Addressing the Treatment Schism: Optimizing Team-Based Therapeutic Engagement of the Patient With Schizophrenia

Up to one-third of individuals with serious mental illnesses are estimated to disengage from mental health care. Risk factors for dropout from mental health treatment include younger age, male gender, racial-ethnic minority background, low social functioning, co-occurring psychiatric and substance use disorders, and early-onset psychosis. The initial period of treatment is the most likely time for dropout to occur. Individuals diagnosed as having schizophrenia and other serious mental disorders require prolonged, close adherence to a treatment regimen and, frequently, intensive psychosocial team-based treatments to optimize prognosis. Thus a focus on implementing strategies aimed at establishing strong and trusting relationships with mental health providers to facilitate long-term engagement in treatment is essential, particularly during the initial engagement period and for individuals in a high-risk category (1–3).

Individuals with serious mental illnesses have cited the following reasons for dropping out of mental health treatment: the inability to actively participate in treatment decision making, unsympathetic providers, and not being listened to (3, 4). Active outreach associated with team-based assertive community treatment teams may demonstrate relative effectiveness in the treatment engagement of individuals with schizophrenia; individuals with schizophrenia have been found to have lower rates of treatment disengagement than individuals with other serious mental illnesses (4). A well-integrated team-based case management program that integrates rehabilitation plans based on patients’ expressed needs and values and that encourages their attendance at team meetings was found to improve overall quality of life and decrease the need for emergency and inpatient services for individuals with schizophrenia (5). Although individuals with chronic psychotic illness may at times be so impaired by their symptoms that they are unable to participate in their treatment decisions for a period of time, it is becoming clear that emphasizing shared decision making and self-determination to the extent to which the individual is capable may be a powerful engagement tool to improve treatment adherence (1).

Clinical Vignette

The Community Mental Health Team pulled up to a homeless shelter in an urban area. Mr. Jones sat on a bench outside, talking to himself. He had missed his last two appointments, including his depot medication, and the team was concerned about him. Mr. Jones stopped mumbling and eyed the team suspiciously. “You just won’t let me be, will you?” he barked, scowling at the team. The social worker, psychiatrist, and peer specialist stood a respectful distance from Mr. Jones.

“We missed you, Mr. Jones” a team-member began, looking kindly at him.

“Yeah, I bet. You missed the money, I suppose,” Mr. Jones bantered back.

“Now, Mr. Jones,” another team member said. “You know that we don’t just want to see you for the money. You are smart and interesting. We want to make sure that your symptoms don’t take that away.” Mr. Jones’s eyes softened briefly until the scowl returned.

“Tell us about what you are doing these days. Anything interesting?” another team member piped in, attempting to engage Mr. Jones in a strength-based manner.

“Yes, as a matter of a fact,” Mr. Jones replied. “I have joined the CIA and am on an undercover operation that I can’t tell you about.”

“Oh,” another team member mused. “I hope it isn’t dangerous. We want you to be safe.”

“Of course it’s dangerous,” Mr. Jones declared, raising his voice again. “It’s always dangerous when you are in the CIA.”

The team continued to engage Mr. Jones, carefully pacing their conversation and attending to Mr. Jones’ nonverbal and verbal cues. They talked about the weather, how he had slept, if the bed was comfortable, how he was eating, and how they missed him at his appointment and in the group. Mr. Jones’s stiff posture notably relaxed.

“Thank you for letting us know how busy you’ve been. Can we go inside and talk further? There is a private room and we brought your medication,” the psychiatrist suggested.

Mr. Jones frowned. “I knew that was going to come up. I don’t think I need that medication. It might cloud my senses.”

“Hmm. I can understand why that might be a worry. What do you think might help you think more clearly?”

Mr. Jones thought for a while. Well, I lost my headphones, so that might help. You know how much I like my music.”

“Well, I happen to have some earbuds. You can have those. You do have your i-Phone, right? How do you like the new app? I think I need one to remind me of appointments and when to go to bed, too.”

“Well, it is really useful for the head of the CIA to communicate with me. I’ve been eating and sleeping on time, too.”

“Good! I’m so glad. You know, you have been very helpful in the development of the app—so it can help others, too.”

“All right. I guess if you came all the way out here to give me my shot, we may as well get that over with. Do you want to see my new drawings? I have started water color painting, too.”

“Sure,” the team members replied in unison. After they had given the injection, taken vital signs, and completed an assessment, the team members followed Mr. Jones to his room where he shared the newest additions to his portfolio.

“Nice! So, shall we come pick you up next week for the group? The others asked about you. And your app will remind you,” the peer specialist said.

“Well, okay,” Mr. Jones replied. “Unless I am working—you can’t predict with the CIA.”

“I think they probably will give you the time off for the group. See you next Wednesday,” the social worker said warmly. As the team drove off, one of them noticed that Mr. Jones seemed to briefly wave.

Tips for Increasing Engagement in Mental Health Treatment

Given the nature of schizophrenia and the potential for adverse consequences of treatment dropout (exacerbation of psychotic symptoms, psychiatric hospitalizations, homelessness, and the potential for harm to self or others), engagement in treatment is of primary importance. Engagement may be particularly challenging because suspiciousness and social withdrawal are often components of the disorder. Linkage strategies, which increase the communication between various providers and systems of care, are often quite helpful in improving treatment adherence. There are pilot programs using computer-based patient support systems and smartphone applications to assist with adherence. The applications should be user-friendly, be able to be personalized, and involve patients in development to optimize utility (6).

A well-functioning team is key to providing services that improve adherence for patients with serious psychiatric disorders. A team that models effective communication is more engaging, listens more astutely, and typically provides more patient-centered care. There is evidence that team-based collaborative interventions improve adherence and decrease treatment dropout (2). As with all psychosocial interventions, the trusting therapeutic relationship is a key ingredient in positive outcomes. One model of treatment engagement is critical time intervention (CTI), a time-limited psychosocial intervention with objectives to strengthen an individual’s ties to service providers and social networks and to provide emotional support and practical assistance during a time of transition. Areas of focus for CTI may include systems coordination, engagement in psychiatric services, sustaining motivation in substance abuse treatment, ensuring medication adherence, building a social support network, providing life skills training, ensuring integration of medical care, establishing community linkages, and assisting with practical needs (7). The more the services are aimed at the needs and desires of the patient, the more effective they tend to be. The intensity of services required should be assessed, and each patient engaged in a manner of his or her preference and need. Identifying patient aspirations early and reinforcing the therapeutic bonds by jointly working toward these goals is often the best buffer for maintaining a strong alliance during periods of symptom exacerbation (8). The following tips promote treatment engagement with the individual who has a psychotic illness: