Equipment, VR scenarios, and Instructions
Equipment: A range of VR setups could be workable, but we recommend an HTC Vive Pro, which can be found here. In our experience, this system has been easy to work with and set up, rarely malfunctions, and allows for a high degree of freedom of movement (~30ft x 30ft area).
In terms of computers, you will need one that meets the specifications for the HTC Vive Pro (see website link above for specific information on this). This typically means a computer specialized for VR (i.e., an advanced graphics card & CPU). There are many computers that would work for this purpose, but most are built by small, specialized companies/vendors — some of which are great, and some of which are less than great. We have had success with MSI Vortex computers (see here). We like them because they are small, powerful, and reliable. But please be aware that these computers come with a wide range of specifications and are often built in small batches. Also please be aware that some companies/vendors are more reliable than others. Out of the 8 MSI Vortex computers that we have ordered, we have had to return two because they were inoperable right out of the box. This is a much better rate than we have experienced with other VR computers.
In total, an HTC Vive Pro + a VR-capable computer could run you as little as $2,000 total, with prices falling each month. The major cost will be the computer, which could run as high as $4,000 depending on what you select (but beware that more expensive VR computers are not necessarily better).
Lab Space: To run our VR suicide scenarios, we recommend a lab space of at least 10ft x 10ft. Our lab space devoted to VR is approximately 15ft x 30ft, and we have our VR computers/monitors in an adjacent lab room.
VR Scenarios & Where to Find Them: After much investigation, we discovered that you do not need to independently develop VR scenarios to use them for our intended purposes. There are hundreds of VR experiences and games that can be re-purposed to investigate responses to/actions within virtual suicidal situations. Over 1,000 VR titles can be found and downloaded here and a similar list can be found and downloaded here. Many of these VR titles are free, most only cost $5-20, and they rarely cost more than $50. The jumping scenario that we used can be found and downloaded here, and the shooting scenario that we used can be found and downloaded here. But these are by no means the only scenarios that could be employed for jumping/shooting scenarios, and by no means are jumping/shooting the only suicidal situations that could be approximated in VR.
Instructions for VR Suicide Scenarios. Through our early work with VR suicide scenarios, we made two important methodological discoveries. First, we discovered that participants required specific, direct instructions. In the absence of these instructions, participants would become absorbed into the virtual world and wander around without respect to researcher instructions. This created a lot of potential problems for internal validity and replicability. To combat this issue, we created highly detailed instructions for each scenario. The instructions we employed across our first three VR suicide studies can be downloaded by clicking here. We recommend using the instructions from Study 2 (which begin on Page 5) as a base. Of course, these are not the only possible instructions that could be used for VR suicide scenarios and there is a trade-off between instructions/structure and ecological validity, immersion, and presence. But based on our pilot studies, we recommend a set instructions that resemble those in the above-referenced document.
Second, we discovered that choice-based instructions were necessarily to most accurately approximate actual suicidal situations and suicidal behavior rates. As described in our first VR suicide paper, we did not give participants an explicit choice between VR suicide and another behavior in Study 1. Despite constantly reminding participants that they could ignore any instructions without penalty, we observed a strong obedience effect on VR suicide in Study 1. This drove high VR suicide rates and likely would obscure any attempts to observe predictors of or experimental effects on VR suicide. In Study 2, we provided participants with an explicit choice between VR suicide and a non-suicidal behavior. This reduced VR suicide to approximately 5% and we observed several significant predictors of VR suicide completion. In Study 3, we used choice-based instructions but added either (a) a monetary incentive for engaging in VR suicide or (b) a social disincentive for not engaging in VR suicide. Each of these manipulations produced VR suicide rates near 25%.
General Safety. As described in our recent VR suicide paper (see here), we received no reports of nausea; experienced no adverse events (this remains true after over 1,000 participants); no reports of distress at the end of the study (i.e., after positive mood induction and debriefing); and no falls or other types of injuries.
