facilitated a joint elaboration on already present

abilities of the patient, hereby furthering participation. All the same, taking the reasoning a bit further, perhaps the helpfulness of having ways to calm oneself could be best understood

as a means to an end; especially patients highlighted how the ability to stay calm provided them with a sense of control of the situation. Thus, it could be argued that the treatment, while

focusing on techniques to calm down, lay a foundation for the attainment of perspective and thereby freeing the patient to act in less aggressive ways through feeling less vulnerable.

Patients as well as therapists recognized role-plays, regardless of whether it was conducted inside or outside of the VR environment, as the principal means through which other aspects of

the treatment intervention were brought into play. Role-plays provided a changeable interpersonal event and constituted a needed arena for a safe exploration of alternative roles,

reminiscent of the notion of psychological treatment involving an essential component of play61. Here, the importance of development of a therapeutic alliance can be seen through using

role-plays as an ongoing collaboration as well as adaptation of the treatment content to patients’ needs62,63. TAILORING OF THE INTERVENTION Therapists reported difficulties for patients to

present risk scenarios and aggression-triggering events, demonstrating the substantial time and effort that was needed in order to formulate viable treatment goals and the corresponding

role-play scenarios. Continuously maintaining a dialogue back and forth was portrayed as crucial for the ongoing adaptation to patients’ needs and limitations. Here, patients favored a

forward-looking perspective where they focused on finding adaptive ways of tackling challenging situations. Therapists, on their hand, focused on identification of risks and finding concrete

situational cues to what might pose a challenge and how this in turn could be utilized in the enactment of scenarios in VR. Taken together, the patients seemingly favored a

recovery-oriented approach while therapists seemed to favor a risk-oriented approach64. While this may seem as different approaches, a common denominator is how a collaborative effort in

constructing role-play scenarios is emphasized and, thus, what aspects should be the focus of the treatment. Finding transparent ways of collaborating between patients and therapists and

staff in forensic psychiatry is at the core of recent studies on patient participation in high-security forensic psychiatric care65. SELF-AWARENESS From patients’ notes in treatment

workbooks, it became clear how their own reflections, little by little, took the form of a progression towards an openness to try out new ways of thinking and acting during the course of

treatment. While many factors affect the process of any aggression treatment, a common denominator is an increased capacity for, and motivation to, engage in self-regulation of thoughts and

feelings and the interconnectedness between them3. Longitudinal research provides support for significant linkages between self-perceived low regulatory efficacy and patterns of aggression

and aggressive behaviour66,67,68. A study69 found a connection between poor self-regulation, off-course attempts at conflict management, inability to harbour negative emotions, and

aggressive recidivism in a sample of adult reoffenders. Thus, it would seem that the treatment content of repeatedly confronting the patient with ever-changing interpersonal events through

role-play could engender a qualitative shift in some patients’ ability to both recognize and utilize physiological, cognitive and emotional signs of heightened aggression in the handling of

challenging situations. Evident was also, from the perspective of patients, how the treatment for some had fostered a change towards a recognition of the necessary balancing act of on the

one hand standing up for what one believes in, to establish and maintain self-respect, and on the other expressing themselves in socially acceptable ways. Or, perhaps one patient said it

best: “To claim, or to give space” (P4). In sum, and perhaps unsurprisingly, within both perspectives lies the notion that reduction in aggression is engendered through combinations of the

different parts of the intervention. Hereby, arguably, some support is offered for the need of integrative frameworks in any properly articulated theory of aggression treatment3. LIMITATIONS

