Marianne Therese Smogeli Holter

• Bjørkli, Cato; Hansen, Magnus Bechmann; Holter, Marianne Therese Smogeli; Hafstad, Marius Duhovic & Fostervold, Knut Inge (2026). The impact of COVID-19 on the gig economy in the creative- and culture sector. Journal of Managerial Psychology. ISSN 0268-3946. p. 1–17. doi: 10.1108/JMP-08-2023-0477. Full text in Research Archive
• Holter, Marianne Therese Smogeli; Bøe, Tore Dag & Bertelsen, Bård (2024). Et alternativ til diagnoser for psykiske lidelser: Makt–trussel–mening-rammeverket. Tidsskrift for Norsk psykologforening (Psykologtidsskriftet). ISSN 0332-6470. 61(7), p. 454–462. doi: 10.52734/PTJO4792. Full text in Research Archive Show summary

  The article presents the Power Threat Meaning Framework (PTMF), which was developed by a working group under the British Psychological Association in 2018 as an alternative to traditional diagnostic systems such as DSM and ICD. PTMF criticises conventional diagnostics for being overly simplistic and based on an implicit assumption of individual vulnerability as the main cause of mental health problems. Instead, PTMF emphasises the importance of social conditions and life events in the development of emotional pain and mental health problems. This perspective entails viewing people’s responses as attempts to deal with threats to their basic life conditions rather than as symptoms of underlying illnesses. The framework is based on a critical reading of the evidence base for existing diagnostic systems and on extensive research supporting alternative understandings of what has traditionally been understood as mental illness. For Norwegian psychologists, PTMF can help enrich evidence-based clinical practice by promoting an understanding of mental illness as meaningful responses to complex life situations. This can be integrated into practice through methodologies such as case formulation, trauma-informed approaches, and network-based working methods that facilitate the exploration of people’s personal narratives and their social context. The article argues that incorporating PTMF as a legitimate conceptual framework in Norwegian health and welfare services could conceivably contribute to a more holistic health service by integrating mental health work with practical help and support from family, friends, and community resources in ways that are more appropriate than the way services work today. PTMF invites psychologists in Norway to challenge traditional models and contribute to more inclusive and contextualised mental health care. With this article, we hope to inspire reflection on new approaches to mental health and debate about the implications of integrating PTMF in clinical work.

• Hamina, Aleksi; Odsbu, Ingvild; Borchgrevink, Petter Chr.; Chen, Li-Chia; Clausen, Thomas & Espnes, Ketil Arne [Show all 18 contributors for this article] (2022). Cohort Description: Preventing an Opioid Epidemic in Norway – Focusing on Treatment of Chronic Pain (POINT) – A National Registry-Based Study. Clinical Epidemiology. 14, p. 1477–1486. doi: 10.2147/CLEP.S382136. Full text in Research Archive Show summary

  Aim: The POINT project aims to provide evidence to optimise chronic pain management, prevent adverse consequences of opioids, and improve chronic pain patients’ pain relief, functional capacity, and quality of life. We describe the outline of the project and its work packages. More specifically, we describe a cohort of persons with chronic pain and a cohort of long-term opioid users identified from a national registry linkage. Data Sources: The project utilises data from nationwide healthcare and population registers in Norway. Using the Norwegian Prescription Database, we identified a cohort of persons who have been dispensed drugs reimbursed for chronic pain and a cohort of persons who used opioids long term from 2010 to 2019. Data from the Norwegian Registry for Primary Health Care and the Norwegian Patient Registry (2008– 2019), Cancer Registry (1990– 2018) Cause of Death Registry (2010– 2019) and demographic and socioeconomic registers from Statistics Norway (2010– 2019) were linked to the cohorts. Study Population: There were 568,869 participants with chronic pain. Sixty-three percent of the cohort was women, and the mean age was 57.1 years. There were 336,712 long-term opioid users (58.6% women; 60.9 years). In chronic pain and long-term opioid user cohorts, the most frequent musculoskeletal diagnosis was back pain diagnosed in primary care (27.6% and 30.7%). Psychiatric diagnoses were also common. Main Variables: Upcoming studies will utilise psychiatric and somatic diagnoses from the patient registers, drug use from the prescription register, causes of death, demographics, and socioeconomic status (eg, education, income, workability, immigrant status) as exposures or outcomes. Conclusion and Future Plans: The two cohorts have numerous pain-related diagnoses, especially in the musculoskeletal system, and noticeably frequent somatic and psychiatric morbidity. The POINT project also includes later work packages that explore prescriber and patient perspectives around safe and effective treatment of chronic pain.

