Psychosis, which encompasses conditions such as schizophrenia, is among the most life-disrupting forms of severe mental illness, touching work, relationships, and daily functioning in profound ways. International mental health policy has increasingly emphasised recovery-oriented and person-centred approaches, in which treatment is organised around the goals and needs that patients themselves articulate rather than solely around symptom management defined by clinicians. In practice, however, translating that philosophy into ordinary outpatient appointments has proved difficult. Consultations often follow a familiar script in which the practitioner asks, the patient answers, and the agenda remains firmly in professional hands. DIALOG+ was developed to break that script by giving patients a formal mechanism for setting the agenda.

The intervention itself is technically straightforward but conceptually ambitious. At the start of each encounter, the patient completes a digital self-assessment rating satisfaction across a range of life and treatment domains, from medication and housing to social contact and personal safety. The scores then serve as the scaffolding for a structured conversation: the patient and practitioner jointly identify which areas matter most, explore them through a problem-solving framework, and agree on concrete actions to be followed up at subsequent meetings. In this way, the tool operationalises what researchers call co-production, the idea that care is designed and delivered collaboratively by patients and professionals rather than prescribed unilaterally. The digital component ensures that the process is consistent from one appointment to the next, turning abstract ideals of patient involvement into a repeatable clinical routine.

To understand what this shift feels like from the practitioner’s side, the Swedish research team recruited fourteen mental health practitioners working in outpatient psychosis care who had used DIALOG+ at least three times with patients. The researchers conducted four focus groups using semi-structured interviews, allowing participants to describe their experiences in their own words and to build on one another’s reflections. The transcripts were then analysed using reflexive thematic analysis, a qualitative method in which researchers actively acknowledge their own perspectives and assumptions while identifying recurring patterns of meaning across the data. The team received ethical approval from the Swedish Ethical Review Authority, and all participants gave informed consent with confidentiality protected through pseudonymisation.

The analysis yielded three overarching themes. The first, labelled the patient’s voice and engagement, captured how the structured approach of DIALOG+ made it easier for patients to express their needs and take a more active role in the conversation. For practitioners, this was often described as a welcome revelation: patients who might otherwise have deferred politely to clinical expertise began to raise concerns, prioritise goals, and steer the discussion toward issues that genuinely mattered to them. The self-assessment scores functioned as a concrete starting point, lowering the threshold for patients who might find it difficult to initiate difficult topics spontaneously. In some cases, this translated into visibly increased engagement, with patients arriving at appointments better prepared and more invested in the outcome.

The second theme concerned the relationship between patient and mental health practitioner. Practitioners reported that DIALOG+ appeared to balance the conversation by distributing responsibility for decisions and follow-up between the two parties. Rather than the practitioner single-handedly determining treatment adjustments, the structured dialogue created a shared space in which both sides contributed to identifying problems and planning actions. This redistribution did not diminish the practitioner’s expertise, the participants suggested, but repositioned it: clinical knowledge became a resource brought into a joint deliberation rather than a verdict delivered from above. The intervention thereby provided a framework for shared reflection and action planning, giving the collaborative ideal of person-centred care a concrete, repeatable form within the limited time of a routine appointment.

The third theme, however, revealed the friction inherent in any redistribution of power. Practitioners reflected candidly on the challenges of letting the patient lead the conversation. Patient-led agendas could collide with the realities of clinical practice, particularly time constraints: when a patient chose to focus on an unexpected domain, the structured conversation could stretch beyond the appointment’s capacity, forcing difficult triage decisions in the moment. More fundamentally, clinicians described the need to balance the patient’s chosen agenda with their own professional responsibility, including duties to monitor symptoms, manage medication, and address risks that the patient might not consider priorities. The tool, in other words, made visible potential differences between what patients preferred to discuss and what practitioners judged clinically necessary, and those differences had to be negotiated rather than resolved by default.

These tensions point to a deeper issue that the authors highlight in their conclusion: the impact of DIALOG+ depends heavily on how the approach is enacted in practice. The intervention does not mechanically produce co-production; it creates an opportunity for it, and the outcome hinges on the practitioner’s willingness and skill to share authority. Some clinicians evidently found the role shift disorienting, since professional identity in psychiatry has traditionally been anchored in expertise and directive responsibility. The study’s authors argue that supporting practitioners in navigating these shifts in professional roles and authority may therefore be essential for realising the intervention’s full potential. Without such support, the risk is that the structured dialogue becomes a procedural ritual, completed but not truly shared, preserving old hierarchies under a new digital veneer.

