Virtual reality-assisted psychological treatment of aggression for violent offenders: a pilot descriptive case series in maximum-security forensic psychiatry.

Background: Aggressive behaviour remains a major clinical challenge in forensic psychiatric care, and effective interventions targeting aggression are limited. Virtual Reality Aggression Prevention Treatment (VRAPT) is a manualized cognitive behavioural intervention that uses immersive virtual reality to provide individualized exposure to emotionally provocative interpersonal situations. Following a previous randomized controlled trial in Dutch forensic psychiatric care, the VRAPT protocol was revised to strengthen its theoretical foundation and therapeutic content. This pilot descriptive case series provides the first clinical description of the revised VRAPT protocol in patients receiving treatment in a Swedish maximum-security forensic psychiatric setting. Methods: A pilot descriptive case series was conducted in a maximum-security forensic psychiatric clinic. Fourteen patients initially consented to participate, of whom seven completed the intervention and follow-up assessments. The revised VRAPT protocol emphasized therapist-guided, individualized virtual reality scenarios targeting emotion regulation during emotionally provocative interpersonal situations. Clinical, psychological, behavioural, and process measures were collected to characterize the study population and describe individual trajectories during treatment and follow-up. Results: Participants who completed treatment generally reported moderate to high levels of perceived presence, suggesting that the virtual environments were experienced as immersive and sufficiently realistic. Individual trajectories varied across participants. Several participants showed favourable changes in measures of emotion regulation, self-reported anger, and aggression, whereas others showed stable or fluctuating trajectories over time. Staff-rated aggressive behaviour also varied considerably across participants. Exploratory group-level analyses did not indicate statistically significant changes. A 50% dropout rate highlighted the challenges associated with treatment engagement and retention in a maximum-security forensic psychiatric setting. The observations were consistent with the theoretical rationale underlying VRAPT, although the uncontrolled design precludes conclusions regarding treatment effectiveness. Conclusions: This pilot descriptive case series provides the first detailed clinical description of the revised VRAPT protocol in Swedish maximum-security forensic psychiatry. The findings provide descriptive clinical observations that may inform the design of future controlled studies, including randomized controlled trials and high-quality single-case experimental designs.