AND STRENGTHS One of the primary limitations of this study concerns the inherent coerciveness of forensic psychiatric settings, which may have influenced participant responses and

engagement70. The therapeutic misconception, where patients fail to distinguish between participation in research and routine clinical care, poses a significant ethical and methodological

challenge56. Patients may feel obligated to participate, believing that their engagement in VRAPT might influence their treatment trajectory or legal status27. Moreover, some may have

misinterpreted research participation as a requirement rather than a voluntary decision, either due to miscommunication or personal assumptions. To mitigate this risk, this study implemented

a comprehensive informed consent procedure, including detailed verbal and written explanations emphasizing the voluntary nature of participation. Despite these efforts, the possibility of

subtle coercion cannot be entirely ruled out. Some evidence suggests that participants retained their autonomy, such as one patient declining to return their workbook and others preferring

face-to-face role-play over VR-assisted sessions, indicating an ability to make independent treatment-related choices. However, future research must further refine communication strategies

to prevent misconceptions about participation. Another limitation relates to the gender imbalance within the sample. Of the seven participants, six were male, which reflects the general

demographic composition of forensic psychiatric populations, where male patients significantly outnumber female patients12. Nevertheless, this skewed representation limits the

generalizability of findings to female patients, as gender may influence aggression patterns, emotional regulation, and responsiveness to treatment16. Future studies should either strive for

a more balanced sample or investigate gender-specific adaptations of VRAPT to assess potential differences in treatment effectiveness. A methodological constraint of this study is its

reliance on workbook-based data collection, which, while offering structured insights from both patients and therapists, introduces several concerns. Workbooks depend on self-reported

reflections, making the data vulnerable to recall bias, social desirability bias, and response distortion71. Patients, particularly in forensic psychiatric settings, may underreport negative

experiences or exaggerate their progress due to institutional pressures or the belief that participation might positively impact their treatment evaluations56. Similarly, therapists may

unconsciously frame their reflections in alignment with expected therapeutic goals, rather than providing entirely objective evaluations72. Additionally, inconsistent engagement with

workbooks across participants presents another challenge. Some participants provided rich, detailed reflections, while others contributed minimal responses or omitted sections entirely,

creating gaps in data. Factors such as literacy levels, cognitive impairments, or motivation may have affected participants’ ability to engage with workbook tasks73. This variability

jeopardizes data saturation, as themes may be overrepresented or underrepresented depending on which participants provided the most comprehensive reflections57. One notable limitation

concerns the reliability of data processing. While coding was initially performed by one researcher and subsequently reviewed by a second author, formal inter-rater reliability measures were

not calculated. Although this process provided a degree of validation, the absence of quantified inter-rater agreement may impact the replicability of the findings. Furthermore, the

workbooks used in the intervention, although described in detail and tailored to the specific aims of VRAPT, have not been formally tested for psychometric reliability and are not based on

previously validated instruments. Future research should seek to strengthen methodological rigor by incorporating inter-rater reliability assessments and evaluating the reliability and

validity of intervention materials.Furthermore, workbooks capture post-session reflections rather than real-time experiences, leading to potential memory distortions. This is particularly

relevant in emotionally intense interventions like VRAPT, where patients may recall only the most salient or emotionally charged moments, rather than providing a comprehensive account of

each session74. Future research should explore real-time data collection methods to complement self-report measures. Despite these limitations, this study offers several notable strengths. A

key advantage is its dual-perspective approach, incorporating insights from both patients and therapists who participated in the same VRAPT intervention. This methodological approach

enhances the depth of analysis, providing a more comprehensive understanding of the treatment experience and implementation challenges. Additionally, by focusing on an innovative aggression

treatment method utilizing VR technology, this study contributes to the growing body of research exploring novel interventions in forensic psychiatry1. To our knowledge, no previous studies

have specifically analyzed the content or use of the workbooks in the context of the VRAPT treatment. While earlier VR studies have focused on outcomes such as emotional regulation,

aggression reduction, or user experience, the integration and role of structured therapeutic materials, such as the VRAPT workbooks, have not been the subject of systematic investigation.

