Unequal access and treatment disengagement in mental health: Implications for social work practice

Abstract

Treatment disengagement in mental health is often framed as an individual problem linked to lack of insight, low motivation, or ambivalence toward care. However, this perspective overlooks broader social conditions. This brief note argues that, from a social justice perspective, disengagement is understood not as “treatment refusal,” but as a consequence of structural barriers and unequal access affecting marginalized populations, including immigrants, refugees, and ethnic minorities. In this view, disengagement reflects limitations in accessibility and cultural responsiveness rather than individual unwillingness. Social work practice—through outreach, relational engagement, and structural advocacy—plays a key role in addressing these barriers and promoting more equitable mental health services.

Introduction

Over the past decades, mental health systems have developed increasingly effective bio-psycho-social and recovery-oriented treatments. Nevertheless, approximately 50% of individuals diagnosed with mental illnesses, including psychotic, mood, and anxiety disorders, disengage from care or discontinue recommended treatment (Girone et al., 2025; Mlay et al., 2025).

Despite the prevalence of this phenomenon, treatment disengagement is commonly framed as an individual-level problem. Individuals with mental illness who discontinue medication, psychotherapy, or rehabilitation services are often described as non-adherent, resistant, or lacking insight (Amador and David, 2004; Roe and Davidson, 2017). Yet such explanations overlook the social context shaping treatment engagement. Individuals encounter mental health systems from unequal social positions, and their ability to seek and sustain care is shaped by structural factors such as poverty, stigma, discrimination, education, migration, and displacement.

This brief note argues that what is often labeled “treatment refusal” may instead reflect unequal access to care. From a social justice perspective, the key question is not only why some individuals disengage from care, but whether mental health systems enable meaningful access for those facing the greatest structural barriers. This perspective aligns with social work’s commitment to addressing social determinants of health and promoting equitable access to care (Pockett and Beddoe, 2017).

Treatment disengagement in mental health: Beyond individual responsibility

The dominant perspective in mental health care places primary responsibility for treatment disengagement on individuals with mental illnesses (Amador and David, 2004; Roe and Davidson, 2017). From this viewpoint, engagement is largely understood as a function of individuals’ insights, beliefs, attitudes, and coping strