Virtual cycling as an exercise intervention in forensic psychiatry: A qualitative study

Forensic psychiatric patients (FPS) face reduced life expectancy due to somatic comorbidities and unhealthy lifestyles. Exercise improves mental and physical health but is hindered by low patient motivation and constraints posed by forensic psychiatric settings. Virtual cycling (VC) programs could enhance motivation and address FPS' needs but remain understudied. This study aimed to explore how patients and staff experience and interact through a VC intervention in a closed forensic psychiatric setting and how these interactions may inform the development of more meaningful and motivating exercise interventions.

The study was conducted in a gym located in a medium secure forensic psychiatric ward at a university hospital in Denmark. Participants in VC included five male forensic inpatients (aged 20-50) and four physiotherapists (three men and one woman, aged 20-50). The data comprised eight sessions of participant observation during VC, informal conversations with patients and staff, and one focus group interview with eight staff members. A constructivist grounded theory method was used.

We found that VC stimulated four interaction types that were used by staff to address patient motivations. These included outcome-focused (goal- and performance-oriented), distributive (teaching and leadership-driven), relationship-focused (emotionally supportive), and accommodating (non-demanding, gently motivating) interactions. We conceptualized them in an overall theory. Each interaction type involved distinct motivations, foci, goals, and communication forms, often unfolding in micro-moments.

Our theoretical categories demonstrate how VC interactions between staff and patients accommodate several often challenging conditions essential to personal recovery. Virtual-cycling-based interventions in forensic psychiatry may enhance motivation by addressing patients' unique needs. Staff must understand virtual biking dynamics to adapt their interactions to promote therapeutic recovery potential and support the further development of such interventions. We recommend integrating staff training in interaction strategies specific to virtual exercise contexts. Future research should explore the long-term impact of VC on patient recovery trajectories.