%0 Journal Article %@ 2561-326X %I JMIR Publications %V 9 %N %P e65206 %T The Effect of the Virtual Reality–Based Biofeedback Intervention DEEP on Stress, Emotional Tension, and Anger in Forensic Psychiatric Inpatients: Mixed Methods Single-Case Experimental Design %A Klein Haneveld,Lisa %A Dekkers,Tessa %A Bouman,Yvonne H A %A Scholten,Hanneke %A Weerdmeester,Joanneke %A Kelders,Saskia M %A Kip,Hanneke %+ Centre for eHealth and Wellbeing Research, Department of Psychology, Health and Technology, University of Twente, Drienerlolaan 5, Enschede, 7522 NB, The Netherlands, 31 619210156, l.kleinhaneveld@transfore.nl %K virtual reality %K VR %K diaphragmatic breathing %K biofeedback %K DEEP %K forensic psychiatry %K mental health %K stress %K single-case experimental design %K experience sampling method %D 2025 %7 12.2.2025 %9 Original Paper %J JMIR Form Res %G English %X Background: Decreasing aggression through stress reduction is an important part of forensic psychiatric treatment. DEEP is an experience-based virtual reality intervention that uses biofeedback to train diaphragmatic breathing and increase relaxation. Although DEEP has shown promising results in reducing stress and anxiety in students and adolescents in special education, it has not been examined in forensic psychiatric populations. Objective: This study aimed to evaluate DEEP’s potential to reduce stress, emotional tension, and anger in forensic psychiatric inpatients. Methods: A mixed methods, alternating treatment, single-case experimental design was conducted with 6 Dutch forensic inpatients. For 20 days, participants engaged in 4 DEEP sessions. Experience sampling was used for continuous monitoring of stress, emotional tension, and anger twice daily. A repeated linear mixed model was used as a primary statistical approach for analyzing the experience sampling data as well as visual analyses. Finally, semistructured interviews were conducted with participants and health care professionals to compare quantitative with qualitative results. Results: Of the 6 participants, 3 (50%) completed all 4 DEEP sessions, while the other 3 (50%) missed one session due to technical difficulties or absence from the inpatient clinic. P1 showed a significant reduction of stress after session 2 (β=–.865; P=.005). No significant changes over time were found, although an experienced effect was reported during the interviews. P2 showed no significant results. They reported the sessions as being repetitive, with no experienced effect. P3 showed a momentary increase of emotional tension after the first session (β=–.053; P=.002), but no changes were observed over time. No experienced effects were reported in the interview. P4 did not show significant results over time, and was hesitant to report clear experienced effects. P5 showed a significant decline of emotional tension (β=–.012; P=.006), stress (β=–.014; P=.007), and anger (β=–.007; P=.02) over time. They also reported short-term experienced effects in the interview. P6 showed a significant decline of stress over time (β=–.029; P<.001) and reported experiencing substantial effects. Finally, health care professionals reported a relaxing effect of DEEP in their patients but did not expect many long-term effects because no clear behavioral changes were observed. Conclusions: DEEP shows promise in teaching deep breathing techniques to forensic psychiatric inpatients, potentially decreasing stress, emotional tension, and anger in some patients. However, DEEP is not a one-size-fits-all intervention that supports every patient because the effectiveness on the outcome measures varied among participants. To increase effectiveness, emphasis should be put on supporting patients to transfer deep breathing skills into their daily lives. This highlights the importance for the structural integration of DEEP into current treatment protocols. %M 39938081 %R 10.2196/65206 %U https://formative.jmir.org/2025/1/e65206 %U https://doi.org/10.2196/65206 %U http://www.ncbi.nlm.nih.gov/pubmed/39938081 %0 Journal Article %@ 2369-2960 %I JMIR Publications %V 10 %N %P e43563 %T Functional Impairment in Individuals Exposed to Violence Based on Electronical Forensic Medical Record Mining and Their Profile Identification: Controlled Observational Study %A Lerner,Ivan %A Chariot,Patrick %A Lefèvre,Thomas %+ Department of Legal and Social Medicine, Hôpital Jean-Verdier, Assistance publique - Hôpitaux de Paris, avenue du 14 juillet, Bondy, 93140, France, 33 148026508, lefevre.thomas@gmail.com %K reproducibility %K interpersonal violence %K functional impairment %K psychological trauma %K clustering %K intimate partner violence %D 2024 %7 27.9.2024 %9 Original Paper %J JMIR Public Health Surveill %G English %X Background: Little is known about the functional consequences of violence when directly assessed as a primary outcome, and even less about how consistently these consequences are evaluated in a judicial context. The World Health Organization (WHO) highlighted the importance of a functional approach to health in 2001 with the release of the International Classification of Functioning, Disability, and Health (ICF). In most European countries, forensic physicians assess individuals exposed to violence to evaluate the outcomes of violence, providing certified medical evidence for magistrates’ sentencing decisions. This evaluation involves a mix of objective, subjective, and contextual elements, such as reported symptoms of