eHealth Technology in Forensic Mental Healthcare: Recommendations for Achieving Benefits and Overcoming Barriers

Figures & data

Table 1. An overview of the technologies and a summary of their definitions in the questionnaire provided to the participants.

Type of technology	Explanation
Virtual reality	A user is immersed in another world by using glasses and has the feeling of being somewhere else.
Mobile apps	Programs/applications that can be downloaded on a smartphone or tablet to deliver parts of treatment.
Neuro- and biofeedback	The use of sensors to measure physiological signals such as brain waves or muscle tension.
Videoconferencing	Direct communication between two or more persons, facilitated by a video connection.
Asynchronous communication	Technologies through which people communicate and a direct response is not required, e.g. e-mail.
Web-based modules	Programs that contain multiple multi-modal lessons, mostly based on existing approaches such as cognitive behavioral therapy.
Serious games	Games that allow patients to work on their treatment in an entertaining way.
Wearables	Devices that can be worn on one’s body, like a watch, which measure, for example, heart rate or steps by the wearer.
Augmented reality	Images are added to reality as an additional layer via glasses or apps.
Domotics	Technologies that automize processes in or around a living space to improve one’s quality of life.
Social media and fora	Users such as patients can come into contact with each other on anonymous or open platforms.
Robotics	Social robots make contact with users and can contribute, for example, to relaxation or the structure of daily activities.

Table 2. Types of technologies with the average score that the participants of the questionnaire (n = 89) gave regarding the extent to which they found the technology promising for forensic mental healthcare on a Likert scale of 1 to 5.

Type of technology	N	Average	Standard deviation
Virtual reality	83	4.41	.73
Mobile apps	84	4.35	.55
Neuro- and biofeedback	78	4.12	.91
Videoconferencing	87	4.05	.96
Asynchronous communication	81	3.98	.74
Web-based modules	84	3.94	.94
Serious games	82	3.93	.81
Wearables	82	3.91	.86
Augmented reality	76	3.70	.92
Domotics	78	3.49	1.11
Social media and fora	80	3.38	.97
Robotics	79	3.19	.93

Table 3. The main codes, sub-codes and the number of interviews and questionnaires they were found in.

Main codes and sub-codes		Interviews (n = 21)		Questionnaire (n = 89)
Development process
	Fit with patients and professionals	8	(38%)	10	(8%)
	Continuous development	7	(33%)	1	(1%)
	Collaboration with IT companies	6	(29%)	0
	Participatory development	2	(10%)	2	(2%)
Implementation in forensic organizations
	Integration in existing routines	15	(71%)	10	(8%)
	Dissemination activities	13	(62%)	12	(10%)
	Organizational prerequisites	11	(52%)	3	(3%)
	Costs	8	(38%)	10	(8%)
	Interdisciplinary collaboration	5	(24%)	3	(3%)
Evaluation
	What works for whom?	10	(48%)	7	(6%)
	Effectiveness	9	(43%)	0
	Reliability and validity	5	(24%)	3	(3%)
	Cost-effectiveness and efficiency	4	(19%)	7	(6%)
Guidelines and standards
	Overview of existing technologies	8	(38%)	0
	Ethical guidelines	6	(29%)	5	(4%)
	Treatment protocols	4	(19%)	2	(2%)
	Legislation	1	(5%)	0
Readiness of user and technology
	Skills of professionals	10	(48%)	12	(10%)
	User-friendly technology	6	(29%)	8	(7%)
	Well-functioning technology	3	(14%)	0
Improving technology
	Innovation	5	(24%)	1	(1%)
	Combining technologies	4	(19%)	1	(1%)
	Incorporating theory in technology	3	(14%)	0
	Adapting technology to new groups	1	(5%)	1	(1%)

Table 4. The sub-codes, definitions and an illustrative quote for the main code “development process.”

