What are some of the key reasons individuals do not follow up on treatment following their initial engagement for crisis care?

Frequently people who have experienced involuntary or coercive treatment resist re-engagement with the system. For many people living with SMI, their first contact with the system is during a crisis. This is a time of extreme vulnerability and when the person is confronted with the loss of the ability to make decisions for themselves, they can become distrustful and even angered with the system of care.

The feeling of lack of control in one’s own treatment erodes self-esteem, autonomy, and self-confidence. Some individuals have experienced restraint, seclusion, and/or forced medication. This can result in refusal to re-engage in a system that they do not trust or that causes fear.

Some feel that clinicians only remember them as they were during crisis and do not perceive them as they currently are. This can result in depersonalization and feelings of inadequacy. The failure of clinicians to establish an alliance with the individual is a frequent cause of disengagement or refusal of all treatment. During a crisis, the therapeutic alliance is difficult establish. The clinician needs to be intentional, consistent, and predictable with their approach. Also, the presenting symptoms of the patient can influence the ability to develop trust and build rapport.

To learn more, watch this SMI Adviser webinar: Using Peer Support to Empower Self-Management and Participation in Treatment for Individuals Who are Difficult to Engage



  • Dixon L. B., Holoshitz Y., Nossel I. Treatment engagement of individuals experiencing mental illness: review and update. World Psychiatry 15:1 – February 2016
  • Piippo J., Aaltonen J. Mental health care: trust and mistrust in different caring contexts. Journal of Clinical Nursing, Mental Health & Psycho-Social Issues. 2008
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