This study therefore provides a novel contribution by shedding light on how these materials are perceived and used by participants within a forensic psychiatric setting. Another relevant

limitation concerns the potential influence of social desirability in patient reports. Given the clinical and institutional context in which the study was conducted, participants may have

felt inclined to present themselves in a favorable light or to provide responses they believed were expected by staff or researchers. This tendency could have influenced the content of the

workbook entries as well as verbal feedback during interviews, thereby impacting the reliability of the data. While efforts were made to create a safe and non-judgmental environment, the

possibility of socially desirable responding should be considered when interpreting the findings. The findings highlight both potential benefits and areas for improvement, paving the way for

future refinement to VRAPT. Furthermore, this study underscores the importance of interpersonal communication skills in aggression treatment. While previous research has emphasized

emotional regulation as a primary mechanism of change, this study suggests that enhancing self-assertiveness and emotional awareness may be equally critical in reducing aggression73. Future

VR-assisted treatments should further integrate interpersonal communication training to maximize therapeutic outcomes. RECOMMENDATIONS FOR FUTURE RESEARCH To enhance data validity and depth,

future studies should incorporate complementary methodologies that reduce self-report biases and provide a more objective assessment of VRAPT’s effectiveness. Potential approaches could

include: recording VRAPT sessions would allow researchers to objectively assess behavioral and emotional responses during treatment, direct therapist observations could provide a more

nuanced evaluation of patient engagement and progress75. Using heart rate variability (HRV), electrodermal activity (EDA), and skin conductance can help track physiological responses and

provide objective measures of emotional engagement during VRAPT sessions74. These measures could help identify patterns of emotional regulation, particularly in response to high-intensity VR

scenarios. Eye-tracking technology can analyze participants’ attentional focus and emotional engagement during VRAPT scenarios76. Motion analysis can track physical reactions and engagement

levels in VR environments, offering valuable data on patient responses. Follow-up interviews with patients and therapists, conducting structured post-treatment interviews would allow

researchers to clarify ambiguous workbook reflections and explore patient experiences in greater depth77. This approach would triangulate qualitative data, reducing the risk of

interpretation bias. Finally, future developments of the VRAPT could integrate the GAM model more clearly, and investigate this in relation to treatment outcome. CONCLUSIONS The findings of

this study provide critical insights into the treatment content and clinical implementation of the revised Virtual Reality Aggression Prevention Training (VRAPT) intervention in forensic

psychiatry. The collaborative nature of the intervention was consistently emphasized by both patients and therapists, suggesting that VRAPT fosters openness to new ways of interacting and

enhances self-awareness. However, notable differences in perspectives emerged between the two groups. Therapists primarily focused on identifying triggers of aggression (risk-perspective),

while patients placed greater emphasis on strategies for managing aggression effectively (recovery-perspective). This discrepancy underscores the importance of bridging these viewpoints to

ensure a more holistic and patient-centered approach in aggression treatment. Furthermore, role-play emerged as a central component of VRAPT, yet it was not merely a technique for behavioral

rehearsal; rather, it served to enhance interpersonal abilities. While both therapists and patients recognized its importance, patients particularly associated role-play with self-respect

and self-assertiveness, suggesting that the intervention’s effectiveness may extend beyond aggression management to broader social and emotional regulation skills. From a practical

standpoint, the intervention appears to focus more on highlighting patient limitations rather than reinforcing existing strengths, which may impact engagement and perceived treatment

efficacy. To maximize therapeutic benefits, a more integrated approach that balances risk-awareness with patient empowerment may be beneficial. Aligning the forward-looking, solution-focused

approach of patients with the risk-oriented framework of therapists could further enhance treatment outcomes and facilitate VRAPT’s successful integration into routine forensic psychiatric

care. While this study has certain methodological limitations, including coercion risks, self-report bias, and gender imbalances, it nonetheless represents a valuable contribution to

forensic psychiatric research. By leveraging technological advancements such as physiological monitoring, digital tracking, and structured post-session interviews, future research can

enhance the validity of VR-assisted aggression interventions. These innovations will not only improve data reliability and patient engagement but also optimize VRAPT’s applicability in

clinical settings, ensuring its effectiveness in real-world forensic psychiatric practice. DATA AVAILABILITY Data cannot be shared openly but are available on request from authors. If the

authors would like to request data from this study, author MW should be contacted. REFERENCES * González Moraga, F. R. et al. New developments in virtual Reality-Assisted treatment of

aggression in forensic settings: the case of VRAPT. _Front. Virtual Real._ 2, 675004. https://doi.org/10.3389/frvir (2022). Article  Google Scholar  * González Moraga, F. R., Garcia, D.,