Sub-code	Definition	Illustrative quote
Fit with patient and professionals	During development, the goal should be to create eHealth technologies of which the content and design fit patients’ and professionals’ preferences and characteristics.	“Make sure the technology is tailored to the intended user. So investigate whether users have a need for it, but also perform adequate usability studies to investigate whether people are capable of using it and how the technology/app/program should be further adapted to make it as user-friendly as possible for clients.”
Continuous development	The content and design of the technology should continuously be improved and updated after its introduction in practice,	“The software has to be improved. It has to be tailored more. For example, the extent to which you, as a professional, are visible or not visible as an avatar.”
Collaboration with IT companies	Forensic organizations, knowledge institutes and IT developers should closely cooperate in the development of technology.	“I would like if all the technologies that exist in the country can work together. That will also require movement, because currently there are a lot of different technology suppliers.”
Participatory development	The importance of an iterative development process, in which developers constantly check whether ideas fit the perspectives of users and characteristics of the context.	“Clients also need to be involved in the development of an app or the development of all eHealth modules. Not only during the foundation, but also during the further steps, the elaboration.”

Table 5. The sub-codes, definitions and an illustrative quote for the main code ‘implementation in forensic organizations’.

Sub-code	Definition	Illustrative quote
Integration in existing routines	eHealth technology should be integrated in the content and structure of existing treatment and processes within an organization.	“Well, what is necessary … is to just make it a part of the standard treatment program. For example, they’re now working on a welcoming eHealth module. Someone starts their treatment here and receives this module right away. Then it is more like ‘well this is just a part of it’, just as all other elements that belong to treatment. To ensure that technology is taken for granted.”
Dissemination activities	There is a need for more activities to disseminate knowledge about the technology on a national or international level.	“I think that you’d need ambassadors in the workplace that kind of function as an initiator in embracing such a new technology. Who are early adopters and can also inspire their colleagues?”
Organizational prerequisites	Organizations should ensure that the basic conditions for using a technology are met and offer practical support for therapists and patients.	“We are offering iPads to all clinics. With headphones, because many of those eHealth modules work with videos. In that way you’ll make it possible for patients to work in their own room with these modules, which right now isn’t the case.”
Costs	The importance of accounting for the costs for developing or purchasing technology in the short- and long-term.	“We have an app which we created, which we also had to partly fund ourselves as an organization, because there are so many possibilities and you have to add a lot to such an app. Or to be able to save data to use the data for research. And many funders don’t provide that. So you always need more than you get.”
Inter-disciplinary collaboration	The collaboration between different types of stakeholders during implementation, such as researchers, care providers, IT developers, health insurers and government officials.	“We’ll have to move toward more intensive collaboration between organizations and researchers. And that, in a competitive market, is an issue here. Along with tensions between organizations. But there’s no escaping working together on this. The sector is too small, and fragmentation means throwing money away.”

Table 6. The sub-codes, definitions and an illustrative quote for the main code “evaluation.”

Sub-code	Definition	Illustrative quote
What works for whom?	There is a need for more insight into which types or part(s) of the eHealth technology work best for which types of patients, and during which phase of treatment.	“Personally, I think that the extent to which a technology is promising depends on the results per target group. For example, is there a difference between effectiveness for people that suffer from a personality disorder and people that suffer from a psychotic disorder?”
Effectiveness	There is a need for more research into whether eHealth technology is effective for treatment of forensic psychiatric patients.	“There’s a field of tension between working in a validated way - so it should be evidence-based, and by the time it takes to do that - and the development of technology, which is going so fast that, like, when scientific research is finished, the technology is already outdated.”
Reliability and validity	There is a need for more research into whether a technology is a reliable and valid method to measure a phenomenon.	“But also, for example, about heart rate variability (HRV) and age groups, the threshold level so to speak. It’s dependent on age, on gender. That you’ll eventually have a table that is based on research, that you can use as a foundation. We really looked into existing studies, but there are hardly any. It is really necessary that more research is done on that topic.”
Cost-effectiveness and efficiency	There is a need for more research into whether the use of eHealth technology results in saving time and costs.	“Perhaps we should say that eventually we make sure– and that the research also shows – that patients can practice more, that their confidence rises, which causes recidivism rates to drop. And because of that, their treatment time decreases.”

Table 7. The sub-codes, definitions and an illustrative quote for the main code “guidelines and standards.”