The significance of the study lies partly in its methodological angle. Most evaluations of DIALOG+ and similar patient-reported outcome tools have focused on quantitative outcomes, measuring changes in quality-of-life scores or treatment satisfaction. By contrast, this investigation interrogated the micro-dynamics of the clinical encounter itself, asking how a structured tool alters conversation, relationship, and role. The answer matters for implementation science: digital interventions often succeed or fail not on their technical merits but on whether they fit the social fabric of the settings into which they are introduced. A tool that asks clinicians to cede agenda-setting power is not merely a software deployment; it is an intervention in workplace culture, and the Swedish findings suggest that culture responds unevenly.

For outpatient psychosis services considering adoption, the study offers both encouragement and caution. On the encouraging side, practitioners with hands-on experience of DIALOG+ recognised its capacity to increase patient influence over the agenda of routine encounters, to foster engagement, and to give shared decision-making a workable structure. On the cautious side, the same practitioners identified real costs and challenges, from time pressure to the delicate negotiation between patient preferences and clinical judgement. The intervention, the authors conclude, has genuine potential to support the operationalisation of co-production in psychosis care, but that potential is conditional. Health services hoping to let patients lead will need to invest not only in software but in preparing the professionals on the other side of the desk for a conversation in which the script, for once, is not entirely theirs.

Subject of Research: Practitioner experiences of using the DIALOG+ patient involvement intervention in outpatient psychosis care

Article Title: Letting patients lead? Practitioners’ experiences of using DIALOG + in psychosis outpatient care – patient involvement, collaborative dynamics, and professional roles

Article References: Letting patients lead? Practitioners’ experiences of using DIALOG + in psychosis outpatient care – patient involvement, collaborative dynamics, and professional roles. (n.d.). https://doi.org/10.1186/s12888-026-08633-6

Image Credits: AI Generated

DOI: 10.1186/s12888-026-08633-6

Keywords: DIALOG+, psychosis, patient involvement, co-production, person-centred care, shared decision-making, mental health practitioners, qualitative research, outpatient care, therapeutic relationship, schizophrenia, digital health

The trial, led by Sinead McLernon and colleagues, set out to answer a question that sounds procedural but carries real clinical weight: is it actually possible to embed DIALOG and DIALOG+ in inpatient rehabilitation settings, where patients often have complex and enduring mental health difficulties and where care is delivered by multidisciplinary teams under constant operational pressure? The study was designed not as a test of effectiveness but as a feasibility and acceptability trial, the crucial first step in the pipeline of implementation science. Before a large-scale evaluation can be justified, researchers must establish whether the intervention can be delivered as intended, whether patients and staff will engage with it, and what practical barriers stand in the way. To that end, the team registered their protocol prospectively on ClinicalTrials.gov in May 2024 and received ethical approval from the Health Research Authority in July 2024, following the UK Policy Framework for Health and Social Care research with informed consent from all participants.

Methodologically, the study used a cluster allocation design, meaning that whole wards rather than individual patients were assigned to the implementation conditions. Feasibility data were collected over a five-month intervention period using a deliberately adapted, paper-based format of DIALOG and DIALOG+, a pragmatic choice reflecting the realities of inpatient wards where access to tablets or shared digital devices cannot be assumed. The researchers set pre-established progression criteria, thresholds that would determine whether the study could reasonably advance to a full trial. Staff recruitment and training proved achievable: seventeen staff members were recruited and trained, demonstrating that the service was willing to engage with the research at the organizational level. The patient side of the equation, however, told a different story.

Patient recruitment fell short of the pre-defined progression criteria, and engagement once enrolled was strikingly low. Across the five-month period, the mean number of DIALOG+ sessions completed per patient was just 1.9 out of a planned 10 sessions. Of the eight patients who participated, only four completed more than a single outcome measure. In implementation science terms, these adherence figures signal that the intervention could not be delivered with anything approaching fidelity in this context. The authors are careful to frame these numbers cautiously given the very small sample size, but the pattern is difficult to ignore: a structured monitoring and solution-focused intervention designed to be delivered repeatedly over months was, in practice, delivered once or twice.

To understand why, the researchers turned to qualitative methods. Patient participants completed qualitative surveys about their experiences, while staff participants took part in focus groups and interviews. Thematic analysis of this material identified four overarching themes that shaped whether DIALOG+ could take root. The first concerned staff and stakeholders’ affective attitude towards the feasibility objectives themselves, that is, their emotional responses to what the research was asking of them. The second theme captured affective attitudes towards the intervention, including how staff and patients felt about the DIALOG+ approach on its own merits. The third theme, alignment with current practice, examined whether the tool fitted the existing rhythms and routines of ward life. The fourth and perhaps most revealing theme was the inpatient setting itself, recognizing that the environment imposes constraints that outpatient or community services do not face.