Billstedt, E. & Wallinius, M. Facets of psychopathy, intelligence, and aggressive antisocial behaviors in young violent offenders. _Front. Psychol._ 10, 449489 (2019). Article  Google

Scholar  * McGuire, J. A review of effective interventions for reducing aggression and violence. _Philosophical Trans. Royal Soc. B: Biol. Sci._ 363 (1503), 2577–2597 (2008). Article  Google

Scholar  * Farrington, D. P., Gaffney, H. & Ttofi, M. M. Systematic reviews of explanatory risk factors for violence, offending, and delinquency. _Aggress. Violent. Beh._ 33, 24–36

(2017). Article  Google Scholar  * Fazel, S., Smith, E. N., Chang, Z. & Geddes, J. R. Risk factors for interpersonal violence: an umbrella review of meta-analyses. _Br. J. Psychiatry_.

213 (4), 609–614 (2018). Article  PubMed  PubMed Central  Google Scholar  * Prins, S. J. & Reich, A. Criminogenic risk assessment: A meta-review and critical analysis. _Punishm. Soc._ 23

(4), 578–604 (2021). Article  PubMed  PubMed Central  Google Scholar  * Mackie, J. L. _The Cement of the Universe_ (Clarendon, 1980). * Ramesh, T., Igoumenou, A., Montes, M. V. & Fazel,

S. Use of risk assessment instruments to predict violence in forensic psychiatric hospitals: a systematic review and meta-analysis. _Eur. Psychiatry_. 52, 47–53 (2018). Article  PubMed 

Google Scholar  * Papalia, N., Spivak, B., Daffern, M. & Ogloff, J. R. A meta-analytic review of the efficacy of psychological treatments for violent offenders in correctional and

forensic mental health settings. _Clin. Psychol. Sci. Pract._, 26(2), e12282 (2019). * Bogaerts, S., Polak, M., Spreen, M. & Zwets, A. High and low aggressive narcissism and Anti-social

lifestyle in relationship to impulsivity, hostility, and empathy in a group of forensic patients in the Netherlands. _J. Forensic Psychol. Pract._ 12 (2), 147–162.

https://doi.org/10.1080/15228932.2012.650144 (2012). Article  Google Scholar  * Krona, H., Anckarsäter, H., Nilsson, T. & Hofvander, B. Patterns of lifetime criminality in mentally

disordered Offenders–Findings from a nationally representative cohort. (2021). Frontiers in psychiatry, 12. * Laporte, N., Tuente, S. & Ozolins, A. Emotion regulation and self-harm among

forensic psychiatric patients. _Front. Psychol._ 12, 710751. https://doi.org/10.3389/fpsyg.2021.710751 (2021a). Article  PubMed  PubMed Central  Google Scholar  * Lobbestael, J., Cima, M.

& Lemmens, A. The relationship between personality disorder traits and reactive versus proactive motivation for aggression. _Psychiatry Res._ 229 (1–2), 155–160.

https://doi.org/10.1016/j.psychres.2015.07.052 (2015). Article  PubMed  Google Scholar  * Munthe, C., Radovic, S. & Anckarsäter, H. Ethical issues in forensic psychiatric research on

mentally disordered offenders. _Bioethics_ 24 (1), 35–44 (2010). Article  PubMed  Google Scholar  * Shapiro, D. L. Ethical issues in forensic psychology and psychiatry. _Ethics Med. Public.

