Therapists’ and patients’ experiences of using patients’ self-reported data in ongoing psychotherapy processes—A systematic review and meta-analysis of qualitative studies

Abstract Objective: Using patient-generated quantitative data in psychotherapy (feedback) appears to enhance treatment outcome, but there is variability in its effect. Different ways and reasons to implement routine outcome measurement might explain such variability. The goal of this review is to address the insufficient knowledge on how these data are used by therapists and patients. Methods: The present study is a systematic review and meta-analysis of qualitative reports of therapists’ and patients’ experiences using patient-generated quantitative data during ongoing psychotherapy. Results: Four main categories of use were identified: (1) uses of patients’ self-reported data as nomothetic/objective markers for assessment, process monitoring, and treatment planning; (2) intrapersonal uses that enhance self-awareness, initiate reflection, and influence patients’ mood or responses; (3) uses that prompt interactional processes by facilitating communication, supporting exploration, creating ownership in patients, changing treatment focus, enhancing therapeutic alliance, or disturbing the psychotherapy process; and (4) patients responding for specific purposes due to uncertainty and interpersonal motives, or strategic responding to achieve a desired result. Conclusion: These results demonstrate that patient-reported data, when used in active psychotherapy, is very clearly not just an objective measurement of client functioning: the inclusion of patient-data has the potential to influence psychotherapy in numerous ways.


Introduction
Regularly measuring treatment outcomes might enhance the effect of psychotherapeutic treatment (Fortney et al., 2017;Shimokawa et al., 2010).Usually, this is done by having patients routinely answer outcome measures in the form of quantitative questionnaires, either at fixed intervals during treatment or session by session (Boswell et al., 2015).The therapist and the patient can then collaboratively use the data from outcome measures to follow treatment progress.There has been increased research interest in recent years on routinely measuring treatment outcomes and using this information during treatment sessions (Lutz et al., 2015;McAleavey & Moltu, 2021).The use of quantitative data to track outcomes is now seen as a vital component of evidence-based treatment (APA Presidental Task Force on Evidence-Based Practice, 2006;Truijens et al., 2022).
Research demonstrates that using patient-generated quantitative data in psychotherapy has positive impacts, such as assessing and improving treatment outcomes by identifying patients not-on-track to recovery (NOT) and personalizing treatment for the individual patient (Lambert et al., 2018;Lutz et al., 2015Lutz et al., , 2019;;Meehan et al., 2006).Even so, assessing the impact of using quantitative measures in psychotherapy is not straightforward.While some quantitative meta-analyses show positive effects (Lambert et al., 2018;Shimokawa et al., 2010), others are inconclusive (Kendrick et al., 2016).A common feature of these quantitative reviews is that they only investigated whether using such measures had an effect, but not how or why they had an effect (Greenhalgh et al., 2018).
Regardless of inconsistencies in the documented outcome effects found using quantitative data, the use of measures is increasingly becoming an integrated part of the psychotherapy treatment process in healthcare organizations around the world (Krägeloh et al., 2015).There is an imminent need for, and increasing interest in research to determine not only if routine outcome monitoring (ROM) leads to improved outcomes in general, but for whom, in which contexts and through which uses these potential effects come about.This line of research could potentially inform implementation and training to make ROM more helpful.Some healthcare systems, like the National Health Service (NHS) (Department of Health, 2016), public health in Australia (Guthrie et al., 2008;Meehan et al., 2006), and an increasing number of healthcare organizations in the US (Garland et al., 2003) have taken the integration of measures one step further by implementing them for psychotherapists and patients as mandatory components of treatment.Despite such measures being mandatory, therapists, and to some degree patients, are still hesitant to use them (Happell, 2008;Ionita et al., 2016;Jenssen-Doss et al., 2018;Kaiser et al., 2018).One potential explanation for this is that the knowledge about how to use them clinically has so far been under-developed.A recent qualitative meta-analysis of patients' experiences with using quantitative measures for ROM was published by Solstad et al. (2019).They found that patients felt empowered by ROM if it was well integrated in the collaboration between an interested therapist and a patient, whereas they distrusted ROM and were disturbed by it if it had no apparent use in the psychotherapeutic process.
As noted by Solstad et al. (2019), the research literature at that time was scarce.Nevertheless, their review suggests that a better understanding of how measures are actually used by therapists and patients might explain the variability in these measures reported effects across quantitative meta-analyses.In addition, updated syntheses might provide helpful suggestions to improve their impact.To the best of our knowledge, no meta-analysis has been published that specifically addresses how patientgenerated quantitative data are used in actual psychotherapy processes, as experienced by therapists and patients.The present study is a systematic review and meta-analysis of qualitative research on patients' and therapists' experiences with using patients' self-reported data in psychotherapy.

