68 Chapter 3 INTRODUCTION Forensic psychiatric patients often suffer from severe mental disorders, addictions, and intellectual disabilities, combined with delinquent behavior (Gunn, 2000; Hodgins, 1992; Ogloff, Lemphers, & Dwyer, 2004; Soderstrom, Sjodin, Carlstedt, & Forsman, 2004). In addition, they are confronted with multiple social problems, including housing problems, unemployment, financial problems, and social network-related problems (Clifton et al., 2007; Estroff et al., 1994; Lamb & Weinberger, 1998; ter Haar-Pomp et al., 2015). Given the complexity of these problems, forensic psychiatric patients are in urgent need of effective treatment. The main goal of forensic psychiatric treatment is to reduce the risk of criminal recidivism. Therefore, forensic psychiatric treatment should be multimodal and personalized; focused on improvement of the social context of the individual patient and multiple mental health problems, related to their delinquent behavior (Skipworth & Humberstone, 2002; Swanson et al., 1998). Forensic psychiatric treatments that comply with the risk-need-responsivity (RNR) principles are found to be most effective (Andrews et al., 1990b). The RNR-model is used worldwide for the indication and execution of forensic treatments (Andrews et al., 1990a; Bonta & Andrews, 2007). This model emphasizes that treatment is effective if: (1) the level of treatment intensity is matched to the risk level of criminal recidivism – risk principle, (2) the criminogenic needs related to criminal recidivism are addressed – need principle, and (3) the type of intervention is matched to the abilities and skills of the delinquent – responsivity principle (Andrews, Bonta, & Wormith, 2011). Forensic assertive community treatment (forensic ACT) and forensic flexible (or function) assertive community treatment (forensic FACT), a Dutch adaptation of forensic ACT (van Veldhuizen, 2007), are examples of broadly applied multimodal treatment models for forensic psychiatric outpatients (Cusack, Morrissey, Cuddeback, Prins, & Williams, 2010; Stermac, 1986; van Veldhuizen, 2007). In order to prevent criminal recidivism, forensic (F)ACT incorporates the RNR-principles by focusing on multiple individual and systemic risk factors (e.g. financial or cultural barriers, a lack of services) as well as patient’s nonadherence (Bähler et al., 2019; Lamberti & Weisman, 2010; Place, van Vugt, & Neijmeijer, 2011). However, there is much variation between individual forensic (F)ACT treatment trajectories and core elements are not well defined (Lamberti, Weisman, & Faden, 2004). Furthermore, many previous effect studies showed methodological limitations; results from randomized controlled trials (RCTs) are scarce (Marquant, Sabbe, vanNuffel, &Goethals, 2016). Overall, theeffectiveness of outpatient forensic interventions is limited. A meta-analysis showed positive effects – statistically significant declines of criminal recidivism in the experimental conditions – in
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