• Kulhánek, Adam; Lukavska, Katerina; Gabrhelík, Roman; Novák, Daniel; Burda, Václav & Prokop, Jindřich [Show all 8 contributors for this article] (2022). Comparing Reminders Sent via SMS Text Messaging and Email for Improving Adherence to an Electronic Health Program: Randomized Controlled Trial. JMIR mhealth and uhealth. 10(3), p. e31040–e31040. doi: 10.2196/31040. Full text in Research Archive
• Holter, Marianne Therese Smogeli (2022). The Ethical and Methodological Dilemma of Questioning the Truthfulness of a Participant’s Story: Using “Circulating Reference” to Enhance the Validity of Qualitative Research. International Journal of Qualitative Methods (IJQM). 21. doi: 10.1177/16094069221117985. Full text in Research Archive Show summary

  The question of how to enhance validity in qualitative research has been thoroughly debated. In this debate, however, the truthfulness of participants’ stories is rarely questioned. But what do you do if you, while working within a critical realist perspective, come across a story that seems almost too incredible to be true? This dilemma of The Almost Too Incredible Story is ethical as well as methodological. In this article, I suggest that it is best handled by conceptualizing the process of qualitative inquiry in terms of Bruno Latour’s concept “circulating reference”. The dilemma is then addressed through a stepwise process starting with (1) analysing all material as if all were believed to be true; (2) retracing the role of the data you question through the study’s ladder of circulating reference; (3) retracing the role of the data in the researcher’s transformed understanding of the phenomenon; and (4) using the results of these steps to determine whether The Almost Too Incredible Story poses a genuine threat to the validity of the results. If the validity is threatened, the researcher may decide to (a) return to the participant to clarify; (b) trust and keep the story; (c) discard all the data from this participant from the analysis; or (d) discard only the data that does not align with other participants’ account. Through this systematic process, the researcher can determine the best course of action for keeping the research as truthful as possible while also honouring the participant’s contribution.

• Sandtrø, Hege Pettersen; Glavin, Kari; Størksen, Hege Therese; Holter, Marianne Therese Smogeli & Drozd, Filip (2022). Mothers and public health nurses' experiences of sleep problems in children aged 6 months to 3 years: A qualitative study. Journal of Clinical Nursing (JCN). ISSN 0962-1067. p. 1–16. doi: 10.1111/jocn.16586. Full text in Research Archive Show summary

  Aim and Objective The aim of this study was to explore mothers' and public health nurses' (PHN) experiences with sleep problems in children aged 6 months to 3 years in Norway. Background Sleep problems in children are common, affecting their health and development, and their mothers' well-being. It is also the primary reason parents seek help in well-child clinics (WCC). However, there is limited knowledge regarding the experiences of these mothers and the public health nurses who consult them. Design Qualitative design. Methods Four semi-structured focus group interviews were conducted: two with mothers (n = 14) who had children with sleep problems and two with public health nurses (n = 14) from well-child clinics. The Framework Method was used for analysing the interviews of mothers. Data from public health nurses were charted onto the analytical framework of maternal data to understand how or whether public health nurses addressed the issues raised by mothers. The study is reported according to the COREQ checklist. Result The analysis resulted in two main themes: ‘therapeutic alliance’ (categories ‘alliance ruptures’ and ‘demanding negotiation process’) and ‘reorganisation of identity’ (categories ‘unfulfilled expectations’ and ‘internal tension conflicts’). Conclusion Young children's sleep problems present challenges to new mothers due to failed expectations, negatively affecting their feelings as mothers and towards their children, and consequently the reorganising of maternal identity. Most mothers experienced unsatisfactory therapeutic alliances while seeking help from public health nurses because advice was considered overly general, contradictory and unsafe for their children. Public health nurses were mostly aware of the parental consequences of children's sleep problems, but many appeared unable to help because of limited time and knowledge. Relevance to Clinical Practice Public health nurses need to establish a therapeutic alliance and provide evidence-based knowledge and guidance on sleep problems while also considering women's reorganisation of identity when becoming mothers. Clinical Trial Registration Open Science Framework: osf-registrations-6ag38-v1 (https://archive.org/details/osf-registrations-6ag38-v1).