Method
This is a systematic review and meta-analysis of all published qualitative studies reporting patients' or therapists' experiences using quantitative patientgenerated data in ongoing psychotherapy processes.

Construct definitions
Use: Use of patient-reported quantitative data within psychotherapy entails both the explicit uses expressed in words and actions, as well as more implicit within-person utilization of data.This implicit use is not explicitly expressed in the dyad but may involve decision-making or changes to thoughts and feelings.Such use can happen outside therapy sessions (e.g., when completing the instrument or when preparing for sessions).
Quantitative instruments: For this review, a quantitative instrument refers to an instrument that collects patient-reported data (PD) with some numeric summary.These instruments could be used as part of assessment, treatment planning or monitoring, with any frequency of assessment.
Psychotherapy: The scope of the present article is limited to the use of PD during psychotherapy.Psychotherapy is taken to mean a conversation-based intervention for mental or behavioral health, operationalized in the inclusion/exclusion criteria.

Inclusion criteria
Included studies had to pertain to the actual use of patient-generated quantitative data in ongoing psychotherapy processes.This excludes any study that used measures for exclusively non-psychotherapeutic reasons and those that did not have an active individual psychotherapy.Participants in the included studies were mental health patients (≥18 year) or therapists treating adult patients (≥18 year).There was no restriction on the therapists' orientation or the patients' diagnosis.Qualitative studies and multi-method (or mixed) studies that contained a qualitative section were included.There was no restriction on the type of qualitative methodology, method of analysis, theoretical framework, or data collection strategy.Studies were restricted to English or Scandinavian languages, with no constraint on the publication date.

Search strategy
A comprehensive electronic search was conducted on 3/8/2022 with the goal of identifying all relevant studies in the PsycInfo (n = 1402), Medline (n = 4380), and Web of Science (n = 3181) databases from their inception to the search date.The fulltext of all the articles in the databases was searched, using a combination of text words and subject heading terms.As there are no common subject headings or Boolean connectors for all the databases, slightly different terms were used that were specific to the database that was searched.Table I shows the search strategy.A research librarian was consulted to develop and refine the search strategy and to review the final searches.A search alert was created for all three databases to ensure the inclusion of relevant articles published during the review period.The final alert was evaluated on 12/31/2022.One relevant article was identified by this process (Marriott et al., 2023) and included in the current study.

Article selection
The search yielded 8963 titles, of which 3381 were duplicates (see Figure 1).The first author read all the titles and after excluding duplicates and articles that were obviously irrelevant to the subject (e.g., dealing with a different subject or setting, not using qualitative methods; for example Flannery et al. (2018), Measuring Outcomes of Psychological Well-Being within Pediatric Health Settings), a total of 241 articles were given closer inspection.The first author consulted with the last author during this initial screening process to calibrate and ensure that no relevant articles were overlooked.
After reading the abstracts of the 241 articles, and excluding articles that were irrelevant to our research questions (e.g., those that dealt with a different subject or setting, that used quantitative methods, or that did not use PD in ongoing psychotherapy processes), the full-text of 47 articles was retrieved and assessed in detail by two persons for final selection.The first and last author individually read all 47 articles, which led to the exclusion of 21 articles due to: not using PD in ongoing psychotherapy processes (n = 6), not using qualitative methods (n = 5); reporting experiences related only to the implementation process (n = 8); taking place in the wrong setting (n = 2).Backward citation searches (by hand searching the reference lists of the included articles) led to the identification of one additional relevant article.Forward citation searches (using Google Scholar) identified four additional relevant articles, one of which was the same as the one identified through backward citation.Including the article identified through search alerts, the final sample consisted of 31 articles, which is an adequate sample for a qualitative meta-analysis (Timulak, 2009).See Table II for an overview of the included studies.
The field of psychotherapy in mental health uses several different terms for the population of helpseeking/help-providing individuals.We chose to use the terms patient and therapist in this review.When describing the articles, we use the terms their authors' used, as well as providing some information about the settings of the studies.

Data extraction
The results section of the qualitative studies and the qualitative results section from multi-method studies were extracted for analysis.Two of the included studies were from a family therapy setting and included data on parents and children (Sundet, 2012(Sundet, , 2014)), so the data that explicitly reported the children's experiences were not extracted.One study reported the experiences of therapists, patients, and relatives (Cuperfain et al., 2021), so the data on the experiences of relatives were not extracted.Data in any study that were purely related to the implementation of quantitative measures (e.g., barriers to uptake on an organizational level) were not extracted for analysis because the focus of this meta-analysis was the actual use of such measures in therapy processes.

