The analysis resulted in two themes: 'The supportive features of DIALOG+' and 'Providing a constructive structure'. The first theme illuminates the participants' experiences in relation to specific features of DIALOG+, while the second theme explores participants’ perceptions of the digital tool and differences between DIALOG + and traditional routine encounters.
[Table 1] Themes and sub-themes
Table 1
Theme 1: The supportive features of DIALOG+ | Theme 2: Providing a constructive structure |
Expanded understanding of my health | Distinguishing DIALOG + as a constructive complement |
Moving toward improvement | Experiences of the digital tool |
Provided memory support | |
Empowering participation | |
Theme 1: The supportive features of DIALOG+
Participants described how different aspects of the DIALOG + session helped them, and these features collectively support a process towards improved health. The features of DIALOG + guided participants in an exploratory process that helped them gain an ‘understanding’ of their health, which was an important first step towards improvement. The enhanced understanding prompted a movement towards improvement through the deliberate selection of areas for further discussion. Identifying concrete problems or goals, and planning corresponding actions were key features that allowed participants to achieve control and work towards improvement. Memory support was provided in various ways, which was considered valuable and enhanced the result of the other features. The encouragement of participation and individual choice had an empowering effect, further strengthening the participants’ engagement.
Expanded understanding of my health
Two aspects assisted participants in achieving a more comprehensive understanding of their health: the rating feature and the holistic approach provided by the various areas rated. Several participants mentioned that actively rating different health areas helped them get an overview of their overall well-being, highlighting areas of both strength and concern.
The rating process served as the basis for reflection and discussion of what influenced the participants’ ratings in different areas. This process transformed the more abstract notion of 'how I feel' into a concrete reflection on the factors that actually impact well-being, allowing participants to understand the numerous aspects that contribute to their emotional state.
It becomes a visualisation ... making my well-being status more concrete. (p8)
I felt that with DIALOG+, it was more mapped out, the feelings you have and how you behave in different situations. You could see that in the rating, on that particular day, I must have felt a bit worse or a bit better. It's interesting to know what affects such things, that you sometimes feel worse. Being able to look at the different variables was good. (p6)
Comparing current ratings with previous ratings also contributed to an overall picture of well-being and changes over time. The ability to track changes in ratings over time added a layer of insight into the participants’ understanding of their own health. This also allowed them to draw conclusions and to understand underlying causes.
It helps to have the overall picture, like how it was then compared to how it is now. (p10)
... the function seems good, because then you can clearly see if you have improved in any area. (p2)
Moreover, it serves the purpose of acknowledging the potential for change; participants could explicitly see improvements or periods of lower satisfaction, fostering a sense of hope. Several participants also linked this feature to an area of discussion, suggesting that an expanded understanding of one's health is an important initial step in identifying relevant areas for further discussion and prioritisation of actions.
It was interesting that the way you feel could change so much, from feeling very bad at one time to feeling much better the next time. You could identify why you felt like that. Sometimes it could be that something had happened, and sometimes it was just my mood on that particular day. (p6)
DIALOG+'s coverage of ratings across 11 different domains provided several participants with a more holistic perspective on their health. They were able to gain insight into areas of health that they may have otherwise overlooked or that they had not thought about bringing up for discussion. One participant also reported that she felt more respected, as the use of DIALOG + made the clinician aware of additional areas that affected her, providing a fuller picture of her life situation and challenges.
I think DIALOG + gives a more holistic perspective. You get the whole picture of mental health. And it's everything from social factors, and specifically the psychiatric, if you have any psychotic symptoms or similar. (p10)
Moving toward improvement
Participants described how DIALOG + helped them move forward by giving them the opportunity to choose relevant areas for further discussion, identify problems, and plan for action. The opportunity to choose specific areas for further discussion and support in DIALOG + was highly valued by most participants. It was viewed as a straightforward and concrete way to identify relevant areas where support was needed. The range of areas identified suggested what could be addressed and allowed for the exploration of difficult topics that might not otherwise be explored. This allowed participants to explore specific topics in more depth, addressing issues more directly compared to previous unstructured conversations.
It is a very straightforward model. When you have a conversation [before using DIALOG+], it takes a while before you start talking about certain things. You may need to meet a few times. This model highlights different areas, that's what I mean by saying it's more straightforward. You choose areas and then we dig deeper into what you need to talk about. (p3)
The ratings helped to address areas in need of improvement, and some participants expressed that this was important when deciding on what area to address during the encounter. Accessing the results of the ratings was also helpful, since areas in need of improvement also became clearer for the clinician. The option to work on areas with lower satisfaction ratings encouraged some participants and clinicians to confront and address challenging issues that might have otherwise been overlooked.