These themes converge on a central insight: the failure was not necessarily one of the intervention’s design but of its integration. The authors identify insufficient adherence and limited integration within multidisciplinary team meetings as key implementation barriers. DIALOG+ is built around the premise that patient-rated outcomes feed directly into care planning conversations, ideally surfacing in the regular reviews where decisions about support are made. When the ratings remain isolated, completed sporadically and discussed outside the team’s main decision-making forums, the mechanism of action is broken. The tool becomes paperwork rather than practice. This finding echoes a broader lesson from implementation research across healthcare: innovations that require changes to team routines need active, sustained support to alter those routines, and simply training individual staff members is rarely enough.

The implications for the wider field of routine outcome monitoring are significant. DIALOG+ has accumulated encouraging evidence in community mental health settings, where structured quality-of-life assessments paired with solution-focused discussions have been associated with improved outcomes. Rehabilitation inpatient wards, however, serve patients with some of the most complex needs in the system, often involving long stays, fluctuating engagement, cognitive and motivational difficulties, and care delivered by shifting combinations of nurses, occupational therapists, psychologists and psychiatrists. The trial suggests that the assumptions about patient throughput and staff continuity that work in community settings may simply not transfer. A patient who is acutely unwell or ambivalent about their care may not reliably complete a ten-session monitoring schedule, however well intentioned the design.

Importantly, the authors do not conclude that DIALOG+ is unsuitable for this population. Instead, they offer concrete directions for future implementation trials: providing dedicated implementation support, additional training, and ongoing supervision to facilitate intervention fidelity and integration into routine multidisciplinary team practice. This recommendation aligns with contemporary implementation frameworks that distinguish between the effort of introducing an intervention and the effort of sustaining it. Dedicated implementation support might include embedding the tool into ward meeting agendas, assigning named staff champions, building completion into care pathways, and providing regular supervision to troubleshoot barriers as they emerge, rather than discovering them at the end of a five-month window.

The study also demonstrates the value of rigorous feasibility methodology itself. By setting progression criteria in advance, registering the trial prospectively, and combining quantitative adherence data with qualitative thematic analysis, the researchers produced a result that is honest and actionable rather than simply disappointing. Many interventions that fail quietly in routine services are never reported, leaving the field to repeat the same mistakes. Publishing a negative feasibility result, with a clear account of the four barrier themes, gives future teams a map of the specific obstacles they must address before investing in a full-scale trial of outcome monitoring in inpatient rehabilitation.

For patients on psychiatric rehabilitation wards, the stakes of getting this right are considerable. Structured monitoring of quality of life has the potential to give voice to people whose preferences are often overlooked in institutional settings, and to convert vague dissatisfaction into specific, solvable problems. The Sheffield-led trial shows that the technology and the clinical logic are portable only up to a point; the surrounding system must carry the intervention, and in this setting it did not. Whether a better-supported, perhaps digitally enabled version of DIALOG+ can succeed where the paper-based approach faltered remains an open question, one that the authors’ recommendations now make possible to test properly. The study, published open access under a Creative Commons licence with support from the University of Sheffield Institutional Open Access Fund, stands as a candid data point in the ongoing effort to make measurement-based mental health care a reality for the patients who need it most.

Subject of Research: Feasibility of implementing the DIALOG+ routine outcome monitoring system in psychiatric rehabilitation inpatient care

Article Title: Is it possible to implement the DIALOG+ routine outcome monitoring system in a psychiatric rehabilitation inpatient setting? A mixed methods feasibility trial in the UK National Health Service

Article References: McLernon, S., Bone, C., Fergusson, A., & Delgadillo, J. (2026). Is it possible to implement the DIALOG+ routine outcome monitoring system in a psychiatric rehabilitation inpatient setting? A mixed methods feasibility trial in the UK National Health Service. BMC Psychiatry. https://doi.org/10.1186/s12888-026-08669-8

Image Credits: AI Generated

DOI: 10.1186/s12888-026-08669-8

Keywords: DIALOG+, routine outcome monitoring, psychiatric rehabilitation, inpatient care, feasibility trial, mixed methods, NHS, implementation science, mental health, quality of life, multidisciplinary team, BMC Psychiatry