Many forensic psychiatric inpatients have difficulties regulating aggressive behavior. Evidence of effective aggression treatments is limited. We designed and investigated the effectiveness of a transdiagnostic application of a virtual reality aggression prevention training (VRAPT). In this randomized controlled trial at four Dutch forensic psychiatric centers, 128 inpatients with aggressive behavior were randomly assigned to VRAPT (N = 64) or waiting list control group (N = 64). VRAPT consisted of 16 one-hour individual treatment sessions twice a week. Assessments were done at baseline, post-treatment and at 3-month follow-up. Primary outcome measures were aggressive behavior observed by staff and self-reported aggressive behavior. Analysis was by intention to treat. This trial was registered in the Dutch Trial Register (NTR, TC = 6340). Participants were included between 1 March 2017, and 31 December 2018. Compared to waiting list, VRAPT did not significantly decrease in self-reported or observed aggressive behavior (primary outcomes). Hostility, anger control, and non-planning impulsiveness improved significantly in the VRAPT group compared to the control group at post-treatment. Improvements were not maintained at 3-month follow-up. Results suggest that VRAPT does not decrease aggressive behavior in forensic inpatients. However, there are indications that VRAPT temporarily influences anger control skills, impulsivity and hostility.

Purpose A clear understanding of an offender's criminal behaviour is a prerequisite for determining suitable treatment. In the literature, several specific frameworks or therapeutic approaches that aim to explicate criminal behaviour can be distinguished (e.g., cognitive analytic therapy, offence paralleling behaviour paradigm), but Schema Therapy (ST) is becoming an increasingly popular paradigm. According to forensic ST's theoretical framework, criminal and violent behaviour can be explained by an unfolding sequence of schema modes, or moment‐to‐moment states that represent emotions, cognitions, and behaviour. In this study, we examine the validity of this theory and the relationship between schema modes, psychopathy, and institutional violence. Methods Schema modes were assessed retrospectively from descriptions of patients’ crimes in a sample of 95 hospitalized cluster B personality disordered offenders. Psychopathy was rated with the Psychopathy Checklist‐Revised and institutional transgressions were coded from daily hospital reports. Results Our findings show that criminal behaviour is often preceded by schema modes that refer to feelings of vulnerability and abandonment, loneliness, and states of intoxication. Criminal behaviour itself is characterized by schema modes that refer to states of impulsivity, anger, and the use of overcompensatory strategies involving threats, intimidation, and aggression. Schema modes involving bullying and manipulation were positively correlated with the interpersonal facet of psychopathy; the vulnerable child mode was negatively correlated with the affective facet of psychopathy. The schema modes in this study moderately predicted later institutional transgressions. Conclusions Our findings suggest that the schema mode concept is of explanatory value in understanding criminal and violent behaviour.

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Background Problems in social functioning (e.g., unemployment, social isolation), are common in people with a psychotic disorder. Social cognition is a treatment target to improve social functioning, as it is a proximal predictor of social functioning. Social Cognition Training (SCT) improves social cognition, but may not generalize (enduringly) to social functioning, perhaps due to insufficient opportunity to practice in daily-life social situations. Using virtual reality (VR) for SCT could address this problem, as VR is customizable, accessible, and interactive. We will test the effect of a VR SCT, ‘DiSCoVR’, on social cognition and social functioning in a randomized controlled trial (RCT). Methods In total 100 people with a psychotic disorder and deficits in social cognition will be recruited for this multicenter randomized controlled trial (RCT). Participants will be randomized to VR SCT (DiSCoVR) or VR relaxation training (VRelax; active control). DiSCoVR is a 16-session individual SCT, consisting of three modules: 1) emotion perception (recognizing facial emotions in a virtual shopping street); 2) social perception and theory of mind (observing social interactions between virtual characters and assessing their behavior, emotions and thoughts); and 3) application of higher-order social cognition in social interaction (role-playing personalized situations in VR). People receiving VRelax complete sixteen individual sessions, in which they receive psycho-education about stress, identify personal stressors, learn relaxation techniques, and explore relaxing immersive virtual environments. Assessments will be performed at baseline, post-treatment, and 3-month follow-up. Primary outcomes are emotion perception (Ekman 60 Faces), social perception and theory of mind (The Awareness of Social Inference Test). Secondary outcomes include social functioning (Personal and Social Performance Scale), experiences and social interactions in daily life (experience sampling of emotions, social participation and subjective experience of social situations), psychiatric symptoms (e.g., depression, perceived stress, anxiety, positive and negative symptoms) and self-esteem. Discussion To our knowledge, this will be the first RCT testing the efficacy of VR SCT. It will also investigate generalization to daily life social situations, the durability of treatment effects, and moderators and mediators of treatment success. Trial registration On December 5, 2017, this trial was registered prospectively in the Dutch Trial Register as NTR6863 . Electronic supplementary material The online version of this article (10.1186/s12888-019-2250-0) contains supplementary material, which is available to authorized users.