Document Type : Research paper


1 School of Health Sciences, City University of London, London, United Kingdom

2 School of Health Sciences, University of Melbourne, Melbourne, Australia School of Health Sciences, City University of London, London, United Kingdom

3 Unit for Social and Community Psychiatry, Queen Mary University of London, London, United Kingdom

4 Department of Psychiatry, Clinical Centre of the University of Sarajevo, Bosnia and Herzegovina

5 Department of Psychology, University of Pristina, Kosovo United Nations Resolution

6 Clinic of Psychiatry, Ss. Cyril and Methodius University in Skopje, North Macedonia Academy of Sciences and Arts of North Macedonia

7 University Clinic of Psychiatry, Ss. Cyril and Methodius University in Skopje, Republic of North Macedonia Department of Psychology, Faculty of Philosophy, Ss. Cyril and Methodius University in Skopje, North Macedonia

8 Psychiatric Clinic, Clinical Centre of Montenegro, Podgorica, Montenegro

9 Faculty of Medicine, University of Belgrade, Belgrade, Serbia

10 Psychiatric Clinic, Clinical Centre of Montenegro, Podgorica, Montenegro Faculty of Medicine, University of Montenegro, Podgorica, Montenegro

11 School of Psychology, University of Pristina, Kosovo United Nations Resolution

12 Clinic of Psychiatry, Ss. Cyril and Methodius University in Skopje, North Macedonia


Background: There are limited resources for improving mental health care across Europe, especially in Low-and-Middle- Income Countries (LMICs) in South-eastern Europe with fewer specialist staff and less funding. Scaling up psychosocial interventions that utilise available time and resources more effectively could improve care for people with psychosis in these settings. One intervention is DIALOG+, delivered via an app on a tablet computer: patients identify life areas to improve and clinicians use a solution-focussed process to help improve these areas. This intervention was piloted across mental healthcare systems in European LMICs, and focus groups were conducted to explore whether such interventions could use available resources effectively to improve care for psychosis in these settings.
Methods: Eleven focus groups were conducted with clinicians and patients with psychosis who used the intervention over three months during the pilot study, in Bosnia and Herzegovina, Kosovo United Nations Resolution, Montenegro, North Macedonia and Serbia. The Theoretical Domains Framework (TDF), which describes factors affecting engagement with healthcare interventions, structured topic guides and guided analysis. Codes from the data were mapped onto the TDF, analysed to identify barriers and facilitators, translated into English and checked for inter-rater reliability.
Results: 25 clinicians and 23 patients participated in focus groups. Clinicians’ barriers included limited time for sessions and difficulties working with acutely psychotic patients. Patients’ barriers were burden of greater concentration when engaging with DIALOG+ and feeling tense or disturbed during the sessions. Facilitators included motivation to use DIALOG+, positive opinions shared by others, perceived benefits for practice and improving clinician-patient conversations, relationships and care.
Conclusions: Barriers to using psychosocial interventions could be overcome even if resources cannot be increased. Despite limited time and other barriers to using DIALOG+, perceived benefits to practice and clinician-patient relationships suggest that psychosocial interventions can use available resources effectively to improve care for psychosis.


