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Hegland, P. A., McAleavey, A., Aasprang, A., Moltu, C., Kolotkin, R. L., & Andersen, J. R. (2022). The Norse Feedback in a population of patients undergoing bariatric surgery—Psychometric properties of a digital computer‐adaptive questionnaire assessing mental health. Clinical Obesity, 12(1), e12491.

https://onlinelibrary.wiley.com/doi/full/10.1111/cob.12491

The Norse Feedback (NF) is a questionnaire developed for patient-reported outcome monitoring with a clinical feedback system (PRO/CFS). As mental health is a concern after bariatric surgery, the use of the NF as part of PRO/CFS may be beneficial. The aim of this study is to test the reliability and validity of the NF in patients who have been accepted for or have undergone bariatric surgery. We performed separate robust confirmatory factor analyses (CFAs) to test the unidimensionality on 19 of the NF scales. We also performed correlation analyses on 19 of the NF scales with the Obesity-related Problems scale (OP). We included 213 patients. In the CFA analyses, three out of 12 scales with four or more items showed satisfactory psychometric properties in all goodness of fit indices (Suicidality, Need for Control and Self-Criticism). Four scales showed satisfactory psychometric properties in all indices but RMSEA (Somatic Anxiety, Substance Use, Social Safety and Cognitive Problems). Several of the scales demonstrated floor effects. In the correlation analyses, 18 of the 19 scales showed small-to-moderate correlation coefficients with the OP.

Our demonstration of satisfactory psychometric properties on several important scales of the NF suggests that this tool may prove valuable in the routine follow-up of mental health in this population. However, further work is needed to innovate the NF for patients undergoing bariatric surgery.

Hegland, P. A., Aasprang, A., Kolotkin, R. L., Moltu, C., Tell, G. S., & Andersen, J. R. (2020). A novel patient-reported outcome monitoring with clinical feedback system in bariatric surgery care: study protocol, design and plan for evaluation. BMJ open, 10(6), e037685.

https://bmjopen.bmj.com/content/10/6/e037685.abstract

Abstract: Background Consultations before and after bariatric surgery should include structured assessments of patients’ health-related quality of life (HRQOL) and mental health. One way to conduct this assessment is to implement patient-reported outcome monitoring with a clinical feedback system (PRO/CFS).

Aim: We will explore patients’ and healthcare professionals’ experiences when a PRO/CFS is an integrated part of bariatric surgery care.

Methods and analyses: This is a design paper in which a PRO/CFS will be implemented in two bariatric outpatient clinics. All patients who have an appointment with a healthcare professional prior to, and 3 and 12 months after surgery, will be asked to complete six digital questionnaires measuring HRQOL, mental health, bowel symptoms and eating self-efficacy prior to each consultation. A digital summary report generated from the patient’s responses will form the basis for the clinical consultation. A team of patient representatives, healthcare professionals and researchers will be involved in all phases of designing the PRO/CFS to ensure its relevance for clinical consultations. The patients’ experiences will be explored with a generic 12-item questionnaire, developed for use in outpatient clinics, prior to and 12 months after bariatric surgery. We will conduct focus-group interviews with patients and healthcare professionals to explore their experiences when PRO/CFS is integrated into the consultations.

Ethics and dissemination: Written informed consent will be obtained for all participants in the study. The project is approved by the Norwegian Center for Research Data, Department of Data Protection Services (ref. no. 282738). The project has also undergone Data Protection Impact Assessments, both at Førde Hospital Trust and at St. Olav Hospital (registration no. 2016/3912). Data from the qualitative and quantitative studies will be kept in de-identified form in a secured research database, and the findings will be published in international peer-reviewed journals and presented at scientific conferences.

Helleseth, M. M., McAleavey, A., & Moltu, C. (2022). Clinical feedback as an additional communication aide in therapy processes: A dual case study of how feedback can influence therapeutic work.

https://assets.researchsquare.com/files/rs-1638440/v1/7179b897-57c0-44e0-887d-97afd746d5b2.pdf?c=1652907565

Abstract.
Background: While routine outcome monitoring and clinical feedback may improve outcomes of psychotherapy, results from efficacy studies have been mixed. Moreover, how clinical feedback is implemented influences how it works for patients and clinicians, and its working mechanisms are not fully understood. Researchers have argued that inviting and using feedback from patients is best conceived of as a clinical skill. In this paper, we use case study methodology to explore and describe feedback’s functions within three clinical skill themes: actualising alliance work, concretising change and stagnation, and verbalizing the nonverbal.

