Engagement

Engagement of the young person and their family into an early intervention service is one of the most crucial aspects of service delivery. Good engagement can be the foundation on which to undertake timely assessment and provide interventions aimed at optimising recovery.

However, young people and their families may be reluctant to seek help for a number of reasons. 
These may relate to:-

  • Perception of the problem itself, where, for instance, people may deny or have no insight that a problem exists or that help is required.
  • Beliefs about mental health problems in general, for example people having concerns about the stigma associated with it, or having other explanatory models of illness.
  • Perception of the services provided, for example having concerns based on sensationalised media or cinema stereotypes which can lead to a lack of confidence in mental health professionals and services.

Furthermore, the developmental stage of most young people experiencing a first episode of psychosis can affect engagement. Issues relating to this include:-

  • An age-appropriate lack of trust and suspiciousness of people in authority and government services.
  • Considering their own health care as a low priority.
  • Being strongly influenced by peers, and having stigma-related concerns about how their peers would perceive them following involvement with mental health services.

Other factors may include:-

  • If relevant, the impact of illicit substances on the young person’s organisation, cognition and judgement may need to be considered.
  • The affect of the illness or disorder itself on judgement, particularly if this includes paranoia or symptoms which could affect motivation or organisation.

 
Therefore careful consideration of strategies to engage young people experiencing their first episode of psychosis and their families are essential within an early intervention service.

Factors assisting engagement include:

  • Flexibility in location.  For example, home visits or meeting in ‘neutral’ environments such as cafés or shopping centres, at least initially, can be helpful in avoiding the stigma which can be associated with mental health clinics.
  • The physical environment of mental health clinics may also be a factor. Where possible the venue for appointments should be as ‘youth-friendly’ as possible. Collaborating with consumers and peer support programmes to design and decorate clinics may help with this.
  • Focussing on problem-solving and agreeing on joint goals can be much more effective than concentrating on diagnostic issues.  For example, assisting a young person with anxiety, stress, concentration difficulties, or poor sleep is more likely to build engagement than excessive emphasis on their symptoms or offering diagnostic labels.
  • Designing interventions that account for the young person’s developmental stage and the phase of their recovery.   For example, detailed relapse prevention work is unlikely to be effective with a young person who does not perceive there is a problem, or does not consider that relapse is a possibility.
  • The motivational interviewing literature can be useful in providing clinicians with advice on how to engage people who may not necessarily be help-seeking (see Miller & Rollnick, 2002).  This model advocates ‘rolling with resistance’ rather than becoming involved in unhelpful debates with young people or their families.  This approach also recognises the importance of avoiding potentially stigmatising labels such as “sick” or “schizophrenic”.
  • Spending time with young person and family understanding their explanatory models can be crucial in building a therapeutic relationship.
  • The clinician should not assume ‘motivation’ or ‘psychological mindedness’ in young people experiencing a first episode of psychosis.
  • Taking time to discuss their experiences of mental health services involvement can provide valuable insights into what young people and their families have found helpful and unhelpful.
  • Discussing strengths as well as difficulties may make a young person’s attendance and engagement with clinicians more likely than if the focus is solely on pathology.
  • Being aware that engagement is an ongoing process and requires nurturance throughout the contact with the young person and their family.
  • Maintaining a spirit of hope and optimism is an extremely important, but often neglected by health professionals.

Further descriptions of the therapeutic relationship are provided in:

Edwards, J., Wade, D., Herrmann-Doig, T., & Gee, D (2004). Psychological Treatment of
Persistent Positive Symptoms in Young People with First-Episode Psychosis in Gleeson,
J.F.M. & McGorry, P.D. (Eds.) Psychological Interventions in Early Psychosis: A Treatment
Handbook. West Sussex: John Wiley & Sons Ltd. 

Macneil, C.A., Hasty, M.K., Conus, P., Berk, M. & Scott, J (2009) Bipolar Disorder in Young
People: A Psychological Intervention Manual. Chapter 2, Assessment and Engagement.
Cambridge; Cambridge University Press.

References
Miller, W.R. & Rollnick, S. (2002). Motivational Interviewing: Preparing People for Change (Second Edition). New York : Guilford Press.
 
 
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