Data analysis
The analysis was conducted using Nvivo software (QSR International Pty Ltd, 2022) was informed by a descriptive-interpretative approach (Timulak, 2009) and by thematic analysis (Braun & Clarke, 2006).The following steps were implemented.
(1) Process of familiarization The first author read and re-read the material, searching for meanings and patterns and writing down initial ideas from the full data material.
(2) Generating initial codes All extracted data were read line by line, and codes were created inductively from the data (Hill et al., 1997;Timulak, 2009).Adhering to a process of reciprocal translation (Melendez-Torres et al., 2015), codes were clustered by similarity across the data forming categories and sorted into preliminary themes.For example the codes "discover things that we did not know about ourselves" (Alves et al., 2016) and " … the questions are to make me look at my situation, really look at it, and to see how I am in the situation … " (Hoy, 2014), were tagged with the tentative category "enhance self-awareness" and sorted into the preliminary theme "withinperson uses."The first author discussed and consulted with the last author in multiple meetings throughout this process.The first and last author met prior to a full team meeting to formally review step two and create a preliminary coding structure.
(3) Preliminary codes and structure The preliminary codes and structure were presented at a meeting of the full research team, during which the preliminary themes were discussed and revised, and the descriptive content of each theme was formulated.
(4) Recoding using the revised coding structure The first author coded the whole material again using the revised preliminary coding structure.Codes were sorted into the themes and further grouped into sub-themes according to the similarity of the properties, dimensions, or variations suggested by the findings (Braun & Clarke, 2006).Constant comparison was performed in the coding process, both by re-reading the material every time a new code emerged and by scrutinizing the re-contextualized material in the individual sub-categories after all of the material had been coded (Sandelowski & Barroso, 2003).
(5) Adjusting codes and subthemes The first and last authors met again to discuss and adjust the codes and subthemes to reach a consensus on the thematic structure.The final structure was made available for critical revision by the full research team, which only resulted in minor adjustments.

Quality appraisal of primary studies
We used the CASP framework (Critical Appraisal Skills Programme, 2018) for quality appraisal, which is a widely used system for this purpose (Majid & Vanstone, 2018;Williams et al., 2020).However, almost all the included articles had different research questions than the research question asked in this review.As such, we chose to assess the quality of the studies for our research question, rather than their original questions.One debate concerning quality appraisal is whether studies that are considered to be of poor quality should be excluded from meta-analysis.Since valid findings might be lost if studies are excluded due to inadequate reporting (Majid & Vanstone, 2018;Sandelowski & Barroso, 2002), we included all studies that we deemed to be relevant for our research question.
In addition, the first author assessed the methodological congruency of each primary study, as reported in the articles.All evaluations of incongruency were confirmed with all authors.Table III contains a summary of the quality analysis, and the full CASP evaluation is available in online Supplementary Material 1.In addition to quality, we also provide a separate rating for value in this review, which accounts for the specific relevance of the findings to the current meta-analysis.For analysis, we decided that themes had to build on codes from articles deemed to be of higher than minimal value, and could be supported by codes from lower value articles.

Results
The included articles reported on: (i) patients' experiences (n = 8); (ii) therapists' experiences (n = 12); and (iii) both therapists' and patients' experiences (n = 11).The studies were conducted in a wide array of mental health settings in Western European countries (n = 22), Canada (n = 1), or the United States (n = 8).All but one article (Ashworth et al., 2005) was published from 2012 and onwards, and 14 articles were published from 2020 and onwards.The main overarching finding across the studies was that participants found PD relevant and expressed having had highly engaging experiences with it.Beyond this, we found significant variation among the included articles regarding which uses and contexts they focused on.Our bottom up analysis found that articles reporting on therapists uses of PD had more nomothetic assessment uses, and less intrapersonal uses compared to articles reporting on patients' perspectives.All articles except one reported uses that prompted interactional processes, and all reports of using PD for specific purposes were reported by patients.Other than this, no significant differences were found when comparing articles reporting on the perspectives of therapists, patients, or both.This broad distribution of focus suggests that using PD in psychotherapy is complex and only part of the total effect is likely to be discovered in any single study.For a full overview of the distribution of inductive codes in the individual articles, see online supplementary material 2.
Four main themes were identified through analysis: (1) Nomothetic uses (using scores for comparisons across individuals).This theme refers to the information that can be read directly from PD, often outside the exploratory conversation between the participants, and focusing on scores and numbers.Uses of PD by therapists and teams to plan or structure interventions outside the interaction with the patient are also included here.This theme includes detection, monitoring, and baseline assessment.Both therapists and patients referred to this theme, though therapists did so more often.
(2) Intrapersonal uses (participants' reflections upon seeing PD or the PD instrument).This theme refers to the subjective impact of PD on participants that resulted from the process of seeing, reading, and filling out a PD instrument.These uses were not always explicitly communicated in the dyad, but triggered an internal change in the individual that could influence the therapeutic process.For the patient, this was reported in the form of reflections, detecting and feeling emotions, understanding new connections, being confronted with novel experiences, and negative experiences such as performance anxiety.
Therapists reported awareness of their own competence and how they affected patients, leading to humility and empathy.
(3) Interactional processes (ways that PD altered the participants' interactions).This theme refers to the communication of the clients' perspective or reflection into the therapeutic relationship, and the translation of this information into a collaborative therapeutic process.Therapists exemplified this theme by using PD to enhance the patient's understanding of themselves and more actively involve patients in treatment.Patients exemplified this theme by referring to PD as a means of presenting themselves and their current problems, communicating a way to help them disclose difficult issues, and a way to experience a sense of control.(4) Patients responding with specific purposes (patients providing motivated responses to items to achieve specific goals beyond answering the items).This theme refers to the act of using PD to achieve something personally important by adjusting answers to fit the purpose.This theme includes the conscious act of using PD to ensure access to services, taking care of one's perceived needs and rights, and more interpersonal needs of being liked and being polite.This theme appears to be closely related to patients' reporting uncertainty about the therapists/services and the purpose of PD.Consequences could be discrepancies between PD and the therapists' perception.Experiences in this theme could be positive or negative contributors to therapy process and outcome, depending on several factors.
Each of these themes had subthemes and detailed findings are presented in Table IV.