Case presentation: Sonja is a young adult patient with a trauma background. She has a history of serious suicide attempts and distrust in relationships. She attended psychotherapy for eight months. Harald is a middle-aged man with a stable family. Traumatic events in his past have made him conceal own needs and develop depression. He attended psychotherapy for 19 months. Case materials include the patient’s clinical feedback over a range of life areas, medical health notes and the therapist’s process notes.

Conclusions: Clinical feedback can be a positive supplement to the therapeutic work and process. The importance of making this as a joint tool between the client and the therapist is significant.

Hovland, R. & Moltu, C. (2020). The challenges of making clinical feedback in psychotherapy benefit all users: a qualitative study. Nordic Psychology. 72, 3, P. 248-262

https://doi.org/10.1080/19012276.2019.1684348

Abstract: Clinical feedback (CF) systems are considered to be effective tools for supporting therapy. However, their implementation can be challenging. In this article, we question whether the Norse Feedback System addresses the needs of the diverse population that consults Norway’s National Health Care Services (e.g., migrants, refugees, and different age groups with mental illnesses of varying severity).

We conducted a comprehensive 10-month case study of the implementation of Norse Feedback in a public mental-healthcare institution. The data consisted of 12 patient interviews (six in individual interviews/six in a focus group), 23 employee interviews (10 were interviewed twice), 23 field notes, and 16 archival documents.

This article presents the findings from employee interviews and field reports. We analyzed the data inductively according to the stepwise-deductive inductive method. We identified six main themes: (i) “An offer to all” versus “Is it for everybody”?; (ii) illness hinders participation; (iii) yet another burden; (iv) distancing the older adults; (v) benefitting native-speaking literate patients; and (vi) benefitting well-functioning young people. Although the evidence on clinical feedback points to its benefits for patients with complex mental-health issues, our study found it was more difficult for clinicians to offer clinical feedback to these patients. Clinical feedback is considered a central means to enhance user involvement. Given the range of mental-health illnesses, symptom severity, and social and cultural backgrounds of the patient population in public mental-health settings, user involvement is most likely to benefit those patients who already benefit the most from therapy.

Hovland, R., Ytrehus, S., Mellor-Clark, J., & Moltu, C. (2020). How patients and clinicians experience the utility of a dynamic clinical feedback system in routine practice. Journal of Clinical Psychology, Online First 1–18.

https://doi.org/10.1002/jclp.22992

Abstract
Objective: The objective was to explore how a person-adaptive clinical feedback system (CFS) effects its users, and how meaning and relevance are negotiated.

Methods: We conducted a 10-month case-study of the implementation and practice of Norse Feedback, a personalized CFS. The data material consisted of 12 patient interviews, 22 clinician interviews, 23 field notes, and 16 archival documents.

Results: We identified four main categories or themes: (i) patients’ use of clinical feedback for enhanced awareness and insight; (ii) patients work to make clinical feedback a communication mode; (iii) patients and clinicians negotiate clinical feedback as a way to influence treatment; and (iv) clinical feedback requires an interactive sense-making effort.

Conclusion: Patients and therapists produced the meaning and relevance of the CFS by interpreting the CFS measures to reflect the unique patient experience of the patient–therapist relationship. Patients regarded CFS as a tool to inform therapy with important issues. Patients became more self-aware and prepared for therapy.

Hovland, R., & Moltu, C. (2019). Making way for a clinical feedback system in the narrow space between sessions: Navigating competing demands in complex healthcare settings. International Journal of Mental Health Systems. 13 (1), 68.

https://link.springer.com/article/10.1186/s13033-019-0324-5

Abstract.
Background: Although substantial empirical research supports the clinical value of routine outcome measures/clinical feedback systems (ROM/CFS), translation into routine practice poses several challenges. The present case study investigated how stakeholders, clinicians, patients and clinical managers related to the implementation of the Norse Feedback (NF) in ordinary practice.