It was very concrete that you had to choose which areas you wanted more support and help, that you can bring up a topic and go into it a bit deeper, gather your thoughts around it. It was helpful to be able to do that. This makes it stricter and more concrete and tackles the problem. Otherwise, it's easy to not talk about what's difficult and avoid it. (p2)
Several participants went on to describe how DIALOG + helped them pinpoint problems and decide on actions to solve them or to create goals and plan actions to reach set goals. This process provided a sense of growth, especially when participants achieved their goals. Most of the participants’ statements regarding defining problems or goals and ways to address these were related to the built-in solution-focused method. Participants’ referred to the approach helping them maintain focus, working together to find solutions, agreeing on actions, and being motivated to enact the plan while deciding on follow-up measures. Some statements suggested that the DIALOG + feature helped participants solve problems that were difficult to solve before. The problem-solving feature also encouraged some participants to consider involving others (e.g. family members) in their support network and helped them seek out care and support. Statements suggest that DIALOG + increased the participants’ engagement and involvement in their own care.
From the second session, we agreed on various actions, which I call some kind of goals. I've actually reached several of them since then. The next time, we sort of started from scratch, but we also looked back at how things looked before. And then we set new goals. And I think it helps me a lot, like... to find some kind of... well, way forward and some balance in life. (p10)
I feel that this [DIALOG+] is more concrete because here you find the weaknesses in a completely different way, simpler, I think. That's how it feels to me. It feels like I can get things I'm unhappy with fixed in a more concrete way. (p7)
Not all participants reported the same degree of success in agreeing on actions or working on the agreed upon actions. One participant pointed to time constraints during the session, namely, that filling in the required information was time-consuming, limiting or completely eliminating the time allocated to discussing the problem and creating agreed actions. Others reported that it was difficult to take action due to ill health or other unknown reasons. However, such failures could be the starting point for a new round of problem-solving and action-planning.
Sometimes I did what we had agreed on, and sometimes not. The interesting thing is why it turned out that way. (p6)
Provided memory support
Several participants touched on different ways in which DIALOG + assisted their memory. Through its range of features, DIALOG + seems to support patients in retaining, organising, and recalling important information. It incorporates multiple modalities, such as written transcripts, visualisation of results, structured discussions, and consistent follow-up. The memory support was helpful both in more concrete activities, such as choosing topics from a list, and in abstract tasks, such as gaining an understanding of one's well-being over time. Regular use of DIALOG + was also mentioned as helpful in remembering previous responses and discussions, which is particularly beneficial for patients with short-term memory issues.
I think it can be quite good to get a printout. I get one to remember what we have talked about. And it becomes a way for me to look at and go back to and think about what I should do to achieve my goals. (p10)
I think that it's good actually, just that you have... we've been doing it regularly now and so on, it means that you might remember why you answered a certain thing and so on. And then you remember, so it doesn't just disappear, so to speak....from your memory. (p8)
Empowering participation
Several participants described how they could make their own choices with the support of DIALOG+. Statements indicated that the participants’ ability to choose topics for further discussion and being encouraged to find their own solutions in the problem-solving structure contributed to feelings of empowerment. Participants valued the ability to make their own choices and generate their own solutions. Several participants touched on the importance of being the one who actually makes the decisions, which offered a sense of self-confidence and independence. Their statements also showed that the clinician sometimes needed to participate more actively in problem-solving and support participants to find the right solution. Furthermore, active participation in decision-making and topic selection can enhance an individual’s sense of autonomy, fostering mutual respect in the therapeutic relationship.
I thought it was very good that the patient independently gets to choose in what areas they want more help or support. I think it's good that people can choose themselves and feel more independent, because when you have a psychotic disorder, you can feel very independent. (p2)
I definitely felt that I was involved when I tested DIALOG+. I was involved in developing these different parts that were needed to come up with ideas on how to solve my problems. (p6)
Theme 2: Providing a constructive structure
Participants distinguished DIALOG + from traditional routine encounters by highlighting its structured yet flexible approach and its effectiveness in promoting proactive health management. While participants appreciated the usefulness of DIALOG+'s structure, they also expressed preferences for the conversational flexibility in encounters where DIALOG was not used. Therefore, many participants suggested that a combination of encounters with and without DIALOG + could be used to optimise their healthcare experience. Additionally, the participants’ feedback on the use of the digital tool suggested that it was user-friendly and supportive, although some encountered challenges with the design of the interface and navigating the tool. Overall, this theme suggested that DIALOG + has the potential to empower patients in managing their own health by providing a constructive structure for discussion and decision-making.
Distinguishing DIALOG + as a constructive complement
Through descriptions of the supportive structure of DIALOG + and reflections on how DIALOG + should best be used, this subtheme captures how participants distinguish DIALOG + as a constructive complement to routine encounters with their clinician. Participants provided varied depictions of routine encounters with no standardised structure. These depictions contributed to the theme by highlighting qualitative differences in routine encounters, where the quality of the encounter is dependent on the skill of the clinician and the therapeutic relationship. Some described more traditional, medically oriented meetings where the clinician would lead the conversation and focus primarily on medication and symptoms.