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Table IV.Synthesized findings (n = number of articles reporting the theme/subtheme).

Themes
Subthemes Descriptors Illustrative quotes Nomothetic uses ( 29) Assessment ( 16) This theme, reported solely by therapists, pertains to using PD for nomothetic assessment of patients in session or to therapists who viewed PD prior to seeing patients.Uses mentioned were using PD for initial assessment and diagnostic clarification, assess current symptom intensity, identification of risk by e.g., reviewing questions on suicide and self-harm, making a comparison between patients response' and clinical impression and provide additional information on symptoms and stresses in the patient's life.Therapists found using PD for assessment somewhat useful.Some reported using PD only in this way and not as part of an interactional process with patients, while others questioned the validity of scores, and thereby the usefulness of PD and stressed the importance of seeing scores in relation to their clinical view.Using PD for risk assessment was found generally helpful.
"ROM was described as a 'quick screener' for present psychiatric symptoms, which can be discussed with the patient" (Brand et al., 2022)."All therapists felt strongly that CORE-Net was a 'safeguard' measure in visually flagging risk and in helping them with initial and risk assessments" (Unsworth et al., 2012).

Process monitoring (21)
A frequently mentioned theme was the use of PD for monitoring treatment process.Both patients and therapists used PD for detecting deterioration and improvement, identifying stagnation or "being stuck," providing a status update and being made aware of incremental changes.To monitor processes was experienced as helpful and could instill hope when patients saw that progress was made.
"Therapists also valued that clinical feedback tracked progress and that this could prevent therapy from going off-track" (Hovland et al., 2023).

Plan and adjust treatment (17)
This theme includes therapists' reports of using PD for planning and adjusting treatment.PD was used for planning treatment sessions, changing treatment modalities or level of care, planning or evaluating whether to discharge or continue treatment, trying to predict treatment outcomes, communicate with other clinicians in the treatment team or treatment meetings, as a basis for justifying referrals, to set and monitor treatment goals and to support clinical reasoning.When experiences with these uses were mentioned, they were most often described as helpful, especially regarding communication with other clinicians, and setting and monitoring goals.
"With most of my patients, I like to incorporate some of the measurement-based care scores as part of their treatment goals and treatment plan, just so that we have something measurable from the beginning of treatment, midway, and towards the end.… It really does help to kind of inform my interventions or my techniques.[on MBC with this patient]" (Brooks Holliday et al., 2021).
"Therapists discussed how they used the clinical cut-off scores for triaging or deciding the number of sessions that might be needed by the client.This demonstrated advanced clinical use of the measure in an integrated way into their clinical practice, particularly for the PCC therapists" (Unsworth et al., 2012).Reference to objectivity (9) Both therapists and patients contributed to this theme, which pertains to seeing PD as providing a "true picture" of the patients' situation.They talked about cut-off scores, trying to reach a specific number on a scale, "see how you really feel," and evidence of change.Seeing PD as something objective was experienced as both helpful and unhelpful by both patients and clinicians.They were helpful when they could be used to instill hope and encourage patients to see that they were actually improving, but unhelpful when patients became too caught up in the numbers and experienced a sense of failure if a specific number was not reached.
"The CORE-OM results were perceived by some participants as giving the 'true' picture of how they felt.Monica expressed a wish to view her results in order to understand her own wellbeing: 'Maybe you would want to know how you really feel, if you are better or worse off.'She somehow seemed to trust the instrument to know more about her inner state than she did herself" (Borjesson & Bostrom, 2020)."Clients really can get a terrible tendency: 'yes, but I have to go below 15 because then I will be cured.'That is very sad when the next time is 17, then you have it again" (Brand et al., 2022).

