Virtual Reality With Adolescents Hospitalized for Suicide-Related Crises

Psychological Services | 2025, Vol. 11, No. 1, p. 145-157

Clinical Services Addressing Violent Extremism: The Quebec Model

Marisa E. Marraccini; School of Education, University of North Carolina, Chapel Hill

Rachel Anonick; School of Education, University of North Carolina, Chapel Hill

Lauren E. Delgaty; School of Education, University of North Carolina, Chapel Hill

Telieha J. Middleton; School of Education, University of North Carolina, Chapel Hill

Emily N. Toole; School of Education, University of North Carolina, Chapel Hill

Jennifer Ying; School of Information and Library Science, University of North Carolina, Chapel Hill

Robert Hubal; Renaissance Computing Institute, University of North Carolina, Chapel Hill

This study applied qualitative methods and a user design approach to develop and iteratively refine a model for a virtual reality intervention designed to supplement standard inpatient treatment for adolescents hospitalized for suicide-related crises: the practice experiences for school reintegration (PrESR). The PrESR model allows patients to practice therapeutic skills within an immersive school environment to increase skill knowledge and skill use and to improve school reintegration. Adolescents previously hospitalized for suicide-related thoughts and behaviors (n = 13), hospital professionals with experience providing supports to hospitalized adolescents (n = 7), and school professionals with experience supporting adolescents with suicide-related risks (n = 12) completed focus group and/or one-on-one interviews to inform the development of the PrESR model. Transcribed interviews were analyzed using content analysis, and structured feedback was analyzed by calculating frequencies. Participating adolescents were between the ages of 13 and 18, identifying their race as White (61%), Asian (7.7%), American Indian and Black (7.7%), or Black (7.7%; note that 15.4% preferred not to answer) and their ethnicity as Hispanic (23%) or non- Hispanic (77%). Adolescents identified their gender as girl or woman (46%), boy or man (38%), or “some other way” (15%). A majority of adolescent and professional participants endorsed the PrESR as holding the potential to promote skill learning. Feedback addressed improvements to scenarios and skills; safety concerns, constraints to consider, and barriers to implementation; and information to include in the treatment manual. Findings also informed the types of difficulties adolescents face in schools and the potential feasibility of a virtual reality intervention to enhance standard inpatient care of adolescents hospitalized for suicide-related crises.

Suicide; virtual reality; psychiatric hospitalization; adolescence; intervention

"Adolescent reports of suicide-related thoughts and behaviors... have risen over the past decade" with "adolescent reports of seriously considering suicide attempts" increasing from "16% in 2011 to 22% in 2021" and reports of attempted suicide rising from "8% in 2011 to 10% in 2021." Hospitalization for suicide-related crises has nearly doubled, with "a significant increase in emergency department visits related to suicidality in the winter of 2021 compared to previous winters." Adolescents face significant challenges upon returning to school, including "ongoing social and academic stressors, symptom management in school settings, and both peer and adult questions related to their absences." However, "few interventions address the immediate transition following psychiatric care," and services "may be delayed or disrupted." While school reintegration efforts have gained attention, "comparatively less work has addressed the need for hospital treatment to prepare adolescents for their return" (p. 146).

This study sought to "iteratively design the PrESR model, a VR intervention designed to supplement standard treatment provided to adolescents hospitalized for suicide-related thoughts and behaviors." It followed the "Person-Based Approach to Intervention Development" which includes "planning, design, development and evaluation of acceptability and feasibility, and implementation and trialing." "Adolescents previously hospitalized for suicide-related thoughts and behaviors (n = 13), hospital professionals with experience providing supports to hospitalized adolescents (n = 7), and school professionals with experience supporting adolescents with suicide-related risks (n = 12)" participated through "focus group and/or one-on-one interviews to inform the development of the PrESR model." Their feedback was used to "inform a subsequent presentation" and iteratively improve the model. Interviews were "transcribed, redacted of identifying information, and reviewed for accuracy" and analyzed using "applied thematic analysis (ATA) and content analysis" to "identify themes and categories across interviews” (p. 147 - 149).