It was different. It was very much about how are your medications going? And how are your symptoms [traditional routine encounters]? And they just focused on that. (p10)
When you're mentally ill, the clinician takes over in a way, and I might have had other things that I wanted to talk about. They see the illness, that you don’t see yourself. You talk about things that the clinician wants to talk about. (p4)
Other participants reflected that during routine encounters (not using DIALOG+), the clinician encouraged them to participate, inviting them to decide on what topics to discuss or taking a more whole-life perspective when asking questions regarding health. When these conversations were described as beneficial, the relationship with the clinician was an important factor, and participants described a good, well-established relationship. Although participants highlighted the importance of a good dialogue, they also highlighted the risk that some topics would be overlooked.
Previously, I used to get asked whether there was anything special I wanted to address and how different things were working out, for example, my medication. Sometimes you miss things that you don't talk about. (p2)
It was more like ‘How are you?’ We talked superficially about whatever came to mind, and then we might forget about different areas. (p4)
DIALOG + was described as a structured yet flexible approach, in contrast to traditional free-form conversations in routine encounters. The model's structure was seen to enable a more focused and efficient dialogue while maintaining the freedom to explore topics in depth. Furthermore, it was seen as a way to ensure that critical areas of concern were addressed in a systematic way. Participants indicated that DIALOG + facilitated dialogue, as it was structured in a way that provided valid questions for discussion and steered the conversation towards the most important topics, especially in the early stages of the therapeutic relationship. Additionally, DIALOG + appears to assist patients in discussing areas they may not otherwise address, thus providing an opportunity for patients to open up more quickly.
There is a clear difference when we’ve used DIALOG+. It's mostly the structure of the conversation. Well, we speak very freely about the topic even when we use DIALOG+, but it's still this thing that you have a follow-up, you get to think about the different ratings and things like that. It sort of creates a structure in the conversation and helps maintain focus. (p8)
DIALOG + was appreciated for its interactive and collaborative nature, providing a platform for patients to develop and share their own ideas while receiving constructive feedback. This aspect was seen as crucial as it helped participants evaluate the viability of their ideas and contributed to a more dynamic and supportive interaction.
You help each other, and it's very good that there is this room to come up with your own ideas, and at the same time, you can get very good feedback on whether it's constructive or not. (p2)
The use of DIALOG + early in the therapeutic process was seen as particularly effective, allowing for prompt identification and discussion of key issues, potentially leading to reduced therapy duration.
I felt I got a lot out of it. It covered important areas and so on, but I would have appreciated if we could have used it a lot earlier. I might have been able to leave certain things behind much sooner. Certain things that might be more difficult to talk about would have been pinpointed in a much earlier stage. (p3)
Although almost all participants described the usefulness of the structure provided by DIALOG+, several participants stated that traditional routine encounters were also needed. Others suggested that a different structure could be used, where helpful features of DIALOG+ (e.g. choosing topics) are used but where the dialogue could then depart from the DIALOG + format, making the conversation more “free” within the DIALOG + session. Some patients also reported time constraints, regarding agreeing on actions at the end of the session. Others pointed out that the ability to observe changes in health over time or monitor the achievement of established goals requires a timespan of several weeks between DIALOG + sessions, and emphasised the significance of employing DIALOG + over an extended period.
Experiences of the digital tool
Participants provided feedback on their experiences of the digital tool. Their statements described their perceptions of and interactions with the user interface in the digital tool, including its design, ease of use, and overall usability. The statements suggest that the participants found the digital tool to be user-friendly and easy to understand. They appreciated the visual presentation of results and felt that it provided valuable support, even for individuals who struggle with the use of technology. Some participants viewed DIALOG + as an effective and accessible self-analysis tool that offered a more comfortable experience than traditional paper-based methods. Some downsides were reported. One participant encountered difficulties navigating the digital interface during the self-rating task, particularly when changing questions or topics and choosing areas for further support, while another participant needed support from the clinician due to limited computer skills. One participant suggested that the design could be more user-friendly and intuitive, with larger icons.
I think it was a great idea (with the DIALOG + program on a computer) actually, because it's not like staring over a piece of paper and not finding the answer. (p1)
I think this seems to be easy to work with. Now I get support from my therapist all the time, because I am so unsure about computers and technology. It seems to be good; I get a good impression of it. Pretty easy to understand for someone who has difficulty understanding computers, so it was easy to understand at the time. (p9)
Statements regarding the use of DIALOG + through video meetings were generally positive. Screen-sharing enhanced clarity, enabling participants to follow and engage with the content.
I think it worked very well, using DIALOG + during video meetings. It was perhaps even easier to do it that way than usual. It makes things more concrete. I'm not a very tech-savvy person, so what you see on a screen feels kind of not real, even though I know that the person I'm talking to through the screen feels a bit strange and distant. DIALOG + makes it more concrete when you meet through a screen. (p2)