Background
Methods
Design, setting and participants
Service users | Mental health professionals |
---|---|
18–70 years old | Qualification as a mental health professional |
Clinical diagnosis of depression with a duration of illness of at least 2 years | Experience of working in health care for at least 6 months |
Using NHS mental health services for the treatment of depression | Currently (or within the last 6 months) treating individuals with chronic depression |
Capacity to provide informed consent | No plans to leave their post within the next 3 months |
Ability to speak and understand English | – |
DIALOG+ intervention
Data analysis
Data protection
Results
Participants | Number of participants approached | Number of participants interviewed | Interview Location | Mean average duration of the interviews (range) |
---|---|---|---|---|
Service Users | 28 service users who received DIALOG+ intervention for 3 months | 19 interviewed 6 declined 2 not contactable 1 unwell | Service users’ homes, community services or premises of research departments | 25 min (12–50.5) |
Mental Health Professionals | 16 mental health professionals who delivered DIALOG+ intervention for 3 months | 15 interviewed 1 left service | Mental health professionals’ work premises | 31 min (14–58) |
Characteristics of participants | N = 19 |
---|---|
Sex | |
Female | 13 |
Male | 6 |
Age (mean; range) | 45(25–68) |
Marital Status | |
Single/unmarried | 10 |
Married / Co-habiting | 6 |
Separated/Divorced | 3 |
Education | |
Primary education or less | 1 |
Secondary education | 6 |
Tertiary/further education | 3 |
Higher education | 9 |
Employment status | |
Employed full/part time | 5 |
Voluntary employment | 3 |
Unemployed | 7 |
Retired | 4 |
Living situationa | |
Living alone | 8 |
Living with partner/family | 9 |
Living in shared accommodation | 1 |
Migration statusb | |
Born in UK | 16 |
Born outside UK | 2 |
Ethnicity | |
White British & Irish & Other | 14 |
Black British African & Caribbean & Other | 4 |
Asian British Indian & Bangladeshi & Pakistani & Other | 1 |
Length of treatment for depression (mean; range) | 6.5 (0–37) |
Type of clinicians currently seen for treatment of depression | |
GP | 9 |
Primary care nurse | 3 |
Care-coordinator | 10 |
Psychiatric Nurse | 8 |
Psychiatrist | 15 |
Psychologist /Psychotherapist | 5 |
Characteristics of participants | N = 15 |
---|---|
Sex | |
Female | 10 |
Male | 5 |
Age rangea | |
< 35 | 3 |
35–49 | 5 |
50–65 | 6 |
Ethnicityb | |
White British & Irish & Other | 12 |
Black British African & Caribbean & Other | 1 |
Other (Latin American) | 1 |
Length of experience of working in mental healthc (mean; range) | 17.4 (4.5–36) |
Professional backgroundd | |
Community psychiatric nurse | 9 |
Psychiatrist | 1 |
Senior Support worker | 1 |
Occupational therapist | 1 |
Social worker | 1 |
Psychologist | 1 |
Current professional roles | |
Care-coordinator | 3 |
Clinical psychologist | 1 |
Consultant psychiatrist | 1 |
Primary care mental health nurse | 1 |
Primary care liaison mental health practitioner | 1 |
Community psychiatric nurse & recovery worker | 6 |
Senior mental health triage nurse | 1 |
Senior support worker | 1 |
Themes
DIALOG+ structure | |
Clarity & focus | |
Getting a whole picture | |
Constraints of the format | |
Therapeutic communication | |
Topics Reminder | |
Opening new conversations | |
Disrupting the flow | |
Losing personal touch | |
Reflecting and monitoring | |
Reflecting on strengths & difficulties | |
Mapping change | |
Quantifying feelings | |
Empowerment and powerlessness | |
Taking ownership of recovery | |
Setting & achieving goals | |
Becoming discouraged | |
Feeling scrutinised | |
The impact of technology | |
Transparency & accessibility | |
Therapeutic aid & hindrance | |
Technical competence & issues |
DIALOG+ structure | |
Clarity & focus | |
T1P08_service user “… our sessions weren’t really aimed at anything, it was just me talking about how my last week’s gone and that’s it, whereas this one was more targeted at what problems I have and what issues I have and how we combat those issues and what we’ll do to move forward from those issues. So I think that was quite good …” | T1C07_clinician “And it helps them to keep focused on the one topic in hand as well. Sometimes if you’re just having a conversation with a person they can tend to drift to another topic. At least with this it kept them focused on, OK, my physical health, let’s just talk about that. So it was good on that score.” |
Getting a whole picture | |
T1P15_service users “… it’s better really because then your therapist can get a whole picture of your life as opposed to only certain aspects of it, which can all contribute on your mental health wellbeing, because they might be causing a certain amount of the issues …” | T3C01_clinician “And that would be helpful to cover, to look at somebody’s life in a holistic way like that I think is great and it kind of reminds you that actually there’s other domains to this person’s life that if there were an improvement actually it would have a knock on effect on their mental health.” |
Constraints of the format | |
T3P01_service user “… with (care co-ordinator) we only have half an hour session, so it can be a little bit, rather than spending time, I felt a little bit rushed … to answer some of these. Rather than when you sit down, and you physically go through them and care co-ordinator will say how’s this, how’s that.” | T3C02_clinician “But because I have had an established relationship and we already had set ways of working it kind of got in the way of things that we’d already found to work ... So some of the questions weren’t relevant or they were too broad for us …” |
Therapeutic communication | |
Topics Reminder | |
T2P10_service user “… once or twice I suppose when we were going down, I thought, oh actually we haven’t talked about that, and it sort of jogged memory a few times. … So that’s again where I think the headings are valuable because they do, they are quite a useful jab in the ribs almost …” | T1C12_clinician “I think the app is brilliant, it’s very good, it helps clinicians because sometimes we get complacent on what sort of questions we ask patients and so it helps to explore more on issues ….” |
Opening new conversations | |
T1P08_service user ” I think it wouldn’t have come up because I wouldn’t have thought about it. But having these specific questions make you think more so then you’ve got more to add to the conversation …” | T2C05_clinician “This particular patient seemed to see its logic straightaway and just go with it and find it pretty helpful and it did lead us into quite useful discussions I hadn’t had with him before so that was all good …” |
Disrupting the flow | |
T3P03_service user ” I think it didn’t really cover the way that I feel and my problems really … I just felt like it was ticking the boxes really rather than an in depth conversation.” | T3C02_clinician “It disrupts the flow of a conversation because you’re having to stick to topics one at a time whereas actually quite often they all mush into one. Medication affects motivation and sleep affects everything else. So it’s just kind of, it’s, yeah, it doesn’t really take into account that which I found frustrating.” |
Losing personal touch | |
T3P01_service user “I think it is a bit impersonal, a little bit. Because sometimes when you’re in a mental health meeting, you go in and speak to your mental health worker, it can make it a little bit, well you’ve got to stick to this. “ | T2C03_clinician “… a lot of work that we do is personable and takes a lot of just general chatting whereas this is like …. some patients … need the focus and other … don’t need that focus, you need to have more of a personal edge to things. … … it’s less personal and I think people with depression (…) they want to feel that you’re listening to them as opposed to collecting scores.” |
Reflecting and monitoring | |
Reflecting on strengths & difficulties | |
T1P15_service user “… it makes a refreshing change to talk about something that’s good … as opposed to everything doom and gloom and no hope and light at the end of the tunnel. So it’s nice to talk about the good things as well as the bad things.” | T2C01_clinician “… following the four step thing actually … made the patients think about what they had scored a little more carefully than they might otherwise have done necessarily. Just that little extra …. helped them to think a little bit more about this … even if didn’t necessarily achieve what they said they did it stimulated them to think about … what could be going on here, what could be doing to try and make a difference even if I can’t do it.” |
Mapping change | |
T3P02_service user “It feels often quite a bit of backsliding, but you looked and thought, oh, actually, that wasn’t as bad as I remembered it to be, or oh actually, that was quite a good week. And, oh damn, this week is not very good, but last week was fine (…) I think it would be great for mapping progress.” | T3C01_clinician “… you can literally show a patient, look how things have changed for you. Or even if things haven’t changed so much, it might be that they had a, maybe a good week or a good month, whatever it might be where you can talk about, well, look how well you did here. I know it feels like everything’s bad now but you had that really good time there and what were the things that were contributing to that? So again I think that could be really helpful.” |
Quantifying feelings | |
T3P04_service user “Sometimes it’s hard because if you’re trying to think over the week, obviously, some days are different to others so it can be quite hard to actually pick a number of what it is overall.” | T2C02_clinician “… for them it was hard to sometimes say, well, I’ll give it a four then rather than a three, without really thinking through, well, what does a four mean compared to a three sort of thing. So I think they were just, it was just throw numbers at me a little bit really. So I don’t think the rating thing was marvellously helpful for the patient or myself. “ |
Empowerment and powerlessness | |
