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A Mixed Methods Study of Program-Level Factors Influencing Patient and Family Engagement in First Episode Psychosis

Cheryl Y S Foo^1,2,3, Catherine J Leonard¹, Merranda M McLaughlin^1,2

¹Center of Excellence for Psychosocial and Systemic Research, Department of Psychiatry, Massachusetts General Hospital, Boston, MA.

Medrxiv : the Preprint Server for Health Sciences

|February 6, 2026

Abstract

Background:

Poor patient retention and family engagement compromise the effectiveness of coordinated specialty care (CSC) for first-episode psychosis (FEP). This mixed methods study aimed to identify program-level characteristics (CSC fidelity and engagement strategies) associated with patient retention and family engagement in Massachusetts CSC programs.

Methods:

Primary outcomes were rates of patient retention and family engagement (≥1 evidence-based family intervention session), based on CSC program census (October 2022 - September 2023). Quantitative analyses explored program characteristics (EPINET Program-Level Core Assessment Battery) and fidelity ratings (Massachusetts Psychosis Fidelity Scale) as predictors using t-tests or univariate linear regressions. Thematic analysis of program interviews compared patient and family engagement strategies employed by high versus low performing programs.

Results:

Across nine programs, mean patient retention was 86% (range: 58-97%) and family engagement was 40% (range: 12-100%). Higher fidelity to evidence-based services (e.g., individual therapy, family intervention, and supported education/employment) was significantly associated with both outcomes (p<.05; R² range: .51-.72). Mixed-methods analysis showed that high performing programs used case management-related supports to meet service users' practical needs. Factors associated with higher patient retention included having comprehensive intake assessments, provider visits during hospitalization, and periodic treatment reviews. Programs that conducted benefits counseling and proactively recommended family services as standard care had higher family engagement.

Conclusions:

Higher fidelity CSC programs had better patient retention and family engagement. Case management-related supports addressed treatment barriers. Strategies designed to strengthen therapeutic alliance and goal alignment may promote patient engagement, while family engagement may benefit from proactive recommendation of family intervention.

Keywords:

coordinated specialty care early intervention family engagement fidelity first-episode psychosis retention treatment engagement

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