Intrapersonal uses (22) Being influenced by PD (9)
This theme encompasses patients' descriptions of how the act of completing PD instruments or viewing PD influenced them.This happened inside or outside of therapy, depending on where instruments were completed.PD could influence patients' mood in both positive and negative ways, evoke or make patients confront their feelings, shape experiences, create ideas by seeing symptoms or connections they otherwise would not have thought of, promote anxiety and both begin the therapeutic process outside of therapy sessions or be a barrier to the therapeutic process.These uses were both positive and negative and could be both helpful and unhelpful depending on the patient and the situation.
"Anna reacted to the phrase 'I feel worthless,' and in the new context it appeared, which triggered new thoughts: 'especially when I get 'I am worthless' followed by a question about suicide, I become like … (sighs).' Presented with this unexpected combination, this patient found it difficult to let go of the thoughts it created" (Hovland et al., 2023).
Enhance selfawareness ( 16) This theme pertains to patients' reports of using PD for enhanced self-awareness.PD could trigger new insights and help patients understand themselves better, contribute to awareness of symptoms or feelings they were experiencing, or help them become aware of therapeutic gains.This enhanced self-awareness was experienced as helpful, although it could also be unpleasant.Becoming more self-aware could facilitate communication with both the therapist and loved ones.Becoming aware of change was reported as motivating.
" … questionnaires made her aware of how much she had changed since starting the therapeutic community programme 'It made me think about how different I am.When I arrived I was at the bottom and now I am a new woman'" (Alves et al., 2016)."Tova described how the questions became a way of becoming aware of her emotions: 'Well, normally I just get on with it and try to distance myself emotionally.And then when you come here and answer the questions / … / then you really see it on paper in front of you and it becomes more real when you really read and then think and then answer, it becomes kind of a reality check'" (Borjesson & Bostrom, 2020).Initiate reflection (8) Patients' talked about PD leading to reflections on why they were feeling and behaving in the ways that they were, as well as how the different aspects of their lives were affected by their symptoms and vice versa.This self-reflection could provide clarity and be an incentive for change.
"The results allowed me to take more account of myself.For example, 'why is it that my anxiety symptoms have increased?',then I could reflect on these feelings.That's what I learned here: standing still" (Brand et al., 2022).Therapists use for selfreflection (8) Therapists also stated intrapersonal uses of PD.These were related to an increased awareness of their role as therapists, perceptions on one's competency, and increased self-reflection and learning, which they reported as useful.Some mentioned that a heavy focus on their appearance or style as therapists could lead to therapists molding themselves too much to fit the client's preferences.This risk was especially highlighted for novice therapists.
"What's interesting is when they get to the mid-point review for us and you see that someone's indicated that they want something to change.It's an interesting process in terms of 'yes, I can do that,' but what goes on for yourself in terms of your own internal supervisor-'wow, why didn't I notice that myself?' or 'why wasn't I already doing that?'" (Bowens & Cooper, 2012)."Another therapist mentioned that feedback helped them to think more critically about treatment, saying, 'It helped me to figure out why the treatment was not working properly.Partly because of this, I started to study the method of group psychotherapy thoroughly and I registered for a training'" (Koementas-de Vos et al., 2022).
(Continued ) Create ownership ( 22) Both therapists and patients contributed to this theme, which pertains to creating ownership of treatment for patients by using PD to engage and involve patients, make them responsible for their care, and promote collaboration in the dyad.Both therapists and patients found using PD in this way empowering for patients, helping them take more control, although sometimes this account of empowerment was more pronounced in the therapists' reports.This theme also contains patients' reports on how they were affected by the therapist's response to their answers on instruments.If patients perceived that their answers to the questionnaires were not important to the therapist, this was detrimental to the treatment process and the therapeutic alliance.
" … 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" (Matanov et al., 2021)."One participant was very interested in monitoring and discussing his own progression.He had previously done so on his own, making notes in his diary about sleep, mood, and energy levels.He seemed to be an ideal candidate for using a CFS.However, having answered NF, his experience was that his therapist only mentioned it briefly, in the one session that was video recorded for the interview.The participant expressed disappointment and frustration over this" (Solstad et al., 2021a).Support exploration (23) This theme consists of therapists' and patients' reports on how they used PD to collaboratively explore aspects of the patient's life, symptoms, and functioning.PD led to therapists discovering new things about patients, and could be like a radar for discovering hidden or buried issues.PD were used to create awareness of the process of change, help in actively selecting focus in sessions, promote insight for patients, and create opportunities for therapists to explore discrepancies between their clinical impression and patients' scores and appearance.Using PD as a basis for discussion to explore and reflect over time was seen as especially helpful, and becoming aware of positive change was seen as encouraging and empowering for patients.In some cases, instead of seeing discrepancies as an opportunity for exploration, therapists reported it meant that the PD instruments were flawed or invalid or that there was something not right with the way the patient had answered.
"My impression is that if I say something like 'you are experiencing difficult times' or 'this looks like it is going better,' almost every time the client responds with 'I did not mean that.I do not know if I understood the question.'But when I phrase my feed-back like 'Would you please explain to me what this means?'I almost never get that defense response.I believe people do not want to be told how they feel.They want to wonder and explore the STIC together with us" (Oanes et al., 2017)."The use of the measures provided a focus for short-term work: 'I found if when I asked a question about 'which question stood out for you', not regarding the score so much, then we can talk about it in that way and bring focus to that and that was helpful'" (Unsworth et al., 2012).