Sub-code	Definition	Illustrative quote
Overview of existing technologies	The need for a clear overview of technologies that are being used or can be used in forensic mental healthcare.	“Especially familiarity. Because I think a lot of people don’t know what is available. I only know a few technologies, but I think there’s a lot more than I actually realize. Give it more publicity, and a good explanation of what you can do with it.”
Ethical guidelines	More attention needs to be paid to identifying and dealing with ethical dilemmas that accompany the use of eHealth technology in forensic mental healthcare.	“To have a good, ethical discussion is indispensable and a necessary development … Relevant because I think there are innovations in technology that will also impact treatment and the measurement of the treatment’s effect… We’ll run into a lot of difficult questions that need to be answered in the years to come.”
Treatment protocols	The importance of developing or improving protocols that prescribe how an eHealth technology can be optimally integrated within treatment.	“What I see too often is that a part of the problem is identified, and an eHealth intervention is selected, like ‘Hey, we should do this!’ But then things are handled as if they were isolated from each other, and not in a broader context. I think it should be very clear why you are using eHealth, and how that fits into the entire range of a patient’s problems and the phase of treatment.”
Legislation	The need for adapting or creating new laws or regulations and ensuring that therapists are aware of existing legislation.	“I am running into a lot of barriers because of the safety demands, that the technology isn’t really ready to meet these demands. Also, to work in forensic care, especially with the current developments of open technologies and sharing more.”

Table 8. The sub-codes, definitions and an illustrative quote for the main code “readiness of user and technology.”

Sub-code	Definition	Illustrative quote
Skills of professionals	The importance of improving the technical and therapeutic skills of professionals to work successfully with the technology.	“It’s more about digital thinking. That’s what we’re trying to achieve with our employees here, bit by bit. You’ll have to become a digital native, you know. You’ll have to be able to easily work with technology. To advise your patient, ‘Hey, use this app, or that app’. It’s more about a broader understanding of the digital world that is up and coming.”
User-friendly technology	The importance of a technology that is easy to use and appealing to both professionals and patients.	“It should be intuitive to use. No elaborate manuals. Yeah, we did develop a written manual for the app we created, but a short video with easy instructions would work better for patients, because they don’t read that much.”
Well-functioning technology	Technology should work flawlessly, without bugs or other technical flaws.	“Technologies have to be beta-tested very thoroughly to ensure that everything goes as smoothly as possible at the moment of introduction. Technologies should not unnecessarily test the frustration threshold of the patients.”

Table 9. The sub-codes, definitions and an illustrative quote for the main code “improving technology.”

Sub-code	Definition	Illustrative quote
Improving technology	The importance of constantly innovating, experimenting and pioneering with technologies in forensic mental healthcare.	“But to do that, it takes guts… We’re still seeing eHealth as creating a PDF of a workbook. We’re keeping it very traditional and very conservative, so to speak. But there are so many opportunities in technologies that are coming out and in development.”
Combining technologies	The possibility of combining different technologies and optimally benefiting from their multiple possibilities.	“Perhaps I’m missing a more combined vision regarding the use of technology? For me, the most promising would be a personalized menu with technological solutions, dependent on age, interest and skills.”
Incorporating theory in technology	The importance of basing eHealth technologies on theories from forensic mental healthcare, behavioral change, or design theory.	“I think that the theoretical foundation of apps can be improved. Like - what, which problem, and why is that problem relevant? We want to know which app we want to use to address this issue, and how and why do we think that this app could influence it?”
Adapting technology to new groups	The possibility to adapt the content or protocols of existing technologies to make them suitable for other target groups.	“Perhaps [there is a need to consider] the intellectual capabilities of the patients. I notice that we’ve created a lot here, but we’re now working on adapting it for the increasing group of people who have a mild intellectual disability.”

Table B1. The main and sub-codes for the identified barriers of technology for forensic mental healthcare, their definitions and the number of interviews and questionnaires they were found in.

