Forensic Network Coaching: a randomised controlled trial investigating the effectiveness of a network coach in improving mental well-being and decreasing psychiatric problems and criminal recidivism.

The group of forensic psychiatric outpatients in the Netherlands is growing due
to the current trend preferring ambulant treatment over clinical interventions
(GGZ Nederland, 2014). Ambulant forensic treatment is often complex and
challenging because of problems on multiple areas of life such as psychiatric
problems, criminal behaviour, debts, housing problems and addiction. However,
evidence about the effectiveness of forensic outpatient treatments and working
mechanisms is scarce. Therefore more research investigating the effectiveness
of ambulant treatments is important.
Having a healthy social network, or a network of people supporting a
person, is known as one of the important protective factors in decreasing the
risk of delinquent behaviour (Lodewijks, de Ruiter & Doreleijers, 2010). A
supportive social network is known to be of importance for the reintegration of
delinquents in society; for example in finding jobs and the prevention of
recidivism (Berg & Heubner, 2011). On the other hand a criminal social network
can increase the chances of future criminal behavior (Haynie, 2001, 2002). The
fact that a major part of forensic outpatients are confronted with poor social
support is therefore concerning (Neijmeijer, Rijkaart & Kroon, 2012;
Neijmeijer, Place, Rijkaart & Kroon, 2012). A descriptive population research
report of Inforsa forensic mental health care, shows that more than 50% of the
patients have a poor social network (intern document Inforsa, 2014). Besides, a
lot of patients are isolated from society, not participating in jobs or other
meaningful day activities (Neijmeijer et al., 2012). Because of the limited
participation and support in their social network, psychiatric treatment of
this complex group of outpatients becomes even more challenging.
Self-sufficiency of patients to increase participation in society and social
support is known to be low (Neijmeijer, Rijkaart & Kroon, 2012; Neijmeijer et
al., 2012; Place, Vugt, Kroon & Neijmeijer, 2011). In current times where
health care budgets are shrinking and a rising political tendency encourages
citizen to rely on care from their own network, mental health institutions
should work together with institutions in the community such as informal health
care, to increase social support and optimize mental health treatments.
Inforsa, forensic psychiatric care, is a department of the mental
health care institution Arkin located in Amsterdam, the Netherlands. At
Inforsa, patients with complex addiction, psychiatric and/or personality
disorders in combination with delinquent behaviour are treated in order to
reduce the risk of criminal recidivism. The type of crimes committed by
patients are diverse; most common offences are violence or theft. Most of the
patients, namely 87%, are obliged by a judge to participate in treatment. In
other words, treatment is a condition during their probation. The majority of
the patients (69%) suffer from a so called double diagnosis: psychiatric or
personality disorders in combination with addiction (e.g. alcohol, drugs or
gambling). Besides, at least 11% of the patients also suffer from intellectual
disabilities, a so called triple diagnosis. Most patients have social problems
such as housing, work and financial problems.
The concept of Forensic Network Coaching is established within a
collaboration between Inforsa, professional or formal mental health care, and
De Regenboog Groep (DRG), a informal health care foundation. The purpose of
Forensic Network Coaching is to improve patients* social network by adding a
network coach (a trained volunteer) to treatment as usual in a forensic
psychiatric population. Coaches use the methodology *Of course, a network
coach!* (Mezzo, 2015; Van de Lustgraaf, 2009). Results of a Dutch qualitive
study show that subjects were more confident, energetic and had improved social
skills after coaching (Goede & Kwekkeboom, 2013). Emperical evidence about the
effectiveness of the methodology *Of course, a network coach!* is limited.
However, the methodology is based on the TO GROW (Goal Reality Options Will)
coachingsmodel (Whitmore, 1992) and Solution Focused (Brief) Therapy (SFT) (de
Shazer et al., 2007; Jong & Berg, 2015). SFT is a proven method in decreasing
psychiatric problems (Gingerich, Kim & McDonald, 2012; Kim, 2008; Kim, Smock,
Trepper, McCollum & Franklin, 2010, Trepper & Franklin, 2012). Additionally,
Solution Focused coaching methodologies seem to be effective in increasing
well-being, social skills and coping skills and in decreasing psychiatric
complaints (Biggam & Power, 2002; Franklin, Trepper, Gingerich & McCollum,
2012; Fraser, Richman, Galinsky, & Day, 2009; Grant, 2003; Green, Oades &
Grant, 2006; Gingerich & Peterson, 2013).
Empirical evidence about the effectiveness of coaching projects with
volunteers is limited. Most of the previous research on this area has been
carried out in the United States of America with only a few studies using an
experimental design. A meta-analysis indicates positive effects on the quality
of life and small positive effects on psychological well-being, personal
development and social-communicative skills (Van der Tier & Potting, 2015).
Further research is required to investigate the effectiveness of such an
approach in improving social networks of a forensic psychiatric population.
As pointed out before, a supportive and healthy social network is known
to be one of the important protective factors in decreasing the risk of
delinquent behaviour (Lodewijks, de Ruiter & Doreleijers, 2010). In forensic
mental health care several effective interventions are available to increase
coping behavior and to decrease psychiatric problems and criminal recidivism.
For example forensic flexible assertive community treatment (forensic FACT),
cognitive behavioral therapy (CBT) and farmacotherapy are often used (for more
information, see p.17). Eventhough these interventions are effective, they are
not designed to address the beforementioned social network problems. Therefore
the question is if forensic treament outcomes can be further improved by adding
informal health care interventions such as a Forensic Network Coaching. The
current study will be conducted to test the effectiveness of this add-on
coaching intervention.
Within the project Forensic Network Coaching a randomised controlled
trial (RCT) design is used to investigate the effectiveness and time course of
a network coach in improving treatment outcome by looking at mental well-being,
psychiatric problems, criminal recidivism, addiction, quality of life, social
network, social support and loneliness among a forensic outpatient population.
Eligible patients will be randomly allocated to either one of the following
conditions: treatment as usual (TAU; N=75) or treatment as usual with a
forensic network coach (TAU+; N=75).
The current study contributes to the existing literature and research
in the following ways: the primary objective is to increase knowledge about the
effectiveness of forensic outpatient treatment, specifically by investigating
the impact and time course of the addition of a Forensic Network Coaching
intervention on treatment outcome. Secondly, results of this study can be used
to improve standard forensic outpatient treatments. The current study will lead
to specific recommendations for innovative and acknowledged interventions for a
forensic population. Thirdly, it describes the opportunities and challenges in
the collaboration between formal and informal health care.