Enhance therapeutic alliance (17)
Therapists and patients both reported using PD to build and enhance the therapeutic alliance.PD were used to help therapists understand patients better and specifically address the therapeutic alliance.
In addition, some patients reported that the provision of PD instruments gave them a sense that someone cared about them because they wanted to see how they were doing.Information on the alliance was perceived as useful by the therapists.Understanding and being understood created feelings of safety for both parties.It was important for patients that their feedback was acknowledged for PD to be perceived as helpful.
"In that respect, both patients and therapists found it easier to actualize the relationship between patients and therapists when using clinical feedback.Both patients and therapists regarded clinical feedback as especially important in the early phase of therapy when one needs to build trust" (Hovland et al., 2023)."Using the SRS and ORS to give feedback to therapists was acknowledged as: 'helping [them] help us' […].To be able to signify when one did not feel heard, when one was dissatisfied with the therapeutic method and when the therapists represented a disturbance were reported as important areas of use for the scales" (Sundet, 2014).Facilitate communication This theme captures therapists and patients' reports on using PD to facilitate communication in therapy sessions.PD were used to focus the dialogue on relevant issues, discuss progress and treatment course, help patients express themselves, initiate conversations on sensitive or difficult topics, and help both parties remember important topics to discuss.In addition, PD could in itself be perceived as a means of communication from patients to the therapist and many patients were concerned about PD conveying an accurate picture of their situation.PD could become a disturbance if patients felt they created a false picture.Related to PD as a means of communication, were patients' accounts of questionnaires prompting them to be honest with themselves and others, and also patients' ambiguity around answering honestly.Trust was reported as essential for providing honesty.
"Participants were keenly aware that their answers were meant to be read by their therapist.All participants said they wanted their answers to be honest and precise, but most described ambivalence in answering" (Solstad et al., 2021b)."For some patients and clinicians, it acted as a reminder of important topics to deal with and made starting a relevant conversation easier" (Hovland et al., 2023).
Re-adjust treatment focus (11) Re-adjusting treatment focus and using PD to personalize treatment for the individual patient was reported as an important function of PD by both therapists and patients.It was equally important that PD could be used flexibly and without constraining the topics discussed or the therapeutic approach.
"Each component of the scales gave opportunities for creating a structure that fitted the family.Structure did not imply rigidity and it was always the response of the family that became decisive for the successive response of the therapist" (Sundet, 2012)." … they connected scores to specific skills or strategies that the patient could use" (Brooks Holliday et al., 2021).A disturbance (13) This theme concerns situations where PD were not perceived as helpful by patients or therapists, but rather created a disturbance in the therapy session.Disturbances mentioned were PD negatively affecting the therapeutic alliance, raising uncomfortable issues, creating a negative and problemfocused mood, rerouting attention away from therapeutic topics, impairing the natural flow of conversation, and imposing unnecessary or irrelevant topics.Some patients referred to quantitative instruments as tick-box exercises.These disturbances made some patients and therapists report that the use of PD in itself was unhelpful, although most still reported a nuanced view of PD use.
"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" (Matanov et al., 2021)."Questions were raised about whether the scales could destroy aspects of the relationship with other family members, especially one's children.Could they, by discussing the scores, be exposed to material that was too difficult for them to handle?" (Sundet, 2014).
Patients responding for specific purposes ( 6) Uncertainty (1) Uncertainty of why PD were completed and who would retrieve their results, could make some patients change their answers as a security measure.
"Some of the participants suggested that the lack of information might make clients cautious when completing the form.Tom said, 'Provide some more information about what it's used for and why.
Be totally open about it so there won't be any doubts about how it will be used.That way you avoid conspiracy theories'" (Borjesson & Bostrom, 2020).Interpersonal reasons (3) This theme is composed of patients' accounts of giving interpersonal reasons of wanting to be liked by their therapist or feeling obliged to show that they had improved, as a rationale for altering their answers.Patients in this theme seemed to think that they had some responsibility for keeping their therapists happy or interested in their case.
"Sometimes I feel that I want things to improve so they can tell that the treatment is having a positive effect on me.That there is a point in treating me and that I am a good client, quote-unquote.That I take myself and the treatment seriously, or otherwise there's no point in investing in me" (Borjesson & Bostrom, 2020).Changing strategically (5) This theme consists of patients' accounts about altering PD to fit a specific purpose.Reasons given were: to achieve access to services, assure that therapists would not make unwanted changes to their therapy or medication, or avoid being involuntarily hospitalized.Patients used PD in this way to gain control of their situation or to obtain a perceived right to treatment.Changing answers strategically seemed to occur more frequently when there was lack of trust in the therapeutic relationship or in services in general, or when patients were uncertain about the purpose of using PD.(Bendall & McGrath, 2020).