The study provided insight into the "stressors adolescents face following hospitalization for suicide-related crises, as well as the skills used by adolescents upon return to school." Adolescents reported that "social experiences were the most commonly described stressors in school" and that "school relationships and social experiences are a primary stressor reported by adolescents with suicide-related risk." These findings align with theories that "propose risk is especially heightened in the context of acute social stressors." Adolescents also described difficulties with "academic stress and pressure and missing work completion," which have been identified as concerns following hospitalization. They reported using "a wide variety of skills to cope with stressors," including "cognitive restructuring, affirmations, mindfulness, distress tolerance, and positive thinking." The findings highlight the importance of "reinforcing skill use and adapting strategies for school context" when supporting adolescents after hospitalization (p. 154).

The study also provided insight into "the broader implementation of interventions delivered in inpatient settings." Professionals expressed "conflicting concerns about the possibility of using the PrESR with specific patient populations," raising questions about its suitability for "patients with trauma, patients on the autism spectrum, patients with significant aggression, and those with complex family situations." However, given "the high degree of comorbidity across conditions" and the "transdiagnostic nature of suicide-related risk," there remains "a critical need for opportunities to enhance treatment options during inpatient hospitalization for adolescents presenting with complex needs” (p. 154).

“The lengthy list of constraints for delivering the PrESR also holds clinical implications for inpatient practices. Varying lengths of stays, limited space, and conflicts in scheduling are issues to be considered. Unfortunately, minimal research has explored the efficacy of inpatient treatments on adolescent outcomes, and criticisms of hospitalization as the de facto practice for handling suicide risk are prevalent. Existing research has pointed to the need for continuum-of-care models that integrate treatment during hospitalization and treatment provided following discharge (Blanz & Schmidt, 2000). Within such models, however, there appears to be a need to apply and test implementation strategies when integrating evidence-based interventions onto the unit, with special attention to the potential for short stays and scheduling challenges. Such constraints point to the need for creative strategies for improving care on inpatient units, such as research examining the efficacy of single-session interventions delivered inpatient. Although not identified by participants in the present study, there is also a need to investigate how a payment model could influence sustainability of this program. For example, although payer reimbursement was recently approved for some pain management VR applications (AppliedVR) that classify as durable medical equipment, numerous questions related to rate of reimbursement, reoccurring payments, and medical conditions outside of pain (such as mental health disorders). 

Third, findings suggest that adolescents and professionals found the PrESR model to be acceptable and feasible, indicating the potential for VR to enhance interventions beyond exposure therapy. Participants were largely enthusiastic about the PrESR model, endorsing the concept overall, but also providing constructive feedback integrated into the model for improvements. Participants’ positive responses led to additional ideas worthy of exploration, such as prosocial interventions for modeling positive interactions and relationships in VR and interventions optimized for specific patient populations.

Despite its promise, it is worth noting that although most participants endorsed the concept, some believed it would require additional follow-up interventions and supports to be effective at preventing suicide-related thoughts and behaviors. Indeed, effective suicide prevention requires multipronged approaches embedded across settings, and one supplemental intervention delivered during psychiatric hospitalization should only be considered within an assortment of treatment and safety considerations throughout recovery. Nonetheless, enhancing quality of care during hospitalization may be considered as one component of treatment for improving outcomes for hospitalized adolescents” (p. 154 - 155).

“Several limitations should be noted about this study. First, this study aimed only to develop and refine the PrESR model but did not test the effects of the PrESR for increasing skill learning or use or preventing suicide-related thoughts and behaviors. Additional research focused on testing and refining the intervention, leading to a pilot clinical trial, is underway. Additionally, findings from the structured feedback form should be considered with caution. Given that the survey was designed for the present study, its psychometric properties have not been tested. Additional limitations related to the generalizability of findings should also be noted. Although the demographic characteristics of the sample of adolescents included in this study were comparable to those typically found among adolescents hospitalized for suicide-related crises (Plemmons et al., 2018, found that 59% hospitalized youth between 2012 and 2015 were non-Hispanic White, 20% were non-Hispanic African American, and 12% were Hispanic), a majority White and cisgendered sample merits additional research centering the perspectives of ethnic and racial minoritized adolescents and adolescents identifying as LGBTQIA+. Indeed, several professionals endorsed the need to center issues related to representativeness and diversity within the intervention model. Likewise, hospital professionals were recruited from one hospital, and school professionals were recruited from one state, limiting the generalizability of feedback to other settings or locations. Indeed, previous work suggests variability in perspectives of treating patients with suicide-related risk according to the type of health care professions, as well as personal experiences and beliefs. Finally, although the researchers strongly encouraged critical feedback from participants, it is possible that social desirability led to overly positive responses from participants” (p. 155).