Health_. 2 (1), 45–58. https://doi.org/10.1016/j.jemep.2016.01.015 (2016). Article  Google Scholar  * Völlm, B., Bartlett, P. & McDonald, R. Ethical issues of Long-Term forensic

psychiatric care. _Ethics Med. Public. Health_. 2 (1), 36–44 (2016). Article  Google Scholar  * Tuente, S. et al. Virtual reality aggression prevention therapy (VRAPT) versus waiting list

control for forensic psychiatric inpatients: a multicenter randomized controlled trial. _J. Clin. Med._ 9 (7), 2258 (2020). Article  Google Scholar  * Verstegen, N. Hurt people hurt people:

Characteristics and impact of inpatient aggression in forensic mental health care. [Doctoral Thesis, Maastricht University]. Maastricht University. (2023).

https://doi.org/10.26481/dis.20230706nv * Gatner, D. T., Moulden, H. M., Mamak, M. & Chaimowitz, G. A. At risk of what?? Understanding forensic psychiatric inpatient aggression through a

violence risk scenario planning Lens. _Int. J. Forensic Mental Health_. 20 (4), 398–407 (2021). Article  Google Scholar  * Wallinius, M. Aggressive antisocial behavior-clinical, cognitive,

and behavioral covariates of its persistence (Doctoral dissertation, Lund University). (2012). * Howner, K. et al. Mapping systematic reviews on forensic psychiatric care: a systematic

review identifying knowledge gaps. _Front. Psychiatry_. 9, 452 (2018). Article  PubMed  PubMed Central  Google Scholar  * Lee, A. H. & DiGiuseppe, R. Anger and aggression treatments: a

review of meta-analyses. _Curr. Opin. Psychol._ 19, 65–74 (2018). Article  PubMed  Google Scholar  * Sygel, K. & Wallinius, M. Immersive virtual reality simulation in forensic psychiatry

and adjacent clinical fields: a review of current assessment and treatment methods for practitioners. _Front. Psychiatry_, 804. (2021). * Trestman, R. L. Treating aggression in forensic

psychiatric settings. _J. Am. Acad. Psychiatry Law_. 45 (1), 40–43 (2017). PubMed  Google Scholar  * Geraets, C., Wallinius, M. & Sygel, K. Use of virtual reality in psychiatric

diagnostic assessments: A systematic review. _Front. Psychiatry_, 260. (2022). * Geraets, C. N., Van der Stouwe, E. C., Pot-Kolder, R. & Veling, W. Advances in immersive virtual reality

interventions for mental disorders: A new reality? _Curr. Opin. Psychol._ 41, 40–45 (2021). Article  PubMed  Google Scholar  * González Moraga, F. R. et al. VR-assisted aggression treatment

in forensic psychiatry: a qualitative study in patients with severe mental disorders. _Front. Psychiatry_. 15, 1307633 (2024). Article  PubMed  PubMed Central  Google Scholar  * Fromberger,

P., Jordan, K. & Müller, J. L. Use of virtual reality in forensic psychiatry: a new paradigm? _Der Nervenarzt_. 85, 298–303 (2014). Article  CAS  PubMed  Google Scholar  * Kip, H.,

Bouman, Y. H. A., Kelders, S. M. & van Gemert-Pijnen, L. J. E. W. C. eHealth in treatment of offenders in forensic mental health: a review of the current state. _Front. Psychiatry_. 9,

42. https://doi.org/10.3389/fpsyt.2018.00042 (2018). Article  PubMed  PubMed Central  Google Scholar  * Kisker, J., Gruber, T. & Schöne, B. Experiences in virtual reality entail

different processes of retrieval as opposed to conventional laboratory settings: A study on human memory. _Curr. Psychol._ 40, 3190–3197. https://doi.org/10.1007/s12144-019-00257-2 (2021).

Article  Google Scholar  * Spiegel, B. _VRx: How Virtual Therapeutics Will Revolutionize Medicine_ (Basic Books, 2020). * Tereso, I. M., Ramos, A. L. G., Santos, B. R. & Costa, J. P. M.

Virtual reality and forensic mental health. In Digital Therapies in Psychosocial Rehabilitation and Mental Health (245–260). IGI Global. (2022). * Bailey, J. O., Bailenson, J. N. &

Casasanto, D. When does virtual embodiment change our Minds?? _Presence_ 25 (3), 222–233 (2016). Article  Google Scholar  * Riva, G. Virtual reality in clinical psychology. _Compr. Clin.