• Holter, Marianne Therese Smogeli (2021). Et fritt behandlingsvalg? – Betingelser for og betydningen av valgfrihet i spesialisthelsetjenesten. Nytt Norsk Tidsskrift (NNT). ISSN 0800-336X. 38(4), p. 298–307. doi: 10.18261/issn.1504-3053-2021-04-04. Full text in Research Archive Show summary

  Pasienter i spesialisthelsetjenesten fikk i 2015 en rett til fritt behandlingsvalg, men som denne studien viser, er det mange som ikke får realisert denne retten. Den som henviser, informerer ikke alltid, systemet er komplisert, og noen pasienter blir direkte motarbeidet. Valgfriheten betinges dermed av evnen til pasientmanøvrering. Valgfriheten har stor betydning for pasienter i visse situasjoner og har også for noen en egenverdi. Tiltak må iverksettes hvis valgfriheten skal være tilgjengelig for flere.

• Holter, Marianne Therese Smogeli; Ness, Ottar; Johansen, Ayna Beate & Brendryen, Håvar (2020). Making Come-Alive and Keeping Un-Alive: How People Relate to Self-Guided Web-Based Health Interventions. Qualitative Health Research. ISSN 1049-7323. 30(6), p. 927–941. doi: 10.1177/1049732320902456. Full text in Research Archive Show summary

  Health interventions delivered online (self-guided web-based interventions) may become more helpful through a person-to program “working alliance.” In psychotherapy, the working alliance signifies a therapeutically useful client–therapist relationship and includes an emotional bond. However, there exist no theories of how program users relate to online programs, or that explain a person-to-program bond theoretically. Addressing this gap, we conducted qualitative interviews with and collected program data from users of a self-guided web-based intervention. Using grounded theory, the analysis arrived at a model of relating based on two relational modes—making comealive and keeping un-alive. Different combinations of these modes could describe a range of ways of relating to the program, including a nonsocial interaction, a semi-social interaction, and a semi-social relationship. A person-to-program bond is explained by the model as an experienced supportive social presence, enabled by making come-alive and a positive program interaction.

• Holter, Marianne T. S.; Ness, Ottar; Johansen, Ayna Beate & Brendryen, Håvar (2019). Getting Change-Space: A Grounded Theory Study of Automated eHealth Therapy. The Qualitative Report (TQR). ISSN 1052-0147. 24(7), p. 1636–1657. doi: 10.46743/2160-3715/2019.3988. Full text in Research Archive Show summary

  A promising tool for bettering people’s health is eHealth (or “mHealth”) programs: fully automated, web-based health interventions. However, we know surprisingly little about eHealth’s working mechanisms. One possible working mechanism is that program users benefit from a collaborative “relationship”—a “working alliance”—with the program. Although evidence support the existence of a person-to-program alliance it is unclear if and how it influences change. Therefore, we conducted a grounded theory study of how relating to an eHealth program for quitting smoking influenced the participants’ change processes. The ensuing model focuses on how participants got change-space—feeling free from social forcing and able to work constructively on changing—and how the relational processes “making come-alive” and “keeping un-alive” were instrumental in this process. By presenting evidence that relating may influence change in automated therapy, this study supports the person-to-program alliance as a working mechanism in eHealth.

• Holter, Marianne T. S.; Johansen, Ayna Beate; Ness, Ottar; Brinkmann, Svend; Høybye, Mette Terp & Brendryen, Håvar (2019). Qualitative Interview Studies of Working Mechanisms in Electronic Health: Tools to Enhance Study Quality. Journal of Medical Internet Research (JMIR). ISSN 1439-4456. 21(5). doi: 10.2196/10354. Full text in Research Archive Show summary

  Future development of eHealth programs (automated web-based health interventions) will be furthered ifprogram design can be based on knowledge of eHealth’s working mechanisms. A promising and pragmaticmethod for exploring potential working mechanisms is qualitative interview studies, in which eHealthworking mechanisms can be explored through the perspective of the program user. Qualitative interviewstudies are promising because they are suited for exploring what is yet unknown, building new knowledgeand constructing theory. They are also pragmatic, because the development of eHealth programs oftenentails user interviews for applied purposes (e.g. getting feedback for program improvement or identifyingbarriers for implementation). By capitalizing on these existing (applied) user interviews to also pursue (basic)research questions of how such programs work, the knowledge base of eHealth’s working mechanisms cangrow quickly. To be useful, such interview studies need to be of sufficient quality, which entails that theinterviews should generate enough data of sufficient quality relevant to the research question (i.e. “richdata”). However, getting rich interview data on eHealth working mechanisms can be surprisingly challenging,as several of the authors have experienced. Moreover, when encountering difficulties as we did, there arefew places to turn to: there are currently no guidelines for conducting such interview studies in a way thatensure their quality. In this paper, we build on our experience as well as the qualitative literature to addressthis need, by describing five challenges that may arise in such interviews and presenting methodologicaltools to counteract each challenge. We hope the ideas we offer will spark methodological reflections andprovide some options for researchers interested in using qualitative interview studies to explore eHealth’sworking mechanisms.