Suicide-Related Safety. It is intuitive to assume that exposure to VR suicide scenarios may have adverse side effects such as increased suicide ideation, capability, etc. Based on the general literature on iatrogenic effects of suicide research/stimuli and our own pilot studies, we reasoned that this intuitive assumption (like many intuitive assumptions) would not hold up when stringently tested. As described in the above paper on VR suicide, in our first study, we conducted a randomized controlled trial that experimentally tested the effects of exposure to VR suicide scenarios on a range of suicide-related outcomes. We randomly assigned participants to be exposed to either VR suicide scenarios (n = 148) or control VR scenarios (n = 139). Results revealed that exposure to VR suicide had no significant effects on the following: (1) passive suicide ideation; (2) active suicide ideation; (3) suicidal desire; (4) suicidal capability; (5) implicit associations with death/suicide; (6) implicit affect toward a range of death/suicide stimuli; and (7) clinician-rated suicide risk. These effects were not just non-significant — the means for the two groups were nearly identical on all measures, with no hint of a potential effect of VR suicide scenario exposure on any of these variables.
We recently conducted two additional studies (currently under review) that further confirm the safety of this approach. In one study, we followed-up over 150 participants randomly assigned to be exposed to VR suicide scenarios or control scenarios. Across a two year follow-up period, results indicated that VR suicide exposure did not cause any increases in suicidality, negative emotions, suicidal capability, or any other such factor. In a separate study of over 120 participants (half of whom had a recent history of suicidality), we followed participants for two weeks after exposure to VR suicide scenarios. Results indicated that exposure to these scenarios did not cause any increases in suicidality, negative emotions, suicidal capability, or any other such factors. Combined with our initial safety study (see above), these findings indicate that exposure to VR suicide scenarios has no immediate, short-term, or long-term effects on suicidality or related phenomena (even in people with a recent history of suicidality). Of course we are continuing to conduct further safety studies, but already at this early point with this method, it has received more extensive safety evaluations than the vast majority of existing suicide-related measures, stimuli, and tasks, and each evaluation has strongly supported its safety.
Recommendations. As noted in our recent VR suicide paper, all participants received a formal, evidence-based suicide risk assessment at the end of the study session. Participants were assessed regardless of responses on questionnaires or actions during the study. This blanket risk assessment protocol helps to ensure the safety of all participants, and we strongly recommend using this protocol in all VR suicide studies.
VR suicide represents the first method for testing ideas about suicide causes. Previous methods could only provide information about correlates or predictors — neither of which can be assumed to generalize to causal evidence. Below, we note three general areas for research. Of course, there are many other potential uses of this method, but there are hundreds of potentially interesting studies that could be conducted within the three areas noted below:
Advancing knowledge about suicide causes. This is a wide-open area with major potential implications for theories, risk assessments, and interventions. It is currently unknown if any risk factor for suicidal behaviors is a causal risk factor. For example, social rejection is thought to be an important risk factor for suicidal behaviors, but it is unclear what (if any) causal effect social rejection has on suicidal behaviors. One possibility is that social rejection predicts suicidal behavior because it is correlated with actual causes of suicidal behavior. Another possibility is that social rejection has a direct causal effect on suicidal behavior. This could be tested by randomly assigning participants to receive (or not receive) a social rejection manipulation, and observing the effects of this manipulation on VR suicide rates. Likewise, suicide theories are essentially series of hypotheses about suicide causes. Due to methodological limitations, constructs in these theories have only been tested as correlates and predictors, not causes. Each of these constructs could be manipulated and their effects on VR suicide could be observed, providing empirical information about the causal effects of these variables on VR suicide (with potential implications for actual suicidal behavior).
Advancing knowledge about proximal suicide causes/risks/correlates. We know very little about what happens immediately before and during suicidal behavior. The VR suicide paradigm provides the opportunity to observe the immediate effects of potential causes on VR suicide; the characteristics of individuals immediately before they engage in VR suicide (e.g., changes in cardiovascular activity); and the characteristics of individuals as they engage in VR suicide.
Improvements and additions to VR suicide methods. There are many improvements that could be made to our published VR suicide methods to further their relevance to actual suicidal behaviors. Likewise, there are many needed additions to these methods, including but not limited to the following: VR suicide scenarios for other methods of suicide, especially less lethal methods; the integration of haptics into these scenarios; and the development of methods that involve approach toward a suicidal situation (vs. immediately placing participants into a suicidal situation).