Taking ownership of recovery | |
T1P07_service user “ … previously, as I said, I would just be sitting down and waiting for him to bring the idea and so that I will bring conversation. But with this it helps to remind me and also help me to speak my mind on what I want to tell him” | T1C09_clinician “And also they get more involved I think … they have to think about how, what they can do to make an improvement, whereas otherwise …. a lot of people … tend to put it on … the professional, they just feel that … there’s nothing they can do and here it’s very much focusing on, they’re taking a bit more responsibility as well, and expectation so they can do something or the family.” |
Setting & achieving goals | |
T2P02_service user “I think the helpful element was again to go back to my experience, was the goals it gave me on physical health which built me, started walking, were very helpful in improving my health and fighting depression. I felt quite combative and as though I was fighting the depression by virtue of the fact that I was walking.” | T3C03_clinician “I think again it’s about specific goal setting, and I think a lot of the patients with depression struggle with functionality, and I think it does break down the different areas in their life, and I think that foundation is really good around recovery.” |
Becoming discouraged | |
T1P08_service user “So like I picked two from the topics for 1 week, and the next week, because those two hadn’t been resolved, I’m still on those two and so it’s kind of like a vicious circle and not being able to do the other lot.” | T3C01_clinician “… job situation for some people that might be a bit of, something that’s contributing to their depression … That might be something that’s quite a trigger thing for them to say, well, no, still no job. Come back to that week by week. It’s like, oh gosh, how’s that going to feel then just revisiting that.” |
Feeling scrutinised | |
T2P03_service user “I found that quite hard to judge the level of where I’m on those topics. After the first session and we come back to the second session, I felt the need to rate it higher. Just so I could see improvement even though I didn’t feel like that.” | T3C05_clinician “Then we introduced the DIALOG system and he dropped out... maybe the expectation of in a conversation … let’s set some goals, and the app was like quantifying how much they’d improved. So if they felt a little bit guilty, like, oh, I’ve got to go and see him now and I haven’t really improved my relationships and things, and he just thought, oh, I’ve got bigger things, whatever …” |
The impact of technology | |
Transparency & accessibility | |
T1P10_service user “Well, before he’d ask me all these issues … but there was no way that he could make a comparison … he’d have to spend a lot of time to analyse what notes have been written last time and then he’d have to read them when I came the next time to make the comparison that have I moved forward or not. But with this it was instant.” | T1C09_clinician “I think also with noting it down on the tablet it makes it easier to remember the actions … you could just go back and you remind yourself what you put down as actions. So that’s good.” |
Therapeutic aid & hindrance | |
T2P09_service user “I think again, yeah, just having a visual representation of how certain things feel at the time, kind of allowed me to explain it a bit more.” | T2C03_clinician “..,you’re trying to establish a relationship with someone to help them get better and that’s normally focused on talking and showing empathy and understanding, it’s quite hard to do that when you’re typing in or when you’re pressing numbers.” |
Technical competence & issues | |
T3P04_service user “… I mean it was quite frustrating because it was quite slow and unresponsive, if I wasn’t necessarily having a good day I didn’t really have the patience to be working with it." | T2C02_clinician “… certainly the first patient was pressing the buttons for me because I got confused and so he seemed to know a bit more about what he was talking, so I relied on him which I suppose is good and bad really. I suppose he owns the session by doing that … “ |
DIALOG+ structure
“ … sometimes the sessions can run on and on and on and you end up getting nowhere. So I thought having a device with an app that gives specific areas that you want to talk about, giving the person the choice of what the questions are, like what they wanted to talk about, I thought that was really good and could hone in and keep the session more specific and help us to work towards goals.”(ID: T2C03_clinician)
“I think also it’s good because obviously mental health does affect a big range of things. And I think it’s a good way of looking at all the different things rather than just discussing mental health as one thing if that makes sense ( … ) because I didn’t realise how some of these different things are affected by my actual mental health. So, for me it was a bit of an eye opener.”(ID: T3P01_service user)