Main Subjects

Bačar Bole, C., Pišlar, M., Mrhar, A. and Tavčar, R., 2017. Prescribing patterns for inpatients with schizophrenia spectrum disorders in a psychiatric hospital in Slovenia: results of 16-month prospective, non-interventional clinical research. Psychiatria Danubina, 29(2), pp. 155–161.
Barbato, A., Vallarino, M., Rapisarda, F., Lora, A. and de Almeida, J.M.C., 2016. EU compass for action on mental health and well- being. Access to mental health care in Europe. Scientific paper. Funded by the European Union in the frame of the 3rd EU Health Programme (2014–2020).
Bucci, S., Barrowclough, C., Ainsworth, J., Machin, M., Morris, R., Berry, K., Emsley, R., Lewis, S., Edge, D., Buchan, I. and Haddock, G., 2018. Actissist: proof-of-concept trial of a theory-driven digital intervention for psychosis. Schizophrenia Bulletin, 44(5), pp. 1070– 1080.
Carey, R.N., Connell, L.E., Johnston, M., Rothman, A.J., de Bruin, M., Kelly, M.P. and Michie, S., 2019. Behavior change techniques and their mechanisms of action: a synthesis of links described in published intervention literature. Annals of Behavioral Medicine, 53(8), pp. 693–707.
Craig, P., Dieppe, P., Macintyre, S., Michie, S., Nazareth,   I. and Petticrew, M., 2008. Developing and evaluating complex interventions: the new Medical Research Council guidance. BMJ, 337, p. a1655.
East London NHS Foundation Trust DIALOG+ Manual © 2012. Available at: Accessed on 26/06/2019.
Fichtenbauer, I., Priebe, S. and Schrank, B., 2019. The German Version of DIALOG+ for Patients with Psychosis-A Pilot Study. Psychiatrische Praxis, 46(7), pp. 376–380.
Francis, J.J., O’Connor, D. and Curran, J., 2012. Theories of behaviour change synthesised into a set of theoretical groupings: introducing a thematic series on the theoretical domains framework. Implementation Science, 7(1), p. 35.
Francis, J.J., Johnston, M., Robertson, C., Glidewell, L., Entwistle, V., Eccles, M.P. and Grimshaw, J.M., 2010. What is an adequate sample size? Operationalising data saturation for theory-based interview studies. Psychology and Health, 25(10), pp. 1229–1245.
Granholm, E., Ben-Zeev, D., Link, P.C., Bradshaw, K.R. and Holden, J.L., 2012. Mobile Assessment and Treatment for Schizophrenia (MATS): a pilot trial of an interactive text-messaging intervention for medication adherence, socialization, and auditory hallucinations. Schizophrenia Bulletin, 38(3), pp. 414–425.
Grant, A.M. and Gerrard, B., 2020. Comparing problem-focused, solution-focused and combined problem-focused/solution- focused coaching approach: solution-focused coaching questions mitigate the negative impact of dysfunctional attitudes. Coaching: An International Journal of Theory, Research and Practice, 13(1), pp. 61–77.
Grol, R., Wensing, M. and Eccles, M., 2005. Implementation of changes in practice. Improving patient care: the implementation of change in clinical practice, 6, p. 14.
Gustavsson, A., Svensson, M., Jacobi, F., Allgulander, C., Alonso, J., Beghi, E., Dodel, R., Ekman, M., Faravelli, C., Fratiglioni, L. and Gannon, B., 2011. Cost of disorders of the brain in Europe 2010. European neuropsychopharmacology, 21(10), pp. 718–779.
Hazell, C.M., Greenwood, K., Fielding-Smith, S., Rammou, A., Bogen-Johnston, L., Berry, C., Jones, A.M. and Hayward, M., 2018. Understanding the barriers to accessing symptom-specific Cognitive Behavior Therapy (CBT) for distressing voices: reflecting
on and extending the lessons learnt from the CBT for psychosis literature. Frontiers in Psychology, 9.
Hetrick, S.E., O’connor, D.A., Stavely, H., Hughes, F., Pennell, K., Killackey, E. and McGorry, P.D., 2018. Development of an implementation guide to facilitate the roll-out of early intervention services for psychosis. Early Intervention in Psychiatry, 12(6), pp. 1100–1111.
Hoffmann, T.C., Glasziou, P.P., Boutron, I., Milne, R., Perera, R., Moher, D., Altman, D.G., Barbour, V., Macdonald, H., Johnston, M. and Lamb, S.E., 2014. Better reporting of interventions: template for intervention description and replication (TIDieR) checklist and guide. BMJ, 348, p. g1687.
Injac-Stevović, L, I., Radojičić, T., & Repišti, S., in progress. Implementation of an effective and cost-effective intervention for patients with psychotic disorders in Low and Middle Income Countries in South Eastern Europe: Exploring the context (WP2): mental health policy analysis.
Jovanovic, N., Francis, J., Maric, N.P.,   Arenliu, A., Barjaktarov, S., Kulenovic, A.D., Injac, L., Feng, Y. and Novotni, A., 2020. Implementing a psychosocial intervention DIALOG+ for patients with psychotic disorders in low and middle income countries in South Eastern Europe: protocol for a hybrid effectiveness- implementation cluster randomized clinical trial (IMPULSE). Global Psychiatry, 3(1), pp. 83–96.
Luther L, Suor JH, Rosen C, Jobe TH, Faull RN, Harrow M. Clarifying the direction of impact of negative symptoms and neurocognition on prospective work functioning in psychosis: A 20-year longitudinal study [published online ahead of print, 2020 Mar 19]. Schizophrenia Research. 2020;S0920-9964(20)30115-8. doi:10.1016/j.schres.2020.03.012
