Engagement is essential for the success of any mental health intervention. Intensive home treatment, when offered as a real alternative to hospital admission, represents a unique opportunity to provide acute treatment in a setting chosen by the patient. The safe and effective delivery of such treatment relies upon the patient's (and usually also the carer's) ability and willingness to accept and engage with the service provided, and to adhere to an agreed treatment plan. The potential promise of offering home-based rather than hospital care is that the experience of greater choice, more active participation in decision making and more acceptable treatment may increase engagement with services and active help seeking in the long term. This chapter will explore the general principles of engagement and describe the use of a health beliefs model to enhance this process and treatment adherence in day-to-day practice. Finally, the particular issues that arise in trying to engage and treat patients in their own homes will be considered.

Engagement

Literature from research on assertive outreach has focused upon the concept of engagement, and the principles outlined can be applied to most patient–clinician interactions in mental health services. Hall et al. (2001) developed an observer-rated measure of engagement that incorporated six dimensions of engagement:

• appointment keeping

• patient–therapist interaction

• communication

• openness

• collaboration with treatment

• medication adherence.

It is useful to think of engagement in this multidimensional way rather than as an ‘all-or-nothing’ concept. Engagement can be seen as a spectrum of behaviours and the number of components a person exhibits may change over time.