Psychol._ 10, 91–105. https://doi.org/10.1016/B978-0-12-818697-8.00006-6 (2022). Article  Google Scholar  * Slater, M. Place illusion and plausibility can lead to realistic behaviour in

immersive virtual environments. _Philos. Trans. R. Soc. Lond._ 364, 3549–3557. https://doi.org/10.3389/frobt.2016.00074 (2009). Article  Google Scholar  * Slater, M. Immersion and the

illusion of presence in virtual reality. _Br. J. Psychol._ 109 (3), 431–433 (2018). Article  PubMed  Google Scholar  * Cummings, J. J. & Bailenson, J. N. How immersive is enough? A

meta-analysis of the effect of immersive technology on user presence. _Media Psychol._ 19 (2), 272–309 (2016). Article  Google Scholar  * Lanier, J. _Dawn of the New Everything: A Journey

Through Virtual Reality_ (Random House, 2017). * Lee, K. M. Presence, explicated. Communication theory, 14(1), 27–50. (2004). * Ticknor, B. _Virtual Reality and the 899 Criminal Justice

System: Exploring the Possibilities for Correctional Rehabilitation_ (Lexington Books, 2018). * Kilteni, K., Groten, R. & Slater, M. The sense of embodiment in virtual reality.

_Presence: Teleoperators Virtual Environ._ 21 (4), 373–387 (2012). Article  Google Scholar  * Slater, M., Spanlang, B. & Corominas, D. Simulating virtual environments within virtual

environments as the basis for a psychophysics of presence. _ACM Trans. Graphics (TOG)_. 29 (4), 1–9 (2010). Article  Google Scholar  * Lobbestael, J. & Cima, M. J. Virtual reality for

aggression assessment: the development and preliminary results of two virtual reality tasks to assess reactive and proactive aggression in males. _Brain Sci._ 11 (12), 1653.

https://doi.org/10.3390/brainsci11121653 (2021). Article  PubMed  PubMed Central  Google Scholar  * Quarmley, M., Vafiadis, A. & Jarcho, J. M. Irritability and rejection-elicited

aggression in adolescents and young adults. _J. Child Psychol. Psychiatry Allied Discip._ 64 (9), 1346–1358. https://doi.org/10.1111/jcpp.13804 (2023). Article  Google Scholar  * Smeijers,

D. & Koole, S. L. Testing the effects of a virtual reality game for aggressive impulse management (VR-GAIME): study protocol. _Front. Psychiatry_. 10, 83.

https://doi.org/10.3389/fpsyt.2019.00083 (2019). Article  PubMed  PubMed Central  Google Scholar  * Smeijers, D., Bulten, E. H., Verkes, R. J. & Koole, S. L. Testing the effects of a

virtual reality game for aggressive impulse management: A preliminary randomized controlled trial among forensic psychiatric outpatients. _Brain Sci._ 11 (11), 1484 (2021). Article  PubMed 

PubMed Central  Google Scholar  * Tuente, S., Bogaerts, S., Van Ijzendoorn, S. & Veling, W. Effect of virtual reality aggression prevention training for forensic psychiatric patients

(VRAPT): study protocol of a multi-center RCT. _BMC Psychiatry_. 18 (1), 1–9 (2018). Google Scholar  * Ivarsson, D., Delfin, C., Enebrink, P. & Wallinius, M. Pinpointing change in

virtual reality assisted treatment for violent offenders: a pilot study of virtual reality aggression prevention training (VRAPT). _Front. Psychiatry_. 14, 1239066.

https://doi.org/10.3389/fpsyt.2023.1239066 (2023). Article  PubMed  PubMed Central  Google Scholar  * Vears, D. F. & Gillam, L. Inductive content analysis: A guide for beginning

qualitative researchers. Focus on Health Professional Education: A Multi-disciplinary Journal, 23(1), 111–127. (2022). * Anderson, C. A. & Bushman, B. J. _Hum. Aggress. Psychol._, 53(1),

27. (2002). Google Scholar  * Anderson, C. A. & Carnagey, N. L. Violent evil and the general aggression model. In (ed Miller, A. G.) The Social Psychology of Good and Evil (168–192).

