Early Psychosis Intervention: A Culturally Adaptive Clinical Guide

16. Engagement and Outreach in Early Psychosis Management

16 Engagement and Outreach in Early Psychosis Management Kai-tai Chan and Gloria Hoi-kei Chan According to the Oxford Advanced Learner’s Dictionary, engagement means “locking together, fitting into; of part of a machine, etc.” (Hornby, 2005). Yet, in psychology or psychiatry literature, there is little consensus on the definition and measurement of engagement or disengagement (see reviews by O’Brien, Fahmy, & Singh, 2009; Tetley et al., 2011) and this construct is often conflated with concepts related to the treatment progression or therapeutic alliance. Despite this, it is well recognized that therapeutic engagement is important for patients to receive appropriate help and achieve better outcomes. Engagement is especially important in first-episode psychosis. First of all, failure in engaging patients may cause delays in treatment, which in turn affects patients’ outcomes. Late presentation of first-episode psychosis has been shown to be associated with slower and less complete recovery (Harrigan, McGorry, & Krstev, 2003; Helgason, 1977, 1990; Loebel et al., 1992; McGorry et al., 1996) and earlier intervention demonstrated to improve subsequent levels of disability (McGorry, 1992). Secondly, successful engagement, which consists of a strong therapeutic alliance, is significantly related to maintenance of psychotherapy , medication compliance, better outcomes, and less medications among non-chronic schizophrenia patients (Frank & Gunderson, 1990). From the evidence available, a strong therapeutic alliance is apparently necessary to enable change (Hewitt & Coffey, 2005) and may maximize the therapeutic effects and benefits of intervention on patients’ and their caregivers’ well-being. Therapeutic engagement is more than therapeutic alliance, however, according to Tetley et al. (2011). In evaluating whether an individual is “actively participating in the treatment on offer”, he or she will show attendance in arranged treatment, completion of treatment, completion of between-session tasks, 190 Kai-tai Chan and Gloria Hoi-kei Chan willingness to self-disclose, and supportive behaviours (in group sessions), in addition to a working alliance. Successful therapeutic engagement is not easy to attain and should never be taken for granted. Its success often depends on the various parties concerned, including the service provider, staff, service, patients, and caregivers. Service Provider A case management system has been adopted by the Early Assessment Service for Young People with Psychosis (EASY) in Hong Kong. The case manager serves as a key person to provide comprehensive care to patients and help them in different aspects of their life, with an aim of ensuring continuous and specialized care for patients. In engaging patients in EASY, accessibility to services is also of paramount importance. Case managers in EASY can be readily contacted by telephone during office hours. Voice messages can be left after office hours, and case managers will respond to them the next working day and provide appropriate and timely management according to the urgency and nature of the presenting problems. With this high accessibility, patients appreciate the service provider more often and start to gain confidence in the service. This in turn enhances patients’ willingness to seek help when they encounter further problems. In this way, patients are more eager to remain in service and the therapeutic alliance is further enhanced. For patients who refuse to attend follow-up consultations—a situation that is often due to poor mental state or lack of insight—outreach services can be arranged. With this type of service, patients can be re-engaged in services with regular psychiatric reviews. Moreover, in EASY, a multidisciplinary team composed of doctors, clinical psychologists, nurses, occupational therapists, and medical social workers working in close collaboration has proven to be important for engaging patients in services. This team holds regular and ad hoc meetings for patients’ management to facilitate accurate information sharing and timely responses to patient’s problems ranging from clinical management to school or occupational issues. With this collaborative effort, patients’ problems can be more thoroughly handled with due consideration to many different aspects. Engagement and Outreach in Early Psychosis Management 191 Staff In managing patients’ problems, the attitude of the staff when providing care is often influential. It has a special impact on patients’ willingness to disclose their feelings and thoughts. Disclosure of information and problems is important as further deterioration in mental well-being can be prevented when problems are handled at an early stage. In order to foster information disclosure, staff members take an empathetic, proactive, and collaborative approach, which encourages patients and their caregivers to seek help in times of difficulty. This step maximizes therapeutic effect. Services Early psychosis...