Conversations about suicide are difficult to practice. Can virtual reality training make a difference? At UCLL University of Applied Sciences and the VLESP prevention center they believe so. ‘Through these simulations, students better understand the challenges people experience in daily life.’
When Stan is told in his hospital room that he can go home again after an acute pancreatitis, he reacts less than enthusiastically. “Home?” he asks in surprise. “But I don’t like that at all. Back to the misery.”
The nurse encourages him to continue talking. It soon turns out that there is a lot more going on. His marriage broke down, he lost his job and he sees less and less of his son. “I ruined everything,” Stan says. “I should have never started drinking. I better not be there anymore. There’s no point anymore.”
That is the conversation we witness when we attend the presentation of the new virtual reality tool (VR) from UCLL University of Applied Sciences, the Flemish Expertise Center for Suicide Prevention (VLESP) and high-tech consultancy company TMC. It is intended to train nursing students and care providers to recognize suicidal signals and discuss them with a patient.
Typically, such delicate conversations are practiced in a role play with colleagues or fellow students. Although this method has its merits, it also has limitations, says Carolien Schalenbourg, lecturer in nursing at UCLL University of Applied Sciences. “In such a role play, students have to practice these conversations while about twelve other students are present. This causes stress to some people, because they are afraid of making mistakes with their fellow students.”
Anyone who tries out the VR tool, on the other hand, can only see how quickly you are drawn into the world of a virtual hospital room. There a conversation takes place between a nurse and Stan, an X-year-old man who has ended up in the hospital with appendicitis. As a user you are instructed to follow the conversation attentively and also to keep an eye on Stan’s body language, because every so often you as a viewer are instructed to determine what next question the nurse should ask.
Each possible answer from the multiple choice can take the conversation in a completely different direction. When I try to make the full risk analysis too quickly after hearing Stan’s negative thoughts, Stan shuts down completely. “Has my behavior changed lately? I do not know that. And no, of course I don’t sleep well. What kind of strange questions are these suddenly?” he responds in surprise. A major dent in the bond of trust that seemed to have just emerged.
On the other hand, if we ask Stan specifically whether he has already thought about suicide, he seems liberated to admit it, and he continues talking. According to Piet De Bruyn, co-director of the Center for the Prevention of Suicide, the organization behind Suicide Line 1813, this touches on an important point. “People intuitively want to avoid the question of how specifically someone has already thought about suicide, because they don’t want to give anyone ideas. But it is just as important to get an idea of the seriousness of the situation as quickly as possible. Is this a person who is anxious or hopeless, and who has had suicidal thoughts before. Or is this someone who has been struggling with suicidal thoughts for some time and has already made a plan? For many people it can even be liberating to be able to tell someone about it.”
When we ask Stan if dying is a done deal for him, he looks thoughtful. “When I’m at home and I feel alone, I think: yes, I’ll do it. But other times I can look at pictures of my son and think, no. I liked that little guy.”
Recognizing signals
This ambivalence is present in almost everyone who struggles with suicidal thoughts, De Bruyn indicates. “People rarely want to die, they want the loneliness or sadness to stop. At the same time, there are almost always reasons that can still make life worth living for them. That wish to die constantly flirts with the will to continue living.”
As a care provider, it is therefore important to respond to this ambivalence. “How can you alleviate that fear or loneliness in a different way? And how can you ensure that that person is more concerned with the things that give him or her energy? You have to look for that together.”
In addition, it is important to draw up a plan to promote the safety of the person in question, the so-called safety plan. The care provider will work with the patient to identify signs that a suicidal crisis may be approaching and what actions are possible. For example, it is advisable to preventively ensure that the home environment is made safe, for example by leaving medication at someone else’s home.
It is also important that someone from the area has insight into the situation. “Prior to a suicidal crisis, we see that people often isolate themselves,” says De Bruyn. “That does not necessarily mean that they no longer see anyone, but that they increasingly keep certain thoughts to themselves. ‘I don’t want to burden others with that’, is often said. Then the task is to work with those people to find who in the area or which care provider can be involved. Because that social contact alone can be enough to work towards recovery.”