• Holter, Marianne Therese Smogeli; Johansen, Ayna Beate & Brendryen, Håvar (2016). How a Fully Automated eHealth Program Simulates Three Therapeutic Processes: A Case Study. Journal of Medical Internet Research (JMIR). ISSN 1439-4456. 18(6), p. e176–e176. doi: 10.2196/jmir.5415. Full text in Research Archive Show summary

  Background: eHealth programs may be better understood by breaking down the components of one particular program and discussing its potential for interactivity and tailoring in regard to concepts from face-to-face counseling. In the search for the efficacious elements within eHealth programs, it is important to understand how a program using lapse management may simultaneously support working alliance, internalization of motivation, and behavior maintenance. These processes have been applied to fully automated eHealth programs individually. However, given their significance in face-to-face counseling, it may be important to simulate the processes simultaneously in interactive, tailored programs. Objective: We propose a theoretical model for how fully automated behavior change eHealth programs may be more effective by simulating a therapist’s support of a working alliance, internalization of motivation, and managing lapses. Methods: We show how the model is derived from theory and its application to Endre, a fully automated smoking cessation program that engages the user in several “counseling sessions” about quitting. A descriptive case study based on tools from the intervention mapping protocol shows how each therapeutic process is simulated. Results: The program supports the user’s working alliance through alliance factors, the nonembodied relational agent Endre and computerized motivational interviewing. Computerized motivational interviewing also supports internalized motivation to quit, whereas a lapse management component responds to lapses. The description operationalizes working alliance, internalization of motivation, and managing lapses, in terms of eHealth support of smoking cessation. Conclusions: A program may simulate working alliance, internalization of motivation, and lapse management through interactivity and individual tailoring, potentially making fully automated eHealth behavior change programs more effective.

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• Holter, Marianne Therese Smogeli (2024). Digital hjelp til smertebehandling. Glimt. ISSN 1890-8489. p. 20–21. Full text in Research Archive
• Holter, Marianne Therese Smogeli (2023). Digital interventions could transform routine care but we need more research on how to achieve this. Acta Paediatrica. ISSN 0803-5253. doi: 10.1111/apa.16715. Full text in Research Archive
• Reme, Silje Endresen; Munk, Alice; Holter, Marianne Therese Smogeli; Falk, Ragnhild Sørum & Jacobsen, Henrik Børsting (2022). Pre- and post-operative psychological interventions to prevent pain and fatigue after breast cancer surgery (PREVENT): Protocol for a randomized controlled trial. PLOS ONE. 17(7). doi: 10.1371/journal.pone.0268606. Full text in Research Archive Show summary