Main and sub-codes	Definition	Inter-views (n = 21)	Questionnaire (n = 89)
Negative attitude	A negative opinion, low satisfaction or acceptance of an eHealth intervention before, during or after its introduction.
Patient	A negative attitude toward an eHealth intervention of the receiver of forensic mental healthcare.	14 (67%)	10 (8%)
Professional	A negative attitude toward an eHealth intervention of the professional that’s treating or supervising the patient.	12 (57%)	7 (6%)
Other stakeholders	A negative attitude toward an eHealth intervention of persons who are in one way or the other involved in the technology, e.g. family and friends of a patient or managers of a forensic organization.	4 (19%)	1 (1%)
Not suitable for everyone	Not every technology can at all times be used by each type of patient or professional.
Patient’s disorder	Patients with a psychiatric or physical disorder are not able to use a specific technology.	8 (38%)	6 (5%)
Technological skills	Not all patients or professionals possess the necessary skills to work with technology.	12 (57%)	6 (5%)
General skills	Not all patients possess a satisfactory level of cognitive skills to work on an eHealth intervention, such as reflective or reading abilities.	13 (62%)	27 (23%)
Privacy	The arising of potential problems related to privacy violation, confidentiality and information leaks of patient-related information.
Safety of data	Data cannot be saved in a secure manner, which makes it accessible for third parties.	15 (71%)	7 (6%)
Eavesdropping or watching of third parties	Other people who are present can watch or listen with a patient or professional who’s using a technology.	13 (62%)	2 (2%)
Contact between patient and professional	Negative consequences of a lack of or reduction in in-person contact between patient and professionals.
Therapeutic relationship	The use of technology can negatively influence the quality of contact between a patient and professional.	11 (52%)	15 (13%)
Clinical observation	Because of the use of technology, certain subtle behaviors or signals can be overlooked by a professional, e.g. fidgeting or smell.	4 (19%)	2 (2%)
Unintended negative consequences	Unexpected, undesired consequences for the patient and/or their environment that are caused by technology.
Misuse of technology	Patients can misuse a technology, for example to generate sexual arousal or by contacting victims.	13 (62%)	6 (5%)
Unnecessary negative emotions	Because of the use of technology, patients can experience extremely negative emotions that are not of added value for treatment.	12 (57%)	5 (4%)
Ineffectiveness	The lack of empirical proof for a specific eHealth intervention or a type of technology.
Not enough proof in general	A lack of studies into the effectiveness of a type of eHealth intervention.	4 (19%)	3 (3%)
Not enough proof in one study	One single study does not show that an eHealth intervention is effective.	7 (33%)	27 (23%)
Inefficiency	Practical disadvantages or a lack of practical advantages of the development, use or implementation of an eHealth intervention for forensic mental healthcare.
High costs	The development, purchase or maintenance of a technology costs more money than it generates in the short or long term.	15 (71%)	7 (6%)
Implementation problems	Issues or difficulties with the introduction and long-term use of an eHealth intervention in forensic mental healthcare.	12 (57%)	14 (12%)
Time investment	The time invested by professionals, patients or management in introducing or using a technology.	6 (29%)	0
Technical problems	Practical problems related to the functioning of a technology.
Faulty soft- or hardware	A technology malfunctions because of for example bugs, nonfunctioning hardware, or obsolescence.	9 (43%)	2 (2%)
Connectivity problems	A technology malfunctions because of a bad internet connection.	6 (29%)	1 (1%)
Lack of standardization	A lack of clear, shared protocols, guidelines, standards and legislation for the use of technology in forensic mental healthcare.
Legislation	There is no or too little legislation regarding the use of a specific technology in forensic mental healthcare.	1 (5%)	1 (1%)
Protocols	There are too little or no protocols, guidelines or standards that support the use of an eHealth intervention in treatment.	2 ( 10%)	0
Content	There is too little content to be able to use a technology in forensic mental healthcare.	6 (29%)	0

Table A1. The main and sub-codes for the identified advantages of technology for forensic mental healthcare, their definitions and the number of interviews and questionnaires they were found in.