“I think it was quite good but it didn't always leave time for me to say what I was struggling with and what I needed help with.”(ID: T2P10_service user)
Therapeutic communication
“And I think it would help a patient, especially patients who are not very confident or can’t remember what issues there, so this sort of triggers them, oh, my medication isn’t right or something. So when you read something it sort of comes back to you, and sometimes, you go shopping and you don’t write things down, you buy everything else but you forget what you went out for ( … ) it works the same way, it just prompts you … ”(ID: T1P10_service user)
“I found the four stepped approach, when you break it down, I found that really helpful because I think some of the questions that, normally, I might not have asked of a client like what can you do, what can I do, what could others do (...) That helped me to have some conversations with patients I’ve actually known quite well for quite a long time that we haven’t explored before.”(ID: T3C03_clinician)
“I didn’t feel I was having a real conversation with her. I felt I was just going through ticking the boxes type of thing.”(ID: T3P03_service user)
Reflecting and monitoring
“Well, it certainly gave me time to think about those areas where you don’t think about when you have to answer that, what is my family life from one to ten, and then you sort of think about it, is it really that bad or is it really that great? And so I think it gives you a tool to analyse yourself before you answer.”(ID: T1P10_service user)
“The clients themselves could have a look and think, yeah, last month I was having this issue but this month I’ve been able to resolve that. They can feel some sense of achievement with themselves, being able to look at the information for themselves and I think it’s very useful like that.”(ID: T1C07_clinician)
“OK, so I’m a bit split on this. I think it’s, like I said, it’s a really good thing because you can see how you’re improving or you’re not improving and then how you need to focus on these different things more than others that are listed. Whereas also ( … ) actually physically seeing it measured, for me was a little bit... I don’t know, it brings home a little bit how bad some of these actually are, and how bad at times my actual mental health is, and how it affects me.” (ID: T3P01_service user)
“ … there wasn’t ever much change and with the one where there was a change she couldn’t really accept that there was that change then. It was more oh, there’d been a mistake or I don't know why it’s higher or lower this week.”(ID: T3CO4_clinician)
Empowerment and powerlessness
“So DIALOG+ was like involving me to let me speak up and look me in my face to say that they’re interested in what I’m saying ( … ) it helped me to have a voice and to be heard … ”(ID: T1P09_service user)
“It gave focus. It gave ownership to the client because the client would be out there seeing where we are going, where we are coming from. Especially after the third session the client understands the framework ( … ) as a practitioner this gives me even more ammunition actually to work with a client, to show and help the client to see that he can be the owner of his co-ordination of care and the tablet does contribute to that.”(ID: T1C08_clinician)
“Sometimes I felt it could be pointless because there wasn't any obvious answers as what could be done to make it better and it was repetitive from one session to the next, like, I'm still feeling rubbish at my mental health and all that could be added for an action was to keep engaging with support and I don't know how useful that was. But on other topics, running through the steps I think were good.”(ID: T2PO5_service user)
The impact of technology
“ … sometimes just in conversation you don’t necessarily really realise how you feel or how serious or how bad a certain thing can be, and then if you can ( … ) see it in front of you, and actually rate it on a scale, you can get a better idea of how it actually is.”(ID: T2P09_service user)
“I want to say positive things but it made it harder because you’re both staring at something together and you’re kind of sat alongside ( … ) it’s harder to pick up on facial cues or things that are going on. So they’re saying one thing but actually they’re showing something else. It kind of takes away that element of it.”(ID: T3C02_clinician)
“ … so this is during a session with somebody to say, oh damn, it’s timed us out ( … ) so it wasn’t a flowing discussion because I had to keep going, oh, hang on, I’ve got to find the password to get us back. So I suppose it didn’t help the therapeutic milieu if you like.”(ID: T2C02_clinician)
“Yeah, and I wanted it to work but I was a bit worried about making myself look a bit of an idiot by not knowing how it was working which is why I tried to go through it quickly before I went to see her so I could at least sound like I knew what I was talking about. But when you’re in a situation with someone crying and you’re trying to work your way through this app it’s quite [difficult] … ” (ID: T2C03_clinician)