The added value of an internet-based intervention for treatment of aggression in forensic psychiatric outpatients: A mixed-methods pilot randomized controlled trial.

Objectives: While internet-based interventions have been used for more than 10 years in Dutch forensic psychiatric outpatient care, it is not clear if, why and for whom they work. The objective of this study was to investigate whether the addition of an internet-based intervention to forensic psychiatric outpatient treatment as usual (TAU) resulted in better treatment outcomes in regulatory emotional self-efficacy, treatment readiness and aggression. Methods: A multicentre mixed-methods pilot randomized controlled trial was used to compare TAU to TAU with the addition of the internet-based intervention 'Dealing with Aggression'. Thirty forensic psychiatric outpatients, treated in four Dutch organizations for aggression regulation problems, were included. Three validated questionnaires were administered at baseline, mid-treatment, post-treatment and follow-up. Semi-structured interviews with patients and therapists from the experimental condition were conducted to gain in-depth insight into the quantitative results. Results: No differences between groups on the outcome measures were found. Often-mentioned reasons for ineffectiveness were suboptimal integration in treatment and the requirement of cognitive and reflective skills. However, several patients reported having experienced benefits from the intervention, mostly because treatment was repeated, combined with new insights in their behaviour. Conclusions: Although the trial was underpowered due to issues with recruitment, no proof for effectiveness of the internet-based intervention was found. Moreover, mostly highly motivated and relative cognitive skilled patients participated, indicating that internet-based interventions might fit only a select number of patients. New insights into why and for whom internet-based interventions might work were identified, providing points of improvement for intervention design and implementation in practice.