Unpacking Ghosting Among Among Transition Age Youth Diagnosed with Serious Mental Health Conditions in Community-Based Multidisciplinary Services

Background & Purpose: Serious mental health conditions are most likely to onset during the transition to adulthood, yet this age group is least likely to engage in community-based mental health treatment (SAMHSA, 2017). Multidisciplinary team-based programming that strategically blends and adapts child and adult evidence-based practices are currently trending to meet transition-age youth (TAY) needs. Engagement is a complex construct to measure as it is both a process and an outcome, and deserves attention in TAY mental health treatment (e.g., Munson et al., 2015). This study aims to unpack the loathsome, and possibly negative (depending on the observer or funder) passive, unplanned exit – or ghosting within the Emerge Model services (Fagan & Klodnick, under review). Our research questions include: Why do participants exit services? What role do individual, team, provider and system level factors play in exits?

Methods: This study uses both provider health and service record data of 165 18-26 year olds enrolled in services between 1/1/14-5/1/18 and in-depth semi-structured interviews with 22 service participants to better understand disengagement and passive service exits. Of the 165 participants (mean age 21.9; SD=2.2), most were male (60%), African American (54%), had a primary mood disorder (68%), experienced a psychiatric hospitalization prior to enrollment (90%); 46% had justice system and 25% child welfare system involvement. Exit service notes and interview transcripts were collected and thematically coded by a team of researchers, including two young people with lived experience with mental health conditions.

Results: Participants exited services based on mental health needs some of the time (reaching clinical goals or needing more intensive, specialized care), but also because of developmental-related factors, including reaching milestones and changing personal resources and life situation. Of 111 exits, (a) 52 were planned: 20 to lower, 16 to higher, 11 to similar care levels between 9-15 months enrollment; while 5 returned to previous provider within 3 months enrollment; and (b) 59 were unplanned: 24 were passive exits where communication with team ceased after 6-12 months enrollment; 15 were “closed” within 3 months of enrollment due to limited engagement; 10 moved out of geographic area without team communication; and 10 chronically missed meetings after 6-12 months enrollment and terminated services. Ghosting appears to be related to poor calibration between (a) participant evolving needs, instability, mobility, (b) relationship and communication between participant and team members, and (c) static, outdated service delivery methods (e.g., communication and processes) and instability (e.g., turnover, team dynamics, service delivery location).

Conclusions and Implications: TAY engagement in multidisciplinary team- and community-based care is developmentally rooted. Increasing concurrent instability during the transition to adulthood in multiple life domains (e.g., work, school, relationships, living situation) is normative for TAY, as are smartphones for communication. New TAY models are embedded within pre-existing child or adult agency structures, culture, and practices, as well as, fee-for-service billing contexts that threaten TAY engagement. TAY treatment models and providers must consider how developmentally appropriate instability impacts engagement – and build increased flexibility into practice and policies for sustained TAY engagement.