Exploring the Mechanisms of a Patient-Centred Assessment with a Solution Focused Approach (DIALOG+) in the Community Treatment of Patients with Psychosis: A Process Evaluation within a Cluster-Randomised Controlled Trial

Abstract

BackgroundDIALOG+ is a new intervention to make routine community mental health meetings therapeutically effective. It involves a structured assessment of patient concerns and a solution-focused approach to address them. In a randomised controlled trial, DIALOG+ was associated with better subjective quality of life and other outcomes in patients with psychosis, but it was not clear how this was achieved. This study explored the possible mechanisms.MethodsThis was a mixed-methods process evaluation within a cluster-randomised controlled trial. Focus groups and interviews were conducted with patients and clinicians who experienced DIALOG+ and were analysed using thematic analysis. The content of DIALOG+ sessions was recorded and analysed according to (i) the type of actions agreed during sessions and (ii) the domains discussed. The subjective quality of life measure was analysed with mixed-effects models to explore whether the effect of DIALOG+ was limited to life domains that had been addressed in sessions or consistent across all domains.ResultsFour qualitative themes emerged regarding the mechanisms of DIALOG+: (1) a comprehensive structure; (2) self-reflection; (3) therapeutic self-expression; and (4) empowerment. Patients took responsibility for the majority of actions agreed during sessions (65%). The treatment effect on subjective quality of life was largest for living situation (accommodation and people that the patient lives with) and mental health. Two of these domains were among the three most commonly discussed in DIALOG+ sessions (accommodation, mental health, and physical health).ConclusionDIALOG+ initiates positive, domain-specific change in the areas that are addressed in sessions. It provides a comprehensive and solution-focused structure to routine meetings, encourages self-reflection and expression, and empowers patients. Future research should strengthen and monitor these factors.Trial RegistrationISRCTN Registry ISRCTN34757603.

Implementing a Digital Mental Health Intervention for Individuals With Psychosis - A Multi-country Qualitative Study

“…The ndings also support previous reports that the comprehensive structure enabled by DIALOG+ is one of its mechanisms of action [11]. Automated data collection offered by digital psychosocial interventions is useful to systematically measure the quality of psychosocial care, a shortcoming identi ed with current psychosocial therapies [26].…”

“…Despite the identi ed implementation facilitators, the ndings show the need to consider the patients' level of existent familiarity with life and treatment satisfaction questionnaires using Likert scales when introducing the intervention, as a few patients found the DIALOG scale unclear. Patients who used DIALOG+ in the UK also reported 'di culty to understand or cope with questions', although this was not explored in detail [11]. Similarly, a systematic review of implementation determinants for digital interventions for people with psychosis recognized the complexity of the intervention as an impediment for those with psychiatric symptoms, premorbid intelligence quotient and low technological competence [24].…”

“…Some participants raised concerns about potential resistance to innovation in mental health care by clinicians, particularly to the technological aspect of the intervention as use of digital interventions is not part of routine mental health care in the SEE countries that participated in this study. A study exploring the experiences of using DIALOG+ in the UK also identi ed 'initial apprehension to the technology' as a barrier [11]. The LEAP similarly stressed that clinicians need to be adequately trained, motivated and willing to use DIALOG+, while not having any resistance.…”

“…A pilot study in Germany also showed signi cant amelioration of schizophrenia and depressive symptoms as well as quality of life [10]. A process evaluation of the intervention identi ed the following likely 'active ingredients': 1) solution-focused structure; 2) patient empowerment; 3) mobilizing social resources; and 4) self-re exion and therapeutic expression [11]. DIALOG+ has been implemented as a care planning tool and patient-reported outcome measure in health institutions in England and Wales [12][13][14].…”

Exploring Needs and Quality of Life of Forensic Psychiatric Inpatients in the Reformed Italian System, Implications for Care and Safety

“…Treatment focused on needs and QoL favors the individual approach and monitoring their outcomes fosters tailoring interventions within particular domains. Additionally, discussing needs and QoL on a regular basis supports the dialogues between patient and clinician, betters the therapeutic alliance and even enhances the patient's experienced QoL (40,41). Systematic assessment of treatment needs and QoL may provide information for treatment planning in addition to other relevant outcomes such as the risk of criminal recidivism, reduction of psychiatric symptoms, psychological functioning, etc.…”