Discussion
The aim of this study was to synthesize patients' and therapists' experiences of using patient-generated quantitative data in ongoing psychotherapy processes.Our analysis identified four main categories of use: (1) nomothetic uses; (2) intrapersonal uses; (3) uses that prompted interactional processes; and, (4) patients responding for specific purposes.

Traditional uses of PD
The nomothetic use of PD corresponds most closely to the traditional use of PD reported in quantitative clinical feedback studies.The frequency and clarity of these reports, mostly by therapists rather than patients, suggest that PD must fulfill the need to assess, measure, and monitor in order to be useful in practice.Many clinicians and patients assume such nomothetic use is valid, which makes sense, since these are the uses that are generally validated and compared using psychometric analyses (see, e.g., Elfström et al., 2013).Therapists' reports of the usefulness of PD for these nomothetic uses are closely related to their perceived validity of the PD instrument.When therapists report that their clinical impression and patients' answers to PD questionnaires are comparable, PD is often perceived as being valid.When the opposite occurs and clinical impressions and PD do not match, the PD instruments were often perceived as being invalid and, therefore, not useful (Ashworth et al., 2005;Hovland et al., 2023;Oanes et al., 2017;Tickle et al., 2013).Rejection of PD when it does not match a clinical impression may be a considerable problem, since valid PD should sometimes conflict with therapists' opinions; this is actually why it should improve therapy outcomes.Clearly, only using PD to confirm clinical impressions will not lead to benefits.In our review, however, it does also seem reasonable that the validity of nomothetic use of PD would sometimes be challenging.Some studies specifically identified ways that patients responded on PD instruments with strategic intent.These motives were generally for their own benefit (to access resources or avoid unwanted consequences), or their therapist's benefit.While these were only a minority of the codes observed in these data, they threaten the validity of the primary nomothetic uses of PD.If patients knowingly provide misleading information on PD instruments, taking scores from PD as markers of outcomes, or even comparing two individuals' scores to each other, is less valid.Additionally, both therapists and patients identified ways that PD could be useful to prompt interactive processes, which is definitionally not nomothetic, and may produce further challenges if patients use PD to change conversation topics, for instance.Further research is needed on the response processes of patients when completing these PD instruments, especially to help understand when nomothetic interpretations can be relied upon and when they should be contextualized.
It would be irresponsible to reject PD solely due to a conflicting clinical impression, but it is also irresponsible to treat PD as valid regardless of other information.Most productively, such discrepancies would be a basis for clinical exploration of patients' needs.Rather than therapists treating the PD as invalid if they disagree with the findings, they could open dialogues to develop shared insight into the psychotherapeutic process.The possibility of such conversations underscores a constructive differentiation between psychometric validity and clinical usefulness.It seems possible in our review that PD can be psychometrically invalid for specific nomothetic uses and still valid for other uses.This understanding may help increase uptake of PD in clinical contexts.