The Guilford Press. (2004). * DeWall, C. N., Anderson, C. A. & Bushman, B. J. The general aggression model: theoretical extensions to violence. _Psychol. Violence_. 1 (3), 245 (2011).

Article  Google Scholar  * Blitz, M. J. Extended reality, mental liberty, and state power in forensic settings. _AJOB Neurosci._ 13 (3), 173–176 (2022). Article  PubMed  Google Scholar  *

Kellmeyer, P., Biller-Andorno, N. & Meynen, G. Ethical tensions of virtual reality treatment in vulnerable patients. _Nat. Med._ 25 (8), 1185–1188 (2019). Article  CAS  PubMed  Google

Scholar  * Ligthart, S., Meynen, G., Biller-Andorno, N., Kooijmans, T. & Kellmeyer, P. Is virtually everything possible? The relevance of ethics and human rights for introducing extended

reality in forensic psychiatry. _AJOB Neurosci._ 13 (3), 144–157 (2022). Article  PubMed  Google Scholar  * Lidz, C. W. & Appelbaum, P. S. The therapeutic misconception: problems and

solutions. _Med. Care_. 40 (9 Suppl), V55–V63. https://doi.org/10.1097/01.MLR.0000023956.25813.18 (2002). Article  PubMed  Google Scholar  * Hennink, M. & Kaiser, B. N. Sample sizes for

saturation in qualitative research: A systematic review of empirical tests. _Soc. Sci. Med._ 292, 114523. https://doi.org/10.1016/j.socscimed.2021.114523 (2022). Article  PubMed  Google

Scholar  * Graneheim, U. H., Lindgren, B. M. & Lundman, B. Methodological challenges in qualitative content analysis: A discussion paper. Nurse education today, 56, 29–34. (2017). *

Bulgari, V. et al. Facial emotion recognition in people with schizophrenia and a history of violence: A mediation analysis. _Eur. Arch. Psychiatry Clin. NeuroSci._ 270, 761–769.

https://doi.org/10.1007/s00406-019-01027-8 (2020). Article  PubMed  Google Scholar  * Tiberi, L. A., Gillespie, S. M., Saloppé, X., Vicenzutto, A. & Pham, T. H. Recognition of dynamic

facial expressions of emotions in forensic inpatients who have committed sexual offenses: a signal detection analysis. _Front. Psychiatry_. 15, 1384789 (2024). Article  PubMed  PubMed

Central  Google Scholar  * Winnicott, D. W. & (Donald, W. _Playing and Reality_ (Routledge, 1991). ([New ed.]). * Bordin, E. S. Theory and research on the therapeutic working alliance:

New directions. In A. O. Horvath & L. S. Greenberg (Eds.), The working alliance: Theory, research, and practice (pp. 13–37). (1994). * Clercx, M., de Vogel, V., Lancel, M. &

Keulen-de Vos, M. The influence of therapy alliance and treatment motivation in patients with cluster B personality disorders on incidents in forensic hospitals. _J. Forensic Pract._ 23 (3),

272–284 (2021). Article  Google Scholar  * Pollak, C. _Bridging the Gap: Patients and Professionals Perspective on Risk and Recovery in Forensic Psychiatry_ (Karolinska Institutet (Sweden),

2021). * Söderberg, A. Patientdelaktighet i rättspsykiatrisk vård: Vårdprocess och vårdvardag (Doctoral dissertation, Linnaeus University Press). (2024). * Bandura, A., Caprara, G. V.,

Barbarinelli, C., Pastorelli, C. & Regalia, C. Sociocognitive self-regulatory mechanisms governing transgressive behaviour. _J. Pers. Soc. Psychol._ 80, 125–135.

https://doi.org/10.1037//0022 (2001). * Bandura, A., Caprara, G. V., Barbarinelli, C., Gerbino, M. & Pastorelli, C. Role of affective self-regulatory efficacy in diverse spheres of

psychosocial functioning. _Child. Dev._ 74, 769–782. https://doi.org/10.1111/1467-8624.00567) (2003). Article  PubMed  Google Scholar  * Caprara, G. V., Regalia, C. & Bandura, A.

