Participants were 145 undergraduate students from a Southern University. Participants were at least 18 years old and were compensated with course credit. Only participants that participated in both the self-report and virtual reality portions of the study were retained for analysis. Participants were excluded from the VR portion of this study if they endorsed a significant medical illness that would prevent the completion of perceptual illusion virtual reality exercises. Additional exclusionary criteria included: evidence of severe suicidal intent that would indicate a need for hospitalization or immediate treatment, evidence of alcohol or substance abuse or dependence, present or past psychotic-spectrum disorders, and uncontrolled bipolar disorder. No participants were excluded from the study because of these criteria.
Materials
Suicidal Ideation Scale (SIS; Rudd, 1989). The SIS is a 10-item measure of past-year presence of suicidal ideation and attempts. Items are scored on a Likert scale of 1 (never) to 5 (always), with a total score ranging from 10 to 50, with higher scores indicating higher suicidal ideation. A score of 10 on the SIS indicates no endorsement of suicidal thoughts or past behaviors, and Rudd (1989) recommended scores of 15 or higher to be considered serious suicidal ideation. Post SIS instructions were adapted to measure acute suicidal ideation. The psychometric properties, including internal consistency, reliability, and validity of the SIS are well established (Rudd, 1989; Luxton et al., 2011). Baseline (a = .93) and post-measured (a = .94) suicidal ideation had excellent internal consistency in this sample.
Subjective Units of Distress (SUDS, Wolpe & Lazarus, 1966). SUDs are self-ratings of distress. This rating scale was used to assess participant current feelings of distress, fear, or discomfort on a scale from 0 (no distress) to 100 (intense distress) after engaging in the VR tasks. Additionally, a second question asked for participants rating of sadness on a scale of 0 (no sadness) to 100 (intense sadness) after participating in the suicide-choice paradigm.
Simulation Sickness Questionnaire (SSQ, Kennedy et al., 1993). The SSQ is a self-report measure of 16 different motion sickness symptoms (e.g., nausea, disorientation, oculomotor disturbance) on a scale from 0 (no symptoms) to 3 (severe symptoms). Raw items were summed to get a total score. Total scores less than five are associated with negligible motion sickness symptoms, and scores above 15 are significant motion sickness symptoms.
Virtual Reality Equipment. The Oculus Rift (2016) is a VR display device with a headset, headphones with three-dimensional sound, controllers, and base stations that provide room-scale positional tracking. The specifications utilized were all above the recommended specifications for the Oculus Rift. All apps were run on Steam, a video game digital distribution service.
Procedure
Participants first completed informed consent and a battery of self-report baseline questionnaires. Participants then engaged in two dissociative induction tasks that created perceptual illusions with Head Mounted Display (HMD) connected to an external camera showing participant live feed can elicit dissociation symptoms through out-of-body experiences (citation removed for masked manuscript). Then, participants played a VR game called Richie's Plank Experience, where they engaged in a virtual suicide choice paradigm (i.e., choosing whether or not to jump off a plank). After completing these scenarios, participants completed a set of post-study questionnaires. These poststudy questions included examining acute levels of suicidal ideation, distress, sadness, and motion sickness after engaging in the virtual tasks. Additionally, participants were asked whether they jumped off the plank and then were prompted to give a qualitative explanation (i.e., what was the main reason you decided to jump off/not jump off the plank?). All questionnaires were completed through Qualtrics system on a lab computer. This study was approved by the (school name removed for mask manuscript) Office of Research Integrity. For space purposes, only VR tasks included in this analysis were described, but complete study procedures can be found in (citation removed for masked manuscript). There was no funding received for this project.
Richie's Plank Experience. Richie's Plank experience was first released for download by a VR developer in 2017. In this VR scenario, participants appeared on a virtual street in a city, entered an elevator, went up a few hundred feet, and watched as elevator doors opened to a plank extending out over a ledge (see Fig. 1). Participants were then presented with a choice to walk onto the plank and step off or ride the elevator back to the ground floor. Specifically, participants were given the following instructions, “For the next task, you may complete this task in one of two ways. You will have 10 seconds to select your option. Remember, do not start until I say so. Here are your options: First, you can commit suicide by stepping out of the elevator, walking the plank, and falling to your death, or, second, you can hit the elevator button labeled ‘ground’ and return to the street in the elevator. Again, choosing either option will complete this task for you. You must make your choice within the next 10 seconds. Do you understand? Ten seconds start now” (note: commit was used here because the general population more commonly understands it, as suggested by Franklin et al., 2019). If they chose to step off the plank, participants virtually fell to the ground below. When they reached the ground, the screen faded to white, and the scenario ended for the participant. Participants were told the context of the scenario but were unaware of suicide choice paradigm until the option was presented to them. An actual 2x12 plank was utilized to make the VR experience more immersive. A research assistant was always with the participant to ensure safety. Prior studies using this suicide choice paradigm showed that participants rated this jumping scenario as realistic and related to suicide (Franklin et al., 2019).
Safety Protocol. A safety protocol was implemented for participants if they scored high on suicidality (SIS score > 15). If this happened, the principal investigator was notified and conducted a suicidal ideation assessment before the participant left the lab. If the risk was determined to be moderate or above, a coping card would be administered, and a clinical supervisor would be contacted. Additionally, these participants would be referred to the student counseling center to set up an appointment or attend an immediate walk-in appointment. If a participant endorsed imminent suicide risk (i.e., a definite plan, inability to keep themselves safe), they would be referred to the student counseling center for an immediate walk-in appointment. In addition, the suicide hotline number was also provided for all participants regardless of risk.
Data Analytic Plan
Descriptive statistics were evaluated and screened for outliers and missing data. Then, a paired samples t-test was utilized to compare suicidal ideation before and after the virtual suicide attempt. Additional qualitative data were collected and summarized. Missing data for suicide-related variables (n = 4) was found to be missing at random and handled through listwise deletion. Post-hoc power analyses indicated that there was sufficient power (i.e., 0.80) to detect medium effects for continuous outcomes in this sample.