  Background Breast cancer is the most common cancer type among women worldwide with over a million new cases each year. More than 40% of these women will struggle with chronic pain and fatigue after surgery, regardless of surgical procedure. These consequences are detrimental and result in distress and disability, including work disability. Few attempts have been made to prevent chronic pain and fatigue after surgery by applying a psychological approach, despite psychological risk factors being crucial in the development of both chronic pain and fatigue. In this study, we aim to develop and test an easily implementable strategy of preventing chronic pain and fatigue after breast cancer surgery. The intervention strategy involves a pre-operative hypnosis session and a web-based post-operative Acceptance and Commitment Therapy (ACT). The hypnosis has previously been found effective in alleviating acute post-operative pain and fatigue in breast cancer patients, while ACT is well suited to cancer populations as it offers a model of healthy adaptation to difficult circumstances. Together they form an intervention strategy with both a preventive and a rehabilitative focus. Methods/Design This randomized controlled trial aims to estimate the effects of the pre- and post- operative interventions compared to attentional control and treatment as usual (TAU) and will also include a qualitative process evaluation. Participants will be randomized to receive either a pre-operative brief hypnosis session and a post-operative web-based psychological intervention (iACT) or a pre-operative one-session mindfulness through an audio file and post-operative TAU. Self-reported questionnaire data and biomarker data will be assessed pre-surgery, post-surgery and 3 and 12 months after surgery. In addition, we will assess registry data on sick leave and prescriptions until 2-year follow-up. In the qualitative process evaluation, data will be collected from participants from both study arms (through interviews and a diary) and two different analyses performed (socio-narrative and Grounded Theory) with the objective to describe the development of chronic post-surgical pain and fatigue and the potential influence of the interventions on these processes. The study is set-up to demonstrate a minimum difference in pain of 1 point on NRS (0–10) and 3 points on FACIT-F (0–52) between the groups at 3-months follow-up by including 200 breast cancer patients in total. Discussion This trial will be the first study to estimate the effect of a combined pre-operative hypnosis with a post-operative iACT to prevent pain and fatigue after breast cancer surgery. The results from our study might i) help the large group of women affected by chronic pain and fatigue after breast cancer surgery, ii) shed light on the mechanisms involved in chronic pain and fatigue development, and iii) serve as a model for other surgical procedures. Trial registration Clinicaltrials.gov, registration number NCT04518085. Registered on January 29th, 2020. https://clinicaltrials.gov/ct2/show/NCT04518085.

• Kaarbøe, Oddvar Martin; Holter, Marianne Therese Smogeli & Linden, Tord Skogedal (2021). Fritt behandlingsvalg – presentasjon av de viktigste resultatene fra evalueringen. Full text in Research Archive
• Holter, Marianne Therese Smogeli; Ness, Ottar; Johansen, Ayna & Brendryen, Håvar (2015). Challenges in qualitative interviewing about user experience in eHealth: Moving beyond the superficial user interview. Full text in Research Archive
• Brendryen, Håvar; Danaher, Brian G; Johansen, Ayna & Holter, Marianne Therese Smogeli (2014). Testing the Efficacy of an Automated Lapse Management System: an RCT-Protocol of an Internet-Delivered Smoking Cessation Intervention. Full text in Research Archive
• Holter, Marianne Therese Smogeli; Brendryen, Håvar; Johansen, Ayna & Danaher, Brian G (2014). What’s therapeutic alliance got to do with it? A qualitative (ongoing) study of how the user’s relationship to an eHealth program for smoking cessation might be important for program adherence and treatment outcome. Full text in Research Archive
• Kaarbøe, Oddvar Martin; Lindén, Tord Skogedal; Ervik, Rune; Holmås, Tor Helge; Iversen, Tor & Holter, Marianne Therese Smogeli [Show all 7 contributors for this article] (2021). Evaluering av fritt behandlingsvalg. Universitetet i Oslo. Full text in Research Archive
• Holter, Marianne Therese Smogeli (2019). The working alliance in automated therapy: Development of an alliance-supporting eHealth program and two grounded theory studies of relating and change. Universitetet i Oslo. Full text in Research Archive Show summary

  Electronic health (eHealth) programs are promising for a variety of health purposes, but there are few eHealth-specific theories describing how such programs work to support change. One possible working mechanism is a “working alliance”, considered an important element in psychotherapy. However, the alliance usually assumes an emotional bond, which seems controversial in the context of automated therapy requiring both empirical and theoretical work. In her PhD study, Marianne T. S. Holter and her associates developed a quitting smoking program specifically to support an alliance. She then conducted two qualitative, grounded theory studies on how the users related to the program and whether ways of relating influenced change. The analysis reached theoretical saturation and is based on interviews (N = 16) and triangulated with written answers within the program (theoretical samples; Study 1: N = 55, Study 2: N = 16). The analysis led to two grounded theory models. The first model suggests that people relate to eHealth program through keeping un-alive and making come-alive; thinking about the program as an inanimate object and thinking about it (through a play-like process) as a social presence. The combination of making come-alive and keeping un-alive leads to a semi-social interaction or -relationship. Most participants alternated between making come-alive and keeping un-alive. The second model suggests that these relational processes can facilitate change-space (feeling free and supported to work constructively on changing on one’s own terms). Making come-alive made participants feel understood and supported by a social presence, while keeping un-alive kept the interaction free from social forcing. The thesis launches models that can be used to generate hypotheses for further research into the working alliance as a possible eHealth working mechanism, and provides evidence supporting the alliance as a meaningful and potentially useful concept in automated therapy.

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