Methods: We did an in-depth qualitative case study of the implementation of NF in a public mental-health institution. The settings were two outpatient clinics and two in-patient clinics organized under the same health trust. Data were drawn from three sources: archival sources (n = 16), field notes (n = 23), and 43 in-depth interviews with clinicians (n = 19), clinical managers (n = 5) and patients (n = 12). Ten of the participants were interviewed twice. The data were coded inductively and analyzed using a stringent qualitative methodology.

Results: We present our findings under three inter-related domains. First, we describe what followed the clinical feedback implementation. Second, we present the context experienced as being complex and high on work-pressure. Third, we describe the situated rules about the priority between competing tasks.

Conclusions: The preliminary results complement and contextualize understandings of known barriers to implementing ROM/CFS in clinical settings. We apply a socio-material perspective to discuss clinicians’ responses to complexity, implementation, and why some incentivized tasks prevailed over others regardless of therapists’ perceived benefits.

Lavik, K., Veseth, M., Frøysa, H., Stefansen, J., Nøtnes, J.C., & Moltu, C. (2020). This is what I need a clinical feedback system to do for me: A qualitative inquiry into adolescents’ and their therapists’ perspectives. Journal of Clinical Psychology, 10.1002/jclp.23100.

https://www.tandfonline.com/doi/abs/10.1080/10503307.2016.1189619

Routine outcome monitoring and clinical feedback systems (ROM/CFSs) are promising methods of providing naturalistic research data and enhancing mental health care. However, implementation in routine care is challenging, and we need more knowledge about clinicians’ and patients’ needs from such systems.

Objective: We aimed to study perspectives of clinicians and patients to explore how ROM/CFS can be helpful and acceptable to them.

Method: We interviewed 55 participants in focus groups and individual interviews and analyzed the data through rigorous team-based qualitative analyses.

Results: We report 3 overarching domains: (a) Shared needs, (b) Specific patient needs, and (c) Specific therapist needs. Shared needs, in which perspectives of different stakeholders converge, was the dominant domain in the material. Under each domain, we report 3 specific themes: (a1) Degree of trust in therapy, (a2) Allowing for openness, (a3) Monitoring joint objectives; (b1) Life functioning, (b2) Canary in the coal mine, (b3) Holistic report; and (c1) Emotional presence and style, (c2) Monitoring risk and symptoms, and (c3) Agency and ownership of process. Conclusions: In what should increase our confidence toward core aspects of ROM, we suggest that an integration of relational feedback concepts and stringent clinical dimension tracking into the ROM/CFS can be beneficial.

McAleavey, A., & Moltu, C. (2021). Understanding routine outcome monitoring and clinical feedback in context: Introduction to the special section. Psychotherapy Research, 31, 2 . DOI: 10.1080/10503307.2020.1866786.

https://www.tandfonline.com/doi/full/10.1080/10503307.2020.1866786

Abstract: The practice of routine outcome monitoring and providing clinical feedback has been widely studied within psychotherapy. Nevertheless, there are many outstanding questions regarding this practice. Is it an evidence-based adjunct to ongoing psychotherapies, or an ineffective complication of treatment? If it is effective, through what mechanism(s) does it act? Is it effective with all patient populations, treatment types, and service delivery mechanisms, or does its impact vary across context? What choices in the implementation process affect the utility of patient-reported data feedback on psychotherapy outcomes? The studies in this special section explore these questions using a wide variety of methods and significantly expand the reach of studies on feedback.

Together, these studies represent a snapshot of a maturing field of study: Initial discoveries are developed into more robust theories and applied in a wider range of contexts, while the limits of that theory are tested. They also signal directions for future clinical and research work that may improve patient care in psychosocial interventions into the future.

McAleavey, A. A., Nordberg, S. S., & Moltu, C. (2021). Initial quantitative development of the Norse Feedback system: A novel adaptive multidimensional tool for use in routine mental healthcare. Quality of Life Research. 10.1007/s11136-021-02825-1. Online First.

https://link.springer.com/article/10.1007/s11136-021-02825-1

Abstract
Purpose: As routine outcome monitoring has become prevalent in psychological practice, there is a need for measurement tools covering diverse symptoms, treatment processes, patient strengths, and risks. Here we describe the development and initial tests of the psychometric properties of a multi-scale system for use in mental healthcare, Norse Feedback.

