JMIR Publications

ABSTRACT

Background:

The ability to regulate anger is often impaired in forensic psychiatric patients, frequently resulting in aggressive behavior. Although some treatment programs are partially successful in enhancing aggression regulation and reducing recidivism among specific subgroups, generalizable conclusions on the effectiveness of these interventions cannot be drawn to date. In forensic outpatient care, low treatment adherence and the predominant focus on cognitive control in most treatment programs may entail some of the factors impeding treatment. Technology-based interventions may address some of these treatment challenges.

Objective:

The aim of this study was to explore whether a new technology-based biocueing intervention, the Sense-IT application, could be a valuable addition to aggression regulation treatment programs in forensic outpatient care. The Sense-IT application, providing the user with real-time physiological feedback and behavioral support, was developed to strengthen emotional awareness and facilitate real life practice. In this study, a new version of the Sense-IT, suitable for forensic outpatients with aggressive behavior, was developed and evaluated.

Methods:

First, a design study was conducted to assess the attitude of forensic professionals and patients towards biocueing, and to collect requirements for a biocueing application in this specific population. Based on this information, a new version of the Sense-IT application was developed. In an evaluation study, 10 forensic outpatients used the application during two weeks. Acceptability, usability and clinical outcomes (aggression, anger and recognition of bodily signals related to anger) were measured pre- and post-intervention, using both quantitative and qualitative measures.

Results:

The design study revealed a cautiously positive attitude towards the use of biocueing as an addition to aggression regulation therapy. The evaluation study among forensic outpatients demonstrated moderate acceptability and adequate usability of the new version of the Sense-IT. Exploratory analysis revealed a significant decrease in trait aggression post-intervention; no significant changes were found on other anger related clinical outcomes. To further increase acceptability and usability, a stable functioning application with self-adjustable settings, the use of smartwatches with a longer battery life and the use of patient’s own smartphone devices were recommended.

Conclusions:

This study, which is one of the first attempts to enroll and evaluate the real-life use of a biocueing intervention among forensic outpatients, emphasized the importance of involving both patients and therapists throughout the development and implementation process. In the future, experimental studies, including single case experimental designs using ecological momentary assessment, should be performed to evaluate the effectiveness of the Sense-IT intervention on clinical outcomes. An open attitude towards new technology, allowing exploration of the potential benefits of the Sense-IT case-by-case, and training of therapists in using the application, are expected to facilitate integration in therapy. Clinical Trial: The evaluation study was registered in the Netherlands Trial Register (NL8206).