Engagement of patients is a critical step in the process of triage and assessment, but barriers often exist, including denial of illness or symptoms such as suspiciousness and social withdrawal. The first contact of patients and families with a mental health service is highly influential, as it lays the foundation for future interactions.

Engagement in first-episode psychosis usually occurs in parallel with assessment and initial treatment, and may require contact with a number of clinicians. Careful planning and organization can assist in reducing the fragmentation of care. Repeated assessment by a range of people from different components of a service - such as the 24-hour community assessment team, an inpatient unit and then a case manager - not only hampers engagement but is also unwieldy and inefficient.

Some patients with first-episode psychosis will have resisted attempts to seek treatment on their behalf by the time they come into contact with a mental health service. They might have increased risk of violence or self-harm, and have been exposed to adverse experiences during their pathway to care. The traumatizing effects of such experiences can interfere with trust and engagement, and the development of a therapeutic alliance, and can also further undermine the patient's fragile social structures.

Engagement is usually more successful if the initial contact occurs prior to a major crisis, while the person retains some awareness that ''something is not quite right''.

Table 2.7 Engagement techniques - a summary [1]

• Recognize that the patient may be nervous, wary or not want to see health professionals.

• Be aware that psychosis might distort patients' interactions and their ability to process information.

• Listen carefully to patients and take their views seriously.

• Acknowledge and respect patients' viewpoints.

• Identify common ground.

• Consider appropriate body language when interviewing patients who may be paranoid, aroused or manic (sit side-by-side, avoid too much eye contact, allow personal space).

• Be helpful, active and flexible.

• Carefully explain the procedures involved in physical or other assessments.

• Gather information gradually, at the same time as fostering a close relationship.

• Introduce key players who will take part in the patient's management.

• Provide good continuity of care and good communication between professionals.

General principles of engagement and developing a therapeutic alliance should be applied, such as warmth, empathy and respect. Dispelling fears and establishing trust are particularly important in first-episode psychosis. Clinicians need to balance a respect for patients' interpretations of their psychotic experiences with the need to communicate their clinical judgment and advice about treatment. Initial contacts can be emotionally charged. Severely disturbed or agitated patients can provoke reactions in clinicians that undermine engagement, as they attempt to control the situation - for example, the use of criticism, implied threats, or alliance with other carers for whom the patient has little respect.

Engagement requires a calm, reassuring, professional and friendly manner, with a commitment to flexibly negotiating the best initial outcome. Time invested at this early stage can help develop rapport and encourage the patient to help develop options for dealing with his/her concerns. Simple techniques may be very effective in gaining trust and cooperation (Table 2.7).

BiPolar Explained

BiPolar Explained

Bipolar is a condition that wreaks havoc on those that it affects. If you suffer from Bipolar, chances are that your family suffers right with you. No matter if you are that family member trying to learn to cope or you are the person that has been diagnosed, there is hope out there.

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