Stokes, B., Fraser, E., Stokes, S., Saric, N., Kriegel, L., & Oluwoye, O. (2024). Exploring service provider perspectives on service user engagement across service components in coordinated specialty care programs for psychosis.Psychological Services, 21(3), 399–405.https://doi.org/10.1037/ser0000844
Key TakeawaysThe primary methods of exploring service provider perspectives on service user engagement in coordinated specialty care (CSC) programs for psychosis included qualitative interviews with 20 service providers from five community-based early intervention programs.Factors like substance use, stigma, trauma, and external pressures significantly affect engagement across different service components of CSC programs.Limitations include potential bias from retrospective recall and limited generalizability due to the sample being from a single CSC network.Understanding barriers to engagement in specific CSC components is crucial for improving program implementation and outcomes for individuals experiencing first-episode psychosis.
Key Takeaways
Rationale
Coordinated specialty care (CSC) programs are comprehensive, team-based early intervention services for individuals experiencing first-episode psychosis.
These programs typically include components such as individual therapy, medication management, family education and support, case management, and vocational services.
CSC aims to provide holistic, person-centered care to improve outcomes and reduce long-term disability for people in the early stages of psychotic disorders (Mueser et al., 2015).
However, engagement in CSC programs remains challenging, with disengagement rates as high as 60% (Kim et al., 2019; Reynolds et al., 2019; Tindall et al., 2020).
Previous research has identified factors contributing to disengagement, such as lack of family involvement, substance use, and medication side effects (Kreyenbuhl et al., 2009; Mascayano et al., 2021).
Qualitative studies have also explored themes related to disengagement, including substance use, traumatic experiences, and stigma (Hamilton et al., 2019). However, little research has examined how engagement may differ between specific service components within CSC programs.
Method
The study employed aqualitative approachusing semi-structured interviews with service providers from five urban- and rural-serving CSCs in Washington State, USA.
Interviews were conducted over the telephone, digitally recorded, and transcribed verbatim.
A purposeful sampling approach was used to recruit participants who could provide insight into the strengths and limitations of CSC programs in engaging service users experiencing psychosis.
The interview guide included questions such as:
Prompts were used when appropriate to ensure complete ideas and thoughts were captured.
Qualitative data analysis was conducted using athematic analysis approach(Braun & Clarke, 2006).
A collaborative process was used to develop and refine thecodebook. NVivo 12 software was used to organize and code all interviews.
Sample
The study included 20 CSC providers from five community-based early intervention programs for psychosis in Washington State.
Participants had a mean age of 37 years (SD = 12.95, range = 24-60 years), and 60% identified as female.
Regarding race and ethnicity, 40% identified as non-Hispanic White, and 30% identified as Hispanic.
On average, participants had 13.80 months (SD = 12.30 months) of experience working within a CSC program.
Results
The study identified several key themes related to barriers and facilitators of engagement across CSC service components:
1. Substance Use
Substance use emerged as a prominent barrier to engagement across multiple components.
In individual psychotherapy, it was observed to increase symptoms of psychosis and reduce motivation to attend sessions.
“Drug use is probably the number one thing that causes people to relapse (in symptoms) or disengage from treatment … a lot of our guys use substances, but they don’t connect it to any sort of consequences.” (Individual Therapist, Site 1)
2. Stigma and Traumatic Experiences
Stigma and traumatic experiences were found to delay access to care and increase difficulty in initiating engagement for various components.
“Most people in private practices or people with private insurance end up with us—a whole lot of private insurance referrals because no private providers will take individuals with psychosis, and they surely won’t take an LRO (least restrictive order).” (Program Director, Site 3)
3. External Pressures
External pressures, such as court orders or family pressure, were identified as factors that could lead to attendance but not meaningful engagement in services.
“I have one client that he is—he’s engaging in the program partly because, um, his mother wants him to. So, he participates, but I don’t know how much of it he’s taking away for himself.” (Individual Therapist, Site 5)
4. Program Component-Specific Challenges and Opportunities
The study found that different components faced unique challenges and opportunities for engagement.