Longitudinal impact of perceived self-regulatory efficacy on violent conduct. _Eur. Psychol._ 7, 63–69. https://doi.org/10.1027//1016-9040.7.1.63) (2002). * Zamble, E. & Quinsey, V. L.

_The Criminal Recidivism Process_ (Cambridge University Press, 1997). * Birks, D. & Douglas, T. (eds) _Treatment for Crime: Philosophical Essays on Neurointerventions in Criminal

Justice_ (Oxford University Press, 2018). * Podsakoff, P. M., MacKenzie, S. B. & Podsakoff, N. P. Sources of method bias in social science research and recommendations on how to control

it. _Ann. Rev. Psychol._ 63, 539–569. https://doi.org/10.1146/annurev-psych-120710-100452 (2012). Article  Google Scholar  * Kazdin, A. E. Mediators and mechanisms of change in psychotherapy

research. _Ann. Rev. Clin. Psychol._ 3 (1), 1–27. https://doi.org/10.1146/annurev.clinpsy.3.022806.091432 (2007). Article  Google Scholar  * Feinberg, J. _The Moral Limits of the Criminal

Law: Harmless Wrongdoing_ (Oxford University Press, 1988). * Diemer, J., Alpers, G. W., Peperkorn, H. M., Shiban, Y. & Mühlberger, A. The impact of perception and presence on emotional

reactions: A review of research in virtual reality. _Front. Psychol._ 6, 26. https://doi.org/10.3389/fpsyg.2015.00026 (2015). Article  PubMed  PubMed Central  Google Scholar  * McLeod, J.

_Qualitative Research in Counselling and Psychotherapy_ (SAGE, 2011). * Adhanom, I. B., MacNeilage, P. & Folmer, E. Eye tracking in virtual reality: a broad review of applications and

challenges. _Virtual Real._ 27 (2), 1481–1505 (2023). Article  PubMed  PubMed Central  Google Scholar  * Creswell, J. W. & Poth, C. N. _Qualitative Inquiry and Research Design: Choosing

among Five Approaches_ 4th edn (SAGE, 2017). Download references AUTHOR INFORMATION AUTHORS AND AFFILIATIONS * Research Department, Regional Forensic Psychiatric Clinic, Växjö, Sweden

Fredrik Sivermo, Fernando Renee González Moraga & Märta Wallinius * Evidence-based Forensic Psychiatry, Department of Clinical Sciences Lund, Psychiatry, Lund University, Lund, Sweden

Fernando Renee González Moraga & Märta Wallinius * Centre for Ethics, Law and Mental Health, Institute of Neuroscience and Physiology, The Sahlgrenska Academy, University of Gothenburg,

Gothenburg, Sweden Fernando Renee González Moraga & Märta Wallinius Authors * Fredrik Sivermo View author publications You can also search for this author inPubMed Google Scholar *

Fernando Renee González Moraga View author publications You can also search for this author inPubMed Google Scholar * Märta Wallinius View author publications You can also search for this

author inPubMed Google Scholar CONTRIBUTIONS FS, FG and MW contributed to the conception of the manuscript. FS wrote the first draft of the manuscript. FG and MW wrote sections of the

manuscript. All authors contributed to manuscript revisions, read and approved the submitted version. CORRESPONDING AUTHOR Correspondence to Fernando Renee González Moraga. ETHICS

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permissions ABOUT THIS ARTICLE CITE THIS ARTICLE Sivermo, F., Moraga, F.R.G. & Wallinius, M. A pilot study on treatment content in virtual reality-assisted aggression therapy at a

maximum-security forensic psychiatric clinic. _Sci Rep_ 15, 16983 (2025). https://doi.org/10.1038/s41598-025-01194-w Download citation * Received: 05 November 2024 * Accepted: 05 May 2025 *

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Aggression * Forensic psychiatry * VRAPT * Treatment * Content analysis