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Engagement in FEP: Challenges & Strategies

Learn about the challenges and strategies for engaging clients in First Episode Psychosis (FEP) treatment. This article provides insights and practical tips for clinicians.

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Engagement in FEP: Challenges & Strategies

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  1. Engagement in FEP: Challenges & Strategies Jessica M. Pollard, Ph.D. STEP Clinical Director Assistant Professor Department of Psychiatry

  2. Challenges • Insight • Disorganization • Competing with other important life domains • Developmental stage • Stigma • Access/poverty • Balancing family involvement • Beliefs about cause(s) of mental illness • Forensic involvement • Delusional beliefs

  3. Strategies • Flexibility, flexibility, flexibility • Warm handoffs • Meeting/visiting client while inpatient • Optimism, instilling hope, positive expectations • Respecting illness/difficulty attributions • Only offering perspective/eduafter listening & w/permission • Emphasis on client goals, strengths & interests • Debunking myths

  4. Strategies • Body language/IOR/Inviting discussion of discomfort • Case management, addressing unmet needs – removing barriers to access • Non-judgmental, non-punitive stance • Warm welcome, notice absence, framed as being missed • Family alliance w/o “over” aligning • Transparency • Low pressure topics

  5. Strategies • Scheduling • Drop in • Rapid access • Location flexibility • Less frequent, monitoring, “checking in” • Acknowledging & emphasizing choice • Avoidance of power struggles • Balance between gentle persistence & giving space • Procedural justice, voluntary whenever possible • Tolerating risk

  6. Strategies • Meaningfully relating individually (normalizing) • Instead of: us/them, pt/provider or provider as separate from community • Use of appropriate self-disclosure • Texting • Snacks & other incentives • Cultural considerations • De-prescribing, minimal prescribing, trials off Rx

  7. An example from STEP Pete: 23yo male referred after bizarre behavior on campus, good premorbid functioning but struggling in college, smoking MJ & drinking. Did not show 1st appt, mom came in, Pete called in & was irate, “don’t need to come in!” Offered/encouraged to “just drop in” any time briefly to get support around returning to school. 1st few weeks, very brief welcoming appts chatting w/clinician about non-clinical topics (e.g. school, hobbies, TV); eventually spontaneously discussed symptoms & difficulties. When well, disclosed had been terrified we were going to harvest his organs.

  8. Further Reading ~Allard J, Lancaster S, Clayton S, Amos T, Birchwood M. Carers' and service users' experiences of early intervention in psychosis services: implications for care partnerships. Early Interv Psychiatry 2016. ~Becker KD, Buckingham SL, Rith-Najarian L, Kline ER. The Common Elements of treatment engagement for clinically high-risk youth and youth with first-episode psychosis. Early Interv Psychiatry 2015. ~Casey D, Brown L, Gajwani R, et al. Predictors of engagement in first-episode psychosis. Schizophr Res 2016. ~Dixon LB, Holoshitz Y, Nossel I. Treatment engagement of individuals experiencing mental illness: review and update. World Psychiatry 2016; 15(1): 13-20. ~Lal S, Dell'Elce J, Tucci N, et al. Preferences of Young Adults With First-Episode Psychosis for Receiving Specialized Mental Health Services Using Technology: A Survey Study. JMIR Ment Health 2015; 2(2): e18. ~Lal S, Malla A. Service Engagement in First-Episode Psychosis: Current Issues and Future Directions. Can J Psychiatry 2015; 60(8): 341-5. ~Leclerc E, Noto C, Bressan RA, Brietzke E. Determinants of adherence to treatment in first-episode psychosis: a comprehensive review. Rev Bras Psiquiatr 2015; 37(2): 168-76. ~Pollard J, Cahill J, Srihari V. Building Early Intervention Services for Psychotic Disorders: A Primer for Early Adopters in the U.S. Curr Psych Reviews (in press). ~Pollard J, Tek C. Woods S, McGlashan T, Srihari V. Early Intervention and Prevention for Psychotic Disorders. Chapter: Yale Textbook of Public Psychiatry, Steiner J and Jacobs S (Eds), 2015, Oxford. ~Tindall R, Francey S, Hamilton B. Factors influencing engagement with case managers: Perspectives of young people with a diagnosis of first episode psychosis. Int J Ment Health Nurs 2015; 24(4): 295-303.

  9. Thank you for your attention! More thoughts? Questions? Answers? Step.yale.edu www.mindmapct.org Facebook: Mindmap Twitter: @MindmapCT

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