Service engagement in psychosis: the role of psychological variables
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Introduction: In psychosis, low engagement with mental health services is both prevalent and frequently associated with negative outcome. The overarching objective of this thesis was to investigate the role of psychological variables in service engagement in people with psychosis. A systematic review was conducted to examine the evidence for clinical and psychological correlates of engagement. An empirical study sought to investigate the association between engagement and psychological variables of a relational nature (i.e. mentalizing and interpersonal functioning). Methods: A systematic search strategy across four electronic databases yielded seventeen journal articles. For the empirical study, forty-two people with multiple-episode psychosis completed self-report measures of service engagement, symptoms, mentalizing and interpersonal functioning, within a cross-sectional design. Results: The review found relatively robust evidence supporting the association between engagement and numerous clinical variables. Eleven psychological variables were revealed as significant correlates of service engagement, encompassing developmental, individual and relational factors. Assessment of quality and risk of bias highlighted a number of limitations within included studies. In the empirical study, greater cognitive/disorganization symptomology was predictive of lower service engagement. Service engagement was significantly correlated with mentalizing, but not with interpersonal functioning. The relationship between cognitive/disorganized symptomology and engagement was not mediated by mentalizing performance. Conclusion: Numerous psychological variables are associated with service engagement, which has the potential to inform clinical practice in view of enhancing engagement. Qualitative and longitudinal studies with both service user and provider samples are required to capture the contextual information surrounding fluctuations in levels of engagement.