Magliano, L., Fiorillo, A., Fadden, G., Gair, F., Economou, M., Kallert, T., Schellong, J., Xavier, M., Pereira, M.G., gonzales, f.t. and palma- crespo, a.l.b.e.r.t.o., 2005. Effectiveness of a psychoeducational intervention for families of patients with schizophrenia: preliminary results of a study funded by the European Commission. World Psychiatry, 4(1), p. 45.
Maric, N.P., Andric Petrovic, S., Rojnic-Kuzman, M. and Reicher- Rössler,A., 2019. Implementation of early detection andintervention services for psychosis in Central and Eastern Europe: Current status. Early Intervention in Psychiatry, 13(5), pp.1283–1288.
McDaid, D., Knapp, M. and Curran, C., 2005. Mental Health III: Funding Mental Health in Europe. World Health Organization.
McHugh, M. L., 2012. Interrater reliability: the kappa statistic. Biochemia Medica, 22(3), 276–282.
Michie, S., Johnston, M., Abraham, C., Lawton, R., Parker, D. and Walker, A., 2005. Making psychological theory useful for implementing evidence based practice: a consensus approach. BMJ Quality & Safety, 14(1), pp. 26–33.
Michie, S., Pilling, S., Garety, P., Whitty, P., Eccles, M.P., Johnston,
M. and Simmons, J., 2007. Difficulties implementing a mental health guideline: an exploratory investigation using psychological theory. Implementation Science, 2(1), p. 8.
Michie, S., Richardson, M., Johnston, M., Abraham, C., Francis, J., Hardeman, W., Eccles, M.P., Cane, J. and Wood, C.E., 2013. The behavior change technique taxonomy (v1) of 93 hierarchically clustered techniques: building an international consensus for the reporting of behavior change interventions. Annals of Behavioral Medicine, 46(1), pp. 81–95.
Omer, S., Golden, E. and Priebe, S., 2016. 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. PloS One, 11(2), p. e0148415.
Patey, A.M., Islam, R., Francis, J.J., Bryson, G.L. and Grimshaw, J.M., 2012. Anesthesiologists’ and surgeons’ perceptions about routine pre-operative testing in low-risk   patients:   application of the Theoretical Domains Framework (TDF) to identify factors that influence physicians’ decisions to order pre-operative tests. Implementation Science, 7(1), p. 52.
Priebe, S., Golden, E., Kingdon, D., Omer, S., Walsh, S., Katevas, K., McCrone, P., Eldridge, S. and McCabe, R., 2017. Developing the DIALOG+ intervention. In Effective patient–clinician interaction to improve treatment outcomes for patients with psychosis: a mixed- methods design. NIHR Journals Library.
Priebe, S., Omer, S., Giacco, D. and Slade, M., 2014. Resource- oriented therapeutic models in psychiatry: conceptual review. The British Journal of Psychiatry, 204(4), pp. 256–261.
Priebe, S., McCabe, RO., Bullenkamp, J., Hansson, L., Lauber, C., Martinez-Leal, R., Rössler, W., Salize, H., Svensson, B., Torres- Gonzales, F. and Van Den Brink, R., 2007. Structured patient– clinician communication and 1-year outcome in community mental healthcare: cluster randomised controlled trial. The British Journal of Psychiatry, 191(5), pp. 420–426.
Priebe, S., Kelley, L., Omer, S., Golden, E., Walsh, S., Khanom, H., Kingdon, D., Rutterford, C., McCrone, P. and McCabe, R., 2015. The effectiveness of a patient-centred assessment with a solution- focused approach (DIALOG+) for patients with psychosis: a pragmatic cluster-randomised controlled trial in community care. Psychotherapy and Psychosomatics, 84(5), pp. 304–313.
Švab, V. and Švab, I., 2013. Barriers and errors in the implementation of community psychiatry in Slovenia. Mental Health in Family Medicine, 10(1), p. 23.
Tong, A., Sainsbury, P. and Craig, J., 2007. Consolidated criteria for reporting qualitative research (COREQ): a 32-item checklist for interviews and focus groups. International Journal for Quality in Health Care, 19(6), pp. 349–357.
Trepper, T.S., McCollum, E.E., De Jong, P., Korman, H., Gingerich,
W. and Franklin, C., 2010. Solution-focused therapy treatment manual for working with individuals. Solution-focused brief therapy: A multicultural approach, pp. 14–31.
Wehr, T., 2010. The phenomenology of exception times: Qualitative differences between problem-focussed and solution-focussed interventions. Applied Cognitive Psychology: The Official Journal of the Society for Applied Research in Memory and Cognition, 24(4), pp. 467–480.
World Health Organization, 2008. mhGAP: Mental Health Gap Action Programme: scaling up care for mental, neurological and substance use disorders. handle/10665/43809/9789241596206_eng.pdf.                                                                                                              Accessed 01/06/2020.
World Health Organisation, 2013. Psychiatric services not meeting demand – reform needed. centre/sections/press-releases/2013/09/psychiatric-services- not-meeting-demand-reform-needed. Accessed 22/06/2020.
World Health Organisation, 2014. Living a healthy life with schizophrenia. noncommunicable-diseases/mental-health/news/news/2014/10/ living-a-healthy-life-with-schizophrenia. Accessed 22/06/2020.