Main and sub-code	Definition	Inter-views (n = 21)	Questionnaire (n = 89)
Positive attitude	A positive opinion, high satisfaction or acceptation of an eHealth intervention before, during or after its introduction.
Patient	A positive attitude toward an eHealth intervention of the receiver of forensic mental healthcare.	9 (43%)	8 (7%)
Professional	A positive attitude toward an eHealth intervention of the professional that’s treating or supervising the patient.	1 (5%)	3 (3%)
Other stakeholders	A positive attitude toward an eHealth intervention of persons who are in one way or the other involved in the technology, e.g. family and friends of a patient or managers of a forensic organization.	1 (5%)	1 (1%)
Change in attitude	A positive change in attitude of a stakeholder toward an eHealth intervention during a certain period of time.	5 (24%)	3 (3%)
Access to care	The practical possibilities that a technology offers to facilitate the delivery of care.
Overcoming geographical distance	The possibility to offer care from a distance via communication technology.	16 (76%)	11 (9%)
Care in a closed setting	The possibility to deliver treatment via technology to patient in a secure, closed setting.	6 (29%)	18 (15%)
Reducing thresholds for patients	The threshold to work on treatment via eHealth interventions can be lower for patients, for example by comfort or anonymity.	14 (67%)	41 (35%)
Accessibility	Allowing patients to work on an eHealth intervention at their moment and place of choice.	13 (62%)	18 (15%)
Privacy	Being able to save patient data in a secure way.	2 (10%)	0
Fit with patient	The possibilities to ensure a fit between an eHealth intervention and the needs, characteristics and context of a patient.
Technological climate	The fit of eHealth interventions with current culture and technological trends.	8 (38%)	18 (15%)
Realism	By means of technology, realistic situations and environments that fit the patient’s world can be created.	6 (29%)	15 (13%)
Fun	Patients can experience the use of an eHealth intervention as fun, which can increase treatment motivation.	15 (71%)	23 (19%)
Personalization	The content and design of an eHealth intervention can be adapted to fit characteristics of individual patients.	7 (33%)	7 (6%)
Ownership	Because the patient is working individually on treatment via the eHealth intervention, a feeling of responsibility for treatment can increase.	15 (71%)	43 (36%)
Effectiveness	The extent to which an eHealth intervention reaches the predetermined goals, related to improvement of care.
Potential effectiveness	A certain type of eHealth intervention is expected to be effective.	8 (38%)	56 (47%)
Proven effectiveness	Research has shown that a certain type of eHealth intervention is effective.	1 (5%)	33 (28%)
Effectiveness in other settings	A certain type of eHealth intervention has not been studied in forensic mental healthcare, but has been proven to be effective in other types of care.	4 (19%)	4 (3%)
Efficiency	The practical advantages of a technology for forensic mental healthcare.
Cost-effectiveness	Saving costs for organizations or individuals because of the use of technology.	4 (19%)	2 (2%)
Traveling time	The reduction of traveling time for patients or professionals because of the use of technology.	4 (19%)	4 (3%)
Decrease of treatment time	The decrease of time that is spent on treatment sessions because eHealth interventions replaces or accelerates parts of treatment.	13 (62%)	24 (20%)
Easy to implement	A specific eHealth intervention is easy to integrate in an existing type of care.	2 (10%)	8 (7%)
Improved security	The physical safety of professionals and/or patients increases because of the use of technology.	7 (33%)	17 (14%)
Unique information	Collecting or providing unique or new information via technology that cannot or is hard to retrieve via standard in-person contact.
Collecting new data on a patient	By means of a technology new information on a patient can be retrieved, either physiological, behavioral or cognitive.	15 (71%)	25 (21%)
Ecological validity	Because of the possibility to create virtual scenarios it is possible to practice and observe behavior in a realistic environment.	12 (57%)	5 (4%)
Observing reactions	Technology can support the collection of a patient’s responses to situations in context.	13 (62%)	14 (12%)
Fidelity	Delivering the theory-based content exactly the way it was intended to a patient via an eHealth intervention.
Behavior change theory	Adding evidence-based behavior change theories to eHealth interventions.	1 (5%)	3 (3%)
Treatment protocols	Integrating or accounting for the standard procedures, structures and content of treatment in an eHealth intervention.	8 (38%)	1 (1%)
Repeating	Allowing the patient to repeat parts of an eHealth intervention as often as necessary.	2 (10%)	0