Methods: In Study 1, we present the item-generation process and structure of the Norse Feedback, a 17-scale digital-first measurement tool for psychopathology and treatment-relevant variables. In Study 2, we present analyses of this initial measure in a nonclinical sample of 794 healthy controls and a sample of 222 mental health patients. In Study 3, we present the analysis of a revised 20-scale system in two separate samples of patients. In each analysis, we investigate item and test information in particular, including analysis of differential item functioning on gender, age, site, and sample differences where applicable.

Results: Scales performed variably. Changes to items and scales are described. Several scales appeared to reliably discriminate individuals entering mental health treatment on severity, and others are less reliable. Marked improvements in scale internal consistency and measurement precision were observed between the first and second implemented versions.

Conclusion: This system includes some scales with reasonable structural validity, though several areas for future development are identified. The system was developed to be iteratively re-evaluated, to strengthen the validity of its scales over time. There are currently a number of limitations on inferences from these scores, which future developments should address.

Moltu, C., McAleavey, A., Helleseth, M.M, Møller, G.H., & Nordberg, S. (2021). How therapists and patients need to develop a clinical feedback system after 18 months of use in a practice-research network: a qualitative study. International Journal of Mental Health Systems. 15:43.

https://doi.org/10.1186/s13033-021-00465-z

Abstract
Background: A personalized computer-adaptive system for clinical feedback and routine outcome monitoring in mental health, Norse Feedback aims to bridge the needs for standardized and idiographic measures in ordinary practice.

Methods: Item response theory analyses of completed treatment processes (n = 800) informed a qualitative study comprising individual in-depth interviews and focus groups with patients (n = 9) and clinicians (n = 10). The research question was: How do clinicians and patients contribute to developing a clinical feedback system in a continuous process aimed at refining its clinical usefulness?

Results: We conducted thematic analyses and found five themes: 1. Added clinical needs, 2. Needs for re-organizing the clinician report, 3.Needs for differentiation of clinical content, 4. User-interface needs, and 5. Item level suggestions.

Conclusion: In this article, we detail resulting needs for continuous adaptation to practice, and discuss implications of the concrete experiences with the Norse action research program for the larger field of ROM/CFS implementation.

Moltu, C., Veseth, M., Stefansen, J., Nøtnes, J.C., Binder, P.E., Castonguay, L.G., & Nordberg, S.S. (2018). This is what I need a clinical feedback system to do for me: A qualitative inquiry into therapists’ and patients’ perspectives. Psychotherapy research. 28 (2), 250-263, DOI: 10.1080/10503307.2016.1189619.

https://www.tandfonline.com/doi/abs/10.1080/10503307.2016.1189619

Abstract: Routine outcome monitoring and clinical feedback systems (ROM/CFSs) are promising methods of providing naturalistic research data and enhancing mental health care. However, implementation in routine care is challenging, and we need more knowledge about clinicians’ and patients’ needs from such systems.

Objective: We aimed to study perspectives of clinicians and patients to explore how ROM/CFS can be helpful and acceptable to them.

Method: We interviewed 55 participants in focus groups and individual interviews and analyzed the data through rigorous team-based qualitative analyses.

Results: We report 3 overarching domains: (a) Shared needs, (b) Specific patient needs, and (c) Specific therapist needs. Shared needs, in which perspectives of different stakeholders converge, was the dominant domain in the material. Under each domain, we report 3 specific themes: (a1) Degree of trust in therapy, (a2) Allowing for openness, (a3) Monitoring joint objectives; (b1) Life functioning, (b2) Canary in the coal mine, (b3) Holistic report; and (c1) Emotional presence and style, (c2) Monitoring risk and symptoms, and (c3) Agency and ownership of process. Conclusions: In what should increase our confidence toward core aspects of ROM, we suggest that an integration of relational feedback concepts and stringent clinical dimension tracking into the ROM/CFS can be beneficial.

