Service Provider Views on User Engagement in CSC for Psychosis

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

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.

This study sought to address this gap by exploring provider perspectives on service user engagement across different CSC components, including individual psychotherapy, family education and support, medication management, and vocational services.

Method

The study employed a qualitative approach using 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:

• “How would you describe participant engagement?”
• “What have been some of the challenges or barriers for participants served by your program?”

Prompts were used when appropriate to ensure complete ideas and thoughts were captured.

Qualitative data analysis was conducted using a thematic analysis approach (Braun & Clarke, 2006).

Three authors independently reviewed and coded 20% of the transcripts using line-by-line open coding to generate general key concepts.

A collaborative process was used to develop and refine the codebook. 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

This study provides valuable insights into the complex nature of engagement in CSC programs by examining barriers and facilitators specific to individual service components.

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:

1. Use of qualitative methods to capture rich, detailed perspectives from service providers
2. Inclusion of providers from multiple CSC sites, covering both urban and rural areas
3. Rigorous thematic analysis approach with multiple coders to enhance reliability
4. Focus on component-specific engagement, addressing a gap in existing literature

Limitations

1. The study sample was limited to providers from a single CSC network in Washington State, potentially limiting generalizability to other regions or program models.
2. Reliance on retrospective recall from service providers may introduce bias in the reported experiences and perspectives.
3. The study did not include perspectives from service users or family members, which could provide additional insights into engagement challenges.
4. Limited diversity in the racial background of participants may not fully capture the experiences of providers from diverse cultural backgrounds.

Clinical Implications

The results of this study have significant implications for the implementation and improvement of CSC programs:

1. Tailored engagement strategies: The findings suggest that different service components may require unique approaches to engagement. Program developers and clinicians should consider component-specific barriers when designing interventions to improve engagement.
2. Substance use interventions: Given the pervasive impact of substance use on engagement across components, CSC programs may need to incorporate more robust substance use prevention and treatment strategies.
3. Stigma reduction: Efforts to reduce stigma associated with psychosis and mental health treatment should be integrated into CSC programs, particularly for components like individual therapy and medication management.
4. Family involvement: The study highlights the importance of family engagement in supporting service user participation. Programs should consider strategies to overcome barriers to family involvement, such as flexible scheduling and education about the recovery process.
5. Meaningful engagement: The findings emphasize the need to distinguish between attendance and meaningful engagement. Programs should focus on aligning service user goals with treatment objectives to promote more active participation.
6. Leveraging vocational services: Given the relative ease of engagement in vocational services, programs may consider using this component as a gateway to engage service users in other aspects of treatment.

References

Primary reference

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

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.

Keep Learning

1. How might the perspectives of service users differ from those of service providers regarding barriers to engagement in CSC programs? What additional insights could be gained by including service user perspectives in future research?
2. In what ways might cultural factors influence engagement in different CSC components? How could future studies address the limited diversity in the current sample?
3. How might the identified barriers to engagement in CSC programs reflect broader societal issues related to mental health stigma and access to care? What systemic changes might be necessary to address these barriers?
4. Given the finding that vocational services were often the easiest component to engage service users in, how might CSC programs leverage this to improve overall engagement? What are the potential benefits and drawbacks of such an approach?
5. How might the concept of “meaningful engagement” differ across various stakeholders (e.g., service users, family members, providers, policymakers)? How can these potentially differing perspectives be reconciled in program design and implementation?
6. Considering the pervasive impact of substance use on engagement, how might CSC programs better integrate substance use interventions without compromising their core focus on early psychosis treatment?
7. What ethical considerations arise when addressing external pressures (e.g., court orders, family pressure) that may lead to attendance but not meaningful engagement in CSC services?
8. How might the findings of this study inform policy decisions regarding the allocation of resources for different components of CSC programs? What are the potential consequences of prioritizing certain components over others?