An extended understanding of PD use
In addition to the standard nomothetic uses of PD, the qualitative research reviewed here also identified many other ways that PD influence the therapeutic process.This is especially well represented by the themes of intrapersonal use and prompt interactional process use.It is clear that if we focus solely on therapists' use of PD for assessing patients and outcomes, important impacts of PD will be overlooked.These intrapersonal and interactional themes indicate that PD do not exist in a vacuum; it is, as Bendall and McGrath (2020) say, "the immovable object," that is always present and influencing the patient, the therapist, and their interaction in both constructive and disruptive ways.This can be seen very clearly in the article by Borjesson and Bostrom (2020) where most of the participating patients had not discussed PD with their therapist, and one participant even thought her answers were anonymous.Even in this case, the patients described uses pertaining to all of our four main themes and 10 of our 17 subthemes.
It is important to consider the non-nomothetic themes that emerged from therapists' and patients' reports, because they may represent especially good avenues for future clinical research.Given that the outcome benefits of PD seem to be heterogeneous and depend on patient, therapist, and clinical environment factors (de Jong et al., 2021), these non-nomothetic themes may help us better target PD interventions to individuals who will make the most use of them, improve PD instruments to make them more impactful, or understand training and implementation needs.These themes also suggest new mechanisms of action for PD.While the nomothetic uses suggest that therapists can indeed use PD to alter treatment plans and identify targets of treatment, we should also consider that patients use PD to focus their own thoughts, generate insights, and identify ways that they would like treatment to improve.These intrapersonal processes can clearly be positive or negative, since patients report that PD sometimes influence their mood negatively, makes them feel anxious, or can change their attitude towards their therapist.This active use of PD by patients is poorly accounted for by quantitative outcome research on feedback, and likely deserves more attention from the field.
The findings of this review indicate that PD can have both positive and negative influences on treatment.These findings may explain, at least in part, the inconsistent findings of previous meta-analysis regarding the effect of measurement-based care and the challenges regarding implementation of these systems in practice.Even though most therapists and patients found PD to be at least somewhat helpful or useful, there were also quite a few accounts of how PD could disturb the therapeutic work and alliance, and even be a barrier to the therapeutic process.These negative impacts could be due to the implementation process, the therapist's style or orientation, and the participants' previous experiences with PD use.Alternatively, it could also be that one particular PD instrument is poorly matched to the style of one particular therapist or the goals of a particular patient.While adding PD to psychotherapy may have benefits, on average, clearly there are times when their addition seems to make treatment worse.In this context, we suggest care be taken when implementing PD instruments and suggest that while routine use is beneficial, therapists and clinic administrators listen to patients and therapists who express negative experiences.Flexibility in PD use may be important and empirical quantitative methods is required to extend this qualitative knowledge.

Limitations
This review and meta-analysis is limited by the source material, which in this case means limited to qualitative findings in published reviews.The methods of synthesis used here, though based on clearly established guidelines, entail some degree of confirmation bias and tend to simplify complex findings.We have tried to limit the points at which researcher bias could enter the analysis, but this will never be completely eliminated.For the purpose of this review, we chose to exclude studies that purely focused on issues related to the implementation of PD instruments, as our research question is concerned with actual use of such instruments in psychotherapy.We acknowledge that issues regarding the implementation of instruments may well affect how they are perceived by therapists and by extension this could affect use.We hypothesize that this limitation would lead us to include a higher portion of therapists in particular who are interested in or see value in PD, and so may not fully capture negative experiences and absence-of-uses with PD among therapists.As such, excluding studies on implementation is a limitation of this review.

Conclusion
This systematic review and meta-analysis of qualitative reports found that PD is used in several distinct ways during ongoing psychotherapy.Previous studies have not taken into account the complex reasons why therapists and patients use routine outcome monitoring and feedback, which may contribute to the inconsistent findings regarding the effect of this evidence-based intervention.While the standard nomothetic uses of PD (e.g., for assessment) is common, participants report several other uses of PD during therapy.These uses could potentially serve as the basis for methods that could be implemented in training and clinical practice, which in turn may improve the impact of measurement-based care and psychotherapy.Our results, which emerge in the qualitative research literature, could beneficially be investigated in future qualitative and quantitative research.

Figure 1 .
Figure 1.Flow chart of the screening process.

Table I .
. The analysis Search strategy.

Table II .
Included articles, aims, methods, and quantitative instruments used.
Analyze the experiences of therapists and what they consider the strengths and drawbacks of the forms TPF/TFP-A, with a particular focus on the effect on the therapist, the client and the therapeutic relationship Design: Qualitative inquiry Data collection: Individual interviews Analysis: Thematic analysis, Rodger's and Cooper's scoring scheme for qualitative thematic analysis TPF, TPF-A

Table II .
Continued.
11 practitioners and 11 patients in step 2 of IAPT with therapy delivered by telephone Explore the administration and therapeutic use of ROM during treatment delivered by telephone at step 2 care in IAPT services Design: Social constructionist approach Data collection: Transcripts of telephone psychotherapy sessions Analysis: Thematic analysis (semantic) PHQ-9, GAD-7, WSAS, IAPT phobia scale Fornells-Ambrojo et al. (2017) 257 clients in IAPT-SMI receiving CBT and/ or family interventions for psychosis Investigate user experiences of ROM (both periodic and sessional) through a thematic analysis of feedback, explicitly focusing on helpful and unhelpful aspects Design: Qualitative and quantitative methods Data collection: Questionnaire with open-

Table II .
Continued.

Table II .
Continued.

Table III .
CASP and relevance analysis.

Table IV .
Continued.