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Home arrow Language & Literature arrow The open door : homelessness and severe mental illness in the era of community treatment


The Recovery Movement in mental health care has yielded new approaches to treatment engagement inspired by rehabilitation models that, in contrast to the medical model, go beyond symptom control to assist individuals to establish satisfying lives in the community (Corrigan et al., 2008; Frese et al., 2009; President’s New Freedom Commission on Mental Health, 2003; Salyers & Tsemberis, 2007). Shared decision-making (Deegan & Drake, 2006; Drake & Deegan, 2009), illness management and recovery (McGuire et al., 2014), and peer support services (Chinman et al., 2014) are based on the notion that mental health treatment should be collaborative, respectful of an individual’s perspective and life goals, and encourage empowerment and independence. Shared decision-making is at the heart of voluntary approaches to engagement in treatment.

Shared Decision-Making

Shedding a paternalistic approach to the clinician-patient relationship, shared decision- making changes the role of the clinician into a collaborator who works in partnership with the patient to share information, clarify preferences, and provide expertise concerning the patient’s care and treatment (Adams et al., 2007; Joosten et al., 2008). Shared decision-making has achieved considerable currency across medicine in general (Joosten et al., 2008), bolstered by the view that placing the patient at the center of care is a mechanism to improving its quality. The export of shared decisionmaking into the behavioral health arena has developed more slowly (Hamann & Heres, 2014). Despite the fact that shared decision-making is viewed positively by individuals with severe mental illness (Adams et al., 2007; Park et al., 2014) and is supported by clinicians for ethical and practical reasons (Drake & Deegan, 2009; Legare et al., 2014), it has not been widely implemented or studied in clinical settings (Beitinger et al., 2014; Joosten et al., 2008). It has been contended that shared decision-making is most relevant when there are several treatments that are possible (Legare et al., 2014).

A challenge to the implementation of shared decision-making in behavioral health care occurs when a patient is experiencing a psychotic break or expresses suicide intent. It has been suggested that shared decisionmaking be modified in “life or death” decisions, when a patient lacks insight, or is resistant to treatment (Hamann & Heres, 2014). Advocates for shared decision making argue that decisional incapacity is rare even in the presence of psychosis (Deegan, 2014), and it is noted that legal statutes to guide proxy decisions when decisional capacity is impaired already exist, making “paternalistic” decisions in crisis situations unnecessary. Joosten et al. (2008) argue that shared decision-making is particularly suitable for long-term decisions, such as in chronic illnesses that involve multiple treatment sessions, enabling a focus on treatment decisions that impact on a person’s life style and personal preferences, including medication management (Deegan & Drake, 2006).

Voluntary and Involuntary Treatment: Future Directions

The relevance of disengagement from treatment for current policy and practice decisions demands that future research, both experimental and descriptive, on leveraged entitlements and housing, shared decisionmaking, conditional release, and legal mechanisms such as compulsory community treatment, be carried out to determine for whom and under what conditions a specific remedy for addressing treatment engagement is most appropriate (Goldman, 2014; Morrissey et al., 2014). In the meantime, issues such as decisional capacity and dangerousness will undoubtedly weigh heavily in clinical decision-making in real-world service settings.

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