Nordberg, S. S., McAleavey, A. A., & Moltu, C. (2021). Continuous quality improvement in measure development: Lessons from building a novel clinical feedback system. Quality of Life Research. DOI: 10.1007/s11136-021-02768-7.

https://link.springer.com/article/10.1007/s11136-021-02768-7

Abstract
Purpose: While the use of clinical feedback systems has become commonplace in psychological treatment, many of the most common instruments used for this purpose have not changed in decades. This paper describes the first four cycles of a measure development method designed to embrace continuous quality improvement.

Methods: Using techniques and philosophies developed in business management and academia—lean continuous quality improvement, action research, and practice research networks—we iterated through multiple cycles of development with the goal of creating an optimal clinical feedback system. These cycles emphasize building capacity to receive and implement feedback from a variety of stakeholders, especially patients and providers of behavioral health services, while also being responsive to quantitative findings from measure development.

Results: Iterating measure development with stakeholder feedback over the course of 5 years has resulted in a novel measurement system with 19 subscales administered via branching logic, and a supporting practice research network to sustain development.

Conclusion: In developing a new clinical feedback system, the less-frequently-discussed practical aspects of measure development require close attention. Specifically, being willing to embrace change, planning for iteration, and systematically seeking stakeholder feedback are identified as central methods for improving clinical feedback systems.

Solstad. S.M., Kleiven, G.S., Castonguay, L.G., & Moltu, C. (2020). Ethical and clinical dilemmas of ROM/CFS: a qualitative study of patient experiences. Psychotherapy Research. Online First.

https://doi.org/10.1080/10503307.2020.1788741

ABSTRACT
Purpose: Routine outcome monitoring (ROM) and clinical feedback systems (CFS) are becoming prevalent in mental health services, but there are several challenges to successful implementation. ROM/CFS seem to be helpful for some patients, but not for others. To investigate this, we explored patients’ experiences with ROM/CFS as an interpersonal and psychotherapeutic process, in naturalistic settings.

Method: We used video-assisted interpersonal process recall interviews to investigate the experiences of 12 patients using ROM/CFS in a Norwegian mental health outpatient clinic. Data were analyzed through systematic text condensation. Results: Our analysis resulted in three pairs of experiences with ROM/CFS: (1) Explicit vs. implicit use of information, (2) Directing focus towards or away from therapeutic topics, and (3) Giving and receiving feedback. These experiences could be helpful or hindering, depending on participants’ needs and preferences. All participants needed to know that the CFS was used in a meaningful way. If not, it could be detrimental to the therapeutic process.

Conclusion: In order to be helpful for patients, ROM/CFS should be used in a way that is flexible, meaningful to patients, and sensitive to individual needs and preferences. Future research should further explore this how-to aspect of ROM/CFS with different CFS and populations.

Solstad, S.M., Kleiven, G.S., & Moltu, C. (2020). Complexity and potentials of clinical feedback in mental health: an in-depth study of patient processes. Quality of Life Research, Online First

https://doi.org/10.1007/s11136-020-02550-1

Abstract
Purpose: Routine outcome monitoring (ROM) and clinical feedback systems (CFS) are becoming increasingly prevalent in mental health services. Their overall efficacy is unclear, but quantitative evidence suggests they can be useful tools for preventing treatment failure and enhancing therapeutic outcomes, especially for patients who are not progressing in therapy. The body of qualitative material, however, is smaller and less refined. We need to know more about how ROM/CFS is used in psychotherapy, and why it is helpful for some patients, but not others.

Methods: We recorded therapy sessions of 12 patients who were using a CFS as part of their therapies at an outpatient clinic in Norway. We then conducted video-assisted interviews and follow-up interviews with patients. Data were analyzed with systematic text condensation.
Results: Analysis revealed three themes: (1) triggering reflections, emotions, and self-awareness, (2) Ambivalent and ambiguous self-presentation, and (3) potential for feeling understood and talking about what matters.

Conclusion: Answering questions in a CFS is an interpretative and intentional process of self-presentation and the results from ROM/CFS must be interpreted and explored in conversation to be clinically useful. When they are, they have potential for enhancing the therapeutic process by stimulating self-awareness, reflexivity, and allowing access to new therapeutic topics. Further research should explore this how-to aspect of ROM/CFS with different CFS and different types of patients. Integrating clinical feedback in therapeutic practice can be conceptualized as a clinical skill, which should be a part of training programs for therapists.