For example, vocational services were often seen as the easiest component to engage service users in, while individual therapy was considered the most difficult due to stigma and external pressures.
“Vocational Services I think has been the bee’s knees of the program. People will engage in wanting to get a job and wanting to get back into school because that they understand and it’s useful for them, and it—it’s meaningful, right?” (Program Director, Site 3)
Insight and Depth
By highlighting how factors like substance use, stigma, and external pressures differentially impact engagement across components, the research offers a more nuanced understanding of the challenges faced in implementing CSC programs.
The findings suggest that a one-size-fits-all approach to engagement may not be effective, and that tailored strategies may be needed for different service components.
For example, the study reveals that vocational services often serve as an entry point for engagement in other components, highlighting the potential for leveraging this component to improve overall program engagement.
Strengths
The study had several methodological strengths, including:
Limitations
Clinical Implications
The results of this study have significant implications for the implementation and improvement of CSC programs:
References
Primary reference
Other references
Braun, V., & Clarke, V. (2006). Using thematic analysis in psychology.Qualitative Research in Psychology, 3(2), 77-101.
Hamilton, J. E., Srivastava, D., Womack, D., Brown, A., Schulz, B., Macakanja, A., Walker, A., Wu, M.-J., Williamson, M., & Cho, R. Y. (2019). Treatment Retention among patients participating in coordinated specialty care for first-episode psychosis: A mixed-methods analysis.The Journal of Behavioral Health Services & Research, 46(3), 415-433.
Kim, D. J., Brown, E., Reynolds, S., Geros, H., Sizer, H., Tindall, R., McGorry, P., & O’Donoghue, B. (2019). The rates and determinants of disengagement and subsequent re-engagement in young people with first-episode psychosis.Social Psychiatry and Psychiatric Epidemiology, 54(8), 945-953.
Kreyenbuhl, J., Nossel, I. R., & Dixon, L. B. (2009). Disengagement from mental health treatment among individuals with schizophrenia and strategies for facilitating connections to care: A review of the literature.Schizophrenia Bulletin, 35(4), 696-703.
Mascayano, F., van der Ven, E., Martinez-Ales, G., Henao, A. R., Zambrano, J., Jones, N., Cabassa, L. J., Smith, T. E., Yang, L. H., Susser, E., & Dixon, L. B. (2021). Disengagement from early intervention services for psychosis: A systematic review.Psychiatric Services, 72(1), 49-60.
Mueser, K. T., Penn, D. L., Addington, J., Brunette, M. F., Gingerich, S., Glynn, S. M., Lynde, D. W., Gottlieb, J. D., Meyer-Kalos, P., McGurk, S. R., Cather, C., Saade, S., Robinson, D. G., Schooler, N. R., Rosenheck, R. A., & Kane, J. M. (2015). The NAVIGATE program for first-episode psychosis: Rationale, overview, and description of psychosocial components.Psychiatric Services, 66(7), 680-690.
Reynolds, S., Kim, D. J., Brown, E., Tindall, R., & O’Donoghue, B. (2019). Defining disengagement from mental health services for individuals experiencing first episode psychosis: A systematic review.Social Psychiatry and Psychiatric Epidemiology, 54(11), 1325-1335.
Tindall, R., Simmons, M., Allott, K., & Hamilton, B. (2020). Disengagement processes within an early intervention service for first-episode psychosis: A longitudinal, qualitative, multi-perspective study.Frontiers in Psychiatry,11, Article 565.
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Olivia Guy-Evans, MSc
BSc (Hons) Psychology, MSc Psychology of Education
Olivia Guy-Evans is a writer and associate editor for Simply Psychology. She has previously worked in healthcare and educational sectors.
Saul McLeod, PhD
BSc (Hons) Psychology, MRes, PhD, University of Manchester
Saul McLeod, PhD., is a qualified psychology teacher with over 18 years of experience in further and higher education. He has been published in peer-reviewed journals, including the Journal of Clinical Psychology.
