Overcoming the Problem of Disengagement from Treatment

Advances in evidence-based mental health treatment have expanded opportunities for people with serious mental illness to avoid unnecessary suffering and disability and establish satisfying lives in the community (Dixon & Schwarz, 2014). Too many, however, fail to engage in mental health treatment and have been left behind (SAMHSA, 2014). The most severe forms of mental illness and substance abuse, if left untreated, can interfere with good judgment, the ability to hold down a job, family and social relationships, and caring for one’s basic needs—any or all of which can play a role in the onset of homelessness. It is unfortunate that the most disabled of the mentally ill sometimes have the weakest connections to the mental health service system, and some that are visibly ill never seek any form of treatment.

Disengagement, or dropping out of contact with the service system before recovery is complete,[1] can lead to devastating consequences, such as a recurrence of symptoms, re-hospitalization, violent and self-destructive behavior (Dixon et al., 2009; Kreyenbuhl et al., 2009), and homelessness (Belcher et al., 1991; Caton et al., 1995; Herman et al., 1998). Studies conducted in the post-deinstitutionalization era indicate that fewer than half of people with severe mental illness in the United States who might benefit from mental health treatment are involved in care (Kreyenbuhl et al., 2009; O’Brien et al., 2009). The figure is at least as high or higher among people with severe mental illness who are homeless (Mowbray et al., 1993; Mowbray et al., 2009). The lack of a stable connection to the service system, common among shelter and street dwelling people, leaves them to cope on their own with the vicissitudes of the homeless condition which often include violence, victimization, and contact with emergency services, hospitals, and the criminal justice system (Hopper et al., 1997; O’Brien et al., 2009). Re-engagement of high-need individuals with severe mental illness in needed services is an ongoing challenge (Smith et al., 2014). There is little doubt that an inadequate and fragmented mental health service system is a most unwelcoming environment for the distressed and vulnerable individuals who need effective evidence-based care the most. In the decades since the federal government ceased funding community mental health centers, the commitment of states to funding mental health and substance abuse treatment services has been uneven. In the competition for public dollars, behavioral health services have been fair game for budget reductions and service cuts in times of financial stress (Aron et al., 2009; Morrissey, 2016). While efforts at the state level to address problems in the service system involve factors such as increased financing, workforce training, and greater organizational commitment to the values of advancing recovery and individual empowerment, progress has been slow (Drake & Latimer, 2012; Drake & Essock, 2009; Glied & Frank, 2009). It is hoped that the Affordable Care Act and mental health parity will increase opportunities at both the individual and systems levels for greater access to state of the art mental health care.

  • [1] O’Brien et al. (2009) discuss the lack of common definitions of “engagement” and“disengagement” that have been used in studies in the area to describe “the complexrelationship between people with mental health problems and the services providingfor them” (p. 559).
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