In this study we will examine the effectiveness and time course of the addition
of a forensic network coach to treatment as usual in improving mental
well-being among a forensic psychiatric outpatient population. Patients will be
randomly allocated to treatment as usual (TAU) or treatment as usual with a
forensic network coach (TAU+).

A two-armed open-label, parallel group randomized controlled trial is
conducted, examining the effectiveness of a forensic network coach added to
treatment as usual, as compared to treatment as usual alone in a forensic
outpatient group. Patients in both the control (TAU) and experimental condition
(TAU+) receive treatment as usual, which is a frequently used and highly
approved intensive treatment for a complex forensic psychiatric population.
Patients in the experimental condition also receive coaching by a forensic
network coach every other week. Assessments will take place before
randomisation at baseline (T0) and every 3 months after T0 (T1, T2, T3) until
the final assessment after one year of treatment and coaching (Te). The
follow-up assessment (Tf) will be conducted 6 months after Te. Number of crime
occurences and recidivism rates, wil be determined at Te and two years after
Te.

Treatment as usual (TAU) consists of a variety of treatments and interventions
in forensic outpatient mental health care. The majority of patients receive
forensic flexible assertive community treatment (FACT; for more information see
the description of Trimbos-institute; Place et al., 2011). In short, forensic
FACT is a widely used treatment model developed for a large group of forensic
outpatients with (severe) psychiatric disorders. A FACT teams are
multidisciplinary teams, involving a range of health professionals such as a
psychiatrists, nurses (specialized in psychiatric problems), psychologists and
social workers. Care is delivered with and within the community of the
patients. Team members work together to deliver care but also have their own
caseload. If necessary, for example when a crisis occurs, more team members can
be involved or the intensity of treatment can be increased. Besides, the
remaining group of patients only receive outpatient treatment such as
CBT-interventions or pharmacotherapy.

In the experimental condition (TAU+) a forensic network coach will be added to
treatment as usual during a period of at least three to a maximum of twelve
months. The forensic network coach is a carefully selected and trained
volunteer who can be both a rolemodel and support for the patient. The
relationship between the coach and patient is called informal, which means that
the coach is not a mental health professional and not paid for the help he or
she provides. The social network coach will be conducting the intervention
called: *Of course, a network coach!* (Mezzo, 2015; Van de Lustgraaf, 2009).
This intervention consists of a structured plan involving ten modules or steps
in which the coach and patient will work together focusing on improving the
social network. The orientation phase (step 1 to 3) focuses on exploring
patients* wishes regarding the social network and setting goals. Subsequently,
in the thinking phase (step 4 and 5) both the coach and patient will explore
the possible ways to improve or rebuild the social network. The last phase is
about acting (step 7 to 10). Formulated plans will be executed. Every plan
involves three components: (1) explanation for the coach, (2) worksheet for the
patient, (3) a practical and theoretical form for the coach. The ten steps
don*t have to be carried out in a strict order. More important is that the
intervention is adjusted to the needs, pace and possibilities of the patient.
The ten steps can be used as a tool while working on the improvement of the
social network.

Does not apply