fear, pain, and details of the assault. Quantifying these subjective elements with scales could enhance their interpretation and application in a judicial context. Objective: This study aims to (1) characterize and (2) assess 6 scales measuring subjective elements of functional impairment among individuals exposed to violence. Methods: We conducted a retrospective study that included individuals exposed to violence examined in a French department of forensic medicine over 12 months. A typology of violence encountered in medical settings was built based on the mining of electronic health records and the use of pattern recognition algorithms. The optimal number of violence types was determined using a robust and stable clustering approach, involving sample resampling and a multimetric scheme. Patients were then paired according to their homogeneous profiles, and the intra- and interrater reproducibility of the scales was evaluated. Results: All pain, fear, and life threat scales were significantly associated with higher functional impairment, suggesting that these measures contribute to the overall assessment of functional impairment. The intra- and interrater reproducibility of scales among similar situations of violence was measured, ranging from mild to good, with coefficients of concordance between 0.46-0.66 and 0.43-0.66, respectively. Individuals reporting intimate partner violence showed higher scores in both fear and perception of a life threat during the assault and medical interview, while individuals reporting battery by multiple unknown assailants presented higher scores only in perception of a life threat during the assault. We identified 5 remarkably stable profiles of situations of violence, consistent with clinical practice. Conclusions: Pain, fear, and life threat scales were related to functional impairment according to expert knowledge and demonstrated fair reproducibility under real-life conditions for similar situations of violence. Subjective elements related to functional impairment in individuals exposed to violence can be quantified using Likert scales during medical interviews. %M 39331422 %R 10.2196/43563 %U https://publichealth.jmir.org/2024/1/e43563 %U https://doi.org/10.2196/43563 %U http://www.ncbi.nlm.nih.gov/pubmed/39331422 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 7 %N %P e40237 %T Forensic Psychiatric Outpatients’ and Therapists’ Perspectives on a Wearable Biocueing App (Sense-IT) as an Addition to Aggression Regulation Therapy: Qualitative Focus Group and Interview Study %A ter Harmsel,Janna F %A Smulders,Lisanne M %A Noordzij,Matthijs L %A Swinkels,Lise T A %A Goudriaan,Anna E %A Popma,Arne %A van der Pol,Thimo M %+ Inforsa Forensic Mental Healthcare, Vlaardingenlaan 5, Amsterdam, 1059 GL, Netherlands, 31 205904578, annemieke.ter.harmsel@inforsa.nl %K biocueing %K biofeedback %K aggression %K behavior change %K forensic psychiatry %K wearable technology %K mobile health %K mHealth %K implementation %K mobile phone %D 2023 %7 1.2.2023 %9 Original Paper %J JMIR Form Res %G English %X Background: Given the increased use of smart devices and the advantages of individual behavioral monitoring and assessment over time, wearable sensor–based mobile health apps are expected to become an important part of future (forensic) mental health care. For successful implementation in clinical practice, consideration of barriers and facilitators is of utmost importance. Objective: The aim of this study was to provide insight into the perspectives of both psychiatric outpatients and therapists in a forensic setting on the use and implementation of the Sense-IT biocueing app in aggression regulation therapy. Methods: A combination of qualitative methods was used. First, we assessed the perspectives of forensic outpatients on the use of the Sense-IT biocueing app using semistructured interviews. Next, 2 focus groups with forensic therapists were conducted to gain a more in-depth understanding of their perspectives on facilitators of and barriers to implementation. Results: Forensic outpatients (n=21) and therapists (n=15) showed a primarily positive attitude toward the addition of the biocueing intervention to therapy, with increased interoceptive and emotional awareness as the most frequently mentioned advantage in both groups. In the semistructured interviews, patients mainly reported barriers related to technical or innovation problems (ie, connection and notification issues, perceived inaccuracy of the feedback, and limitations in the ability to personalize settings). In the focus groups with therapists, 92 facilitator and barrier codes were identified and categorized into technical or innovation level (n=13, 14%), individual therapist level (n=28, 30%), individual patient level (n=33, 36%), and environmental and organizational level (n=18, 20%). The predominant barriers were limitations in usability of the app, patients’ motivation, and both therapists’ and patients’ knowledge and skills. Integration into treatment, expertise within the therapists’ team, and provision of time and materials were identified as facilitators. Conclusions: The chances of successful implementation and continued use of sensor-based mobile health interventions such as the Sense-IT biocueing app can be increased by considering the barriers and facilitators from patients’ and therapists’ perspectives. Technical or innovation-related barriers such as usability issues should be