Engagement in specialized early intervention services for psychosis as an interplay between personal agency and critical structures: A qualitative study

Background: Specialized early intervention programs for individuals experiencing a first episode of psychosis prioritize service engagement, generally operationalized as attendance, treatment completion, therapeutic alliance, and treatment adherence. However, there are critical theoretical and methodological gaps in understanding how service users experience and define their engagement with the service. Objectives: This study aimed to explore how current and former service users define their engagement with a specialized early intervention program. Design: A qualitative descriptive approach was used to explore service users' decisions to use, remain involved with, and/or leave early intervention services. Setting: This study took place in an early intervention service for psychosis in Montreal, Canada. Participants: Twenty-four participants who had experienced a first episode of psychosis and had been engaged in the service to varying degrees (fully engaged, partially engaged, disengaged) took part in in-depth interviews. Methods: In-depth interviews were employed to collect rich insights into participants' experiences and perceptions. The interviews were transcribed and analysed using thematic analysis, beginning with an inductive approach and completing the analysis using a theoretical approach. During the analysis, our original notions of engagement and disengagement were challenged by theorizing engagement in terms of agency and structure. Researchers engaged in reflexive practices to maintain and promote research rigor and trustworthiness. Results: Participants' narratives were thematically analyzed and organized into three themes: fluidity and temporality of engagement and disengagement; engagement as an ongoing negotiation; and critical structures and agency. Participants described engagement in a variety of ways, some of which were broader than service use and focused on self-care and commitment to recovery. These conceptions were subject to change as the individuals' perceptions of their needs changed. As needs changed, individuals also negotiated and renegotiated their care needs with themselves and with their treatment team. These exercises of agency were constrained by key structures: the treatment team, family and friends, and societal conceptions of mental health. Conclusions: Our study findings argue for an expanded definition of engagement which prioritizes individuals' experience and acknowledges the steps towards recovery that they may make outside of the purview of the service. It also underlines the importance of a treatment structure which aligns with individuals' needs for both support and autonomy. (C) 2020 Elsevier Ltd. All rights reserved.