Case manager interpretations of disengagement from services by their clients

Objective: Disengagement from services by persons experiencing homelessness and co-occurring disorders is a constant challenge for mental health systems. Case managers, as front line providers, are charged with the task of retaining hard-to-engage clients in services. The mental health recovery movement has emphasized the need for collaboration as opposed to coercion within case manager-client relationships. Nevertheless, such relationships are frequently thwarted by premature disengagement from services. Given this reality, it is important to understand how case managers handle situations in which these clinical relationships do not go as planned or end abruptly. This study explores case manager understandings and interpretations of disengagement in general and in the specific incidents in this study. Case manager perspectives are juxtaposed against the post-departure circumstances documented by study staff working closely with the clients.

Methods: This qualitative study involved 18 case managers who experienced 29 cases of disengagement. Disengagement occurred during the New York Services Study that followed new enrollees from four programs for dually diagnosed homeless adults over a 12-month period in 2005-2007. One program used a ‘housing first' approach and the other three programs used a ‘treatment first' approach. Case managers were recruited through their client's participation in the study. The analyses used a case study approach based on 29 in-depth retrospective interviews with case managers. Case managers were asked about their attributions for the disengagement, whether they anticipated the departure and whether they would be willing to work with the client again. The study compared case manager accounts with post-departure circumstances derived from monthly tracking interviews with the clients. Descriptive data matrices were developed to aid the analyses and conceptualize the findings (Miles & Huberman, 1994).

Results: The overwhelming majority of disengagement cases (93%) occurred in the ‘treatment first' programs. Case managers viewed all incidents of disengagement as negative and described them as resulting from substance use and/or a consumer's preference for alternative living arrangements. Case managers acknowledged a lack of program fit in several cases but rarely considered the program role in disengagement. Often, they reported having anticipated disengagement, perceiving the consumer to be “the type” that fails in services. Post-departure circumstances recorded by study staff revealed that the majority of clients (55%) experienced homelessness after disengagement, but some eventually found stable living arrangements with families or on their own.

Conclusions/Implications: That case managers interpreted disengagement to be universally negative regardless of post-departure circumstances demonstrates a perspective that may be overly pessimistic about consumer decision-making. At the practice level, the problem can be addressed by helping case managers honor their clients' perspectives and proactively work with them to address issues that lead to disengagement. The fact that disengagement is a disproportionate problem in mainstream treatment first programs points to the need for greater flexibility in services if consumer-driven recovery is to be enhanced.