addressed first. At the therapist level, increasing integration into daily routines and enhancing affinity with the intervention are highly recommended for successful implementation. Future research is expected to be focused on further development and personalization of biocueing interventions considering what works for whom at what time in line with the trend toward personalizing treatment interventions in mental health care. %M 36724008 %R 10.2196/40237 %U https://formative.jmir.org/2023/1/e40237 %U https://doi.org/10.2196/40237 %U http://www.ncbi.nlm.nih.gov/pubmed/36724008 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 5 %N 5 %P e18096 %T Usability and Acceptance of Wearable Biosensors in Forensic Psychiatry: Cross-sectional Questionnaire Study %A de Looff,Pieter Christiaan %A Nijman,Henk %A Didden,Robert %A Noordzij,Matthijs L %+ Behavioural Science Institute, Radboud University, Postbus 9104, Nijmegen, Netherlands, 31 030 2256405, peterdelooff@gmail.com %K forensic psychiatry %K wearable biosensors %K intellectual disabilities %K usability %K acceptance %K continuous use %K emotion regulation %K behavior regulation %D 2021 %7 10.5.2021 %9 Original Paper %J JMIR Form Res %G English %X Background: The use of wearable biosensor devices for monitoring and coaching in forensic psychiatric settings yields high expectations for improved self-regulation of emotions and behavior in clients and staff members. More so, if clients have mild intellectual disabilities (IQ 50-85), they might benefit from these biosensors as they are easy to use in everyday life, which ensures that clients can practice with the devices in multiple stress and arousal-inducing situations. However, research on (continuous) use and acceptance of biosensors in forensic psychiatry for clients with mild intellectual disabilities and their caretakers is scarce. Although wearable biosensors show promise for health care, recent research showed that the acceptance and continuous use of wearable devices in consumers is not as was anticipated, probably due to low expectations. Objective: The main goal of this study was to investigate the associations between and determinants of the expectation of usability, the actual experienced usability, and the intention for continuous use of biosensors. Methods: A total of 77 participants (31 forensic clients with mild intellectual disabilities and 46 forensic staff members) participated in a 1-week trial. Preceding the study, we selected 4 devices thought to benefit the participants in domains of self-regulation, physical health, or sleep. Qualitative and quantitative questionnaires were used that explored the determinants of usability, acceptance, and continuous use of biosensors. Questionnaires consisted of the System Usability Scale, the Technology Acceptance Model questionnaire, and the extended expectation confirmation model questionnaire. Results: Only the experienced usability of the devices was associated with intended continuous use. Forensic clients scored higher on acceptance and intention for continuous use than staff members. Moderate associations were found between usability with acceptance and continuous use. Staff members showed stronger associations between usability and acceptance (r=.80, P<.001) and usability and continuous use (r=.79, P<.001) than clients, who showed more moderate correlations between usability and acceptance (r=.46, P=.01) and usability and continuous use (r=.52, P=.003). The qualitative questionnaires in general indicated that the devices were easy to use and gave clear information. Conclusions: Contrary to expectations, it was the actual perceived usability of wearing a biosensor that was associated with continuous use and to a much lesser extent the expectancy of usability. Clients scored higher on acceptance and intention for continuous use, but associations between usability and both acceptance and continuous use were markedly stronger in staff members. This study provides clear directions on how to further investigate these associations. For example, whether this is a true effect or due to a social desirability bias in the client group must be investigated. Clients with mild intellectual disabilities might benefit from the ease of use of these devices and their continuing monitoring and coaching apps. For these clients, it is especially important to develop easy-to-use biosensors with a minimum requirement on cognitive capacity to increase usability, acceptance, and continuous use. %M 33970115 %R 10.2196/18096 %U https://formative.jmir.org/2021/5/e18096 %U https://doi.org/10.2196/18096 %U http://www.ncbi.nlm.nih.gov/pubmed/33970115 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 7 %N 11 %P e24245 %T Shaping Blended Care: Adapting an Instrument to Support Therapists in Using eMental Health %A Kip,Hanneke %A Wentzel,Jobke %A Kelders,Saskia M %+ Centre for eHealth and Wellbeing Research, Department of Psychology, Health & Technology, University of Twente, Drienerlolaan 5, Enschede, 7500 AE, Netherlands, 31 53 489 9180, h.kip@utwente.nl %K eHealth %K blended care %K implementation science %K participatory development %K forensic psychiatry %K mobile phone %D 2020 %7 13.11.2020 %9 Original Paper %J JMIR Ment Health %G English %X Background: Although eMental health interventions, especially when delivered in a blended way, have great potential to improve the quality and efficiency of mental health care, their use in practice lags behind expectations. The Fit for Blended Care (FfBC) instrument was developed to support therapists and clients in shaping blended care in a way that optimally fits their needs. However, this existing version cannot be directly applied to specific branches of mental health care as it is too broad and generic. Objective: The goal of this study is to adapt the existing FfBC instrument to fit a specific, complex setting—forensic mental health care—by means of participatory development with therapists. Methods: The participatory process was divided into 4 phases and was executed by a project team consisting of 1 manager, 3-5 therapists, and 1 researcher. In phase 1, general requirements for the adaptation of the existing instrument were discussed in 2 focus groups with the project team. In phase 2, patient-related factors that influence the use of an existing web-based intervention were elicited through semistructured interviews with all 18 therapists working at an outpatient clinic. In phase 3, multiple focus groups with the project teams were held to create the first version of the adapted FfBC instrument. In phase 4, a digital prototype of the instrument was used with 8 patients, and the experiences of the 4 therapists were discussed in a focus group. Results: In phase 1, it became clear that the therapists’ main requirement was to develop a much shorter instrument with a few items, in which the content was specifically tailored to the characteristics of forensic psychiatric outpatients. The interviews showed a broad range of patient-related factors, of which 5 were used in the instrument: motivation for blended treatment; writing about thoughts, feelings, and behavior; conscientiousness; psychosocial problems; and social support. In addition, a part of the instrument was focused on the practical necessary preconditions that patients should fill by themselves before the treatment was developed. The use of the web-based prototype of the instrument in treatment resulted in overall positive experiences with the content; however, therapists indicated that the items should be formulated in a more patient-centered way to encourage their involvement in discussing the factors. Conclusions: The participatory, iterative process of this study resulted in an adapted version of the FfBC instrument that fits the specific forensic context and supports shared decision making. In general, the adaptiveness of the instrument is important: its content and implementation should fit the type of care, the organization, and eHealth intervention. To adapt the instrument to other contexts, the guidelines described in this paper can be followed. %M 33185559 %R 10.2196/24245 %U http://mental.jmir.org/2020/11/e24245/ %U https://doi.org/10.2196/24245 %U http://www.ncbi.nlm.nih.gov/pubmed/33185559 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 21 %N 9 %P e15620 %T Predicting Inpatient Aggression in Forensic Services Using Remote Monitoring Technology: Qualitative Study of Staff Perspectives %A Greer,Ben %A Newbery,Katie %A Cella,Matteo %A Wykes,Til %+ Department of Psychology, Institute of Psychiatry, Psychology and Neuroscience, King's College London, Henry Wellcome Building, 16 De Crespigny Park, London, SE5 8AF, United Kingdom, 44 02078480423, ben.greer@kcl.ac.uk %K telemedicine %K remote sensing technology %K wearable sensors %K aggression %K risk assessment %D 2019 %7 19.09.2019 %9 Original Paper %J J Med Internet Res %G English %X Background: Monitoring risk of imminent aggression in inpatient forensic mental health services could be supported by passive remote monitoring technology, but staff attitudes toward the relevance and likelihood of engagement with this technology are unknown. Objective: This study aimed to explore staff views, specifically potential benefits and implementation barriers, on using this technology for monitoring risk of inpatient aggression. Methods: We conducted semistructured focus groups with nurses in an inpatient forensic mental health service. We used thematic analysis with two independent raters to identify themes and subthemes related to staff attitudes toward passive remote monitoring. We subsequently checked with members to ensure the validity of the themes identified by the raters. Results: From January to March 2019, a total of 25 nurses took part in five focus groups. We identified five main themes, one of which concerned the potential benefits that passive remote monitoring could provide for monitoring risk of aggression. Staff suggested it could provide an early warning of impending aggression and enable support to be provided earlier. The remaining themes concerned implementation barriers, including risks to the users’ physical and mental well-being; data security concerns and potential access by third parties; the negative impact of a constant stream of real-time data on staff workload; and design characteristics and user awareness of the benefits of passive remote monitoring. Conclusions: Passive remote monitoring technology could support existing methods of monitoring inpatient aggression risk, but multiple barriers to implementation exist. Empirical research is required to investigate whether these potential benefits can be realized, and to identify ways of addressing these barriers to ensure acceptability and user engagement. %M 31538943 %R 10.2196/15620 %U https://www.jmir.org/2019/9/e15620 %U https://doi.org/10.2196/15620 %U http://www.ncbi.nlm.nih.gov/pubmed/31538943