Research shows that there is an average of two years between the first suicidal thoughts and a suicide attempt. This shows how important it is to recognize suicidal signals as early as possible. It is not without reason that the VR tool from UCLL University of Applied Sciences is intended for all students following the nursing course. “A lot of people come to a hospital,” says Eva Dumon of VLESP. “It is therefore important that healthcare providers, not only in psychiatric settings, but also in physiotherapy practices or emergency departments, pay attention to possible suicidal signals, so that they can refer for help in a timely manner if necessary.”
Thanks to the increasing accessibility of VR, care providers can practice these conversations during a work break, or even in their own home environment. “It is an ideal way to bring practice closer to the people,” says Rob Belleman, who conducts research into VR at the University of Amsterdam. “You can tell students or care providers how to respond to certain situations, but that information is often not sufficiently retained. By seeing how it translates into a real-life situation, it immediately becomes a lot more concrete.”
Although VR has undergone impressive development in recent years, you can hardly call it a new technology. Research into the application of VR in medicine and psychology has been conducted for more than fifteen years. “The first studies focused mainly on how VR could be used to gradually re-expose people after a trauma to the environment that was traumatic for them,” says Sylvie Bernaerts, who is researching the application of VR at Thomas More. in psychology. “For example, VR appeared to help soldiers who had experienced a serious explosion in Iraq to gradually get used to that environment.”
So VR turned out to be useful as exposuretherapy, and it was increasingly used as a treatment for other anxiety disorders. “Research has shown that VR can help people with agoraphobia get used to busy environments,” says Belleman. “We ourselves investigate how children with selective mutism (who develop a fear of talking in certain social situations, JL) can be helped by creating a school environment in VR that they can get used to.”
In the first years, research into VR mainly focused on how patients could be helped with it. Since the corona crisis, it has also been increasingly used to train professionals. Today, there are already numerous VR tools that allow emergency responders to practice complex operations. For example, there is a VR application from UCLL University of Applied Sciences and Oost-Limburg Hospital, where nurses can practice specific nursing actions in VR, such as removing mucus from a patient’s throat via a tracheotomy.
Empathy
But VR is also inescapable in mental health care. A pioneer is the American company Embodied Labs, which teaches students through VR environments what it is like to go through life as the patients they care for, such as people with Alzheimer’s, Parkinson’s or hearing or vision loss. This way they can experience in VR how a person with Alzheimer’s deteriorates over ten years. Or do they see in first person what it is like to come to a party as a hearing-impaired older man and have difficulty following the conversations. “The idea is that through these simulations, students better understand the challenges people experience in daily life, which gives them more empathy for them,” says Bernaerts.
That empathy is also necessary when dealing with suicidal people, says De Bruyn. “As a care provider you have to take off your own glasses as much as possible and learn how that person looks at life. That is much easier said than done.”
Whether VR offers added value in this regard remains to be seen from scientific research. The students at UCLL University of Applied Sciences are already enthusiastic: 83 percent of them indicate that the VR training is an absolute added value compared to traditional training methods. “The big advantage is that such a VR setting is a safe environment,” says Belleman. “You’re usually just practicing it. And if you make a ‘mistake’, it has no consequences in the real world. That simply means that people try things more often, which helps the learning process.”
In the future, VR could also play a role in training the broader population in suicide prevention. An important part of the Flemish Suicide Prevention Action Plan, with which Flanders aims to reduce the number of suicides by 10 percent by 2030, is that the broader population becomes more alert to possible signals. For example, teachers and pharmacists are already receiving further training on suicide prevention today. Last week, the Flemish government allocated 248,000 euros for a project on suicide prevention in the workplace.
“That is a good thing,” says De Bruyn. “Because once you go through such a training, you take that alertness with you for the rest of your life.” For people in the area, for example colleagues, a suicide often comes as a complete surprise. Only afterwards do the puzzle pieces fall together.
“It is often preceded by a series of spoken or semi-spoken signals,” says De Bruyn. “Someone suddenly comes to social activities much less often, or becomes a lot quieter. Someone gives away something that he or she has always been attached to, or says: ‘I’m tired, I would like to travel far and long.’ All these things can be a signal that something is wrong. And then it can be very valuable to say: ‘I see that you have been feeling less comfortable lately. Would you like to talk about that?’ If more people are able to discuss suicide, we can save a lot of people.”
Questions about suicide? Then you can contact the Suicide Line on 1813, via www.zelfbloed1813.be or via the chat service. The Suicide Line is also always looking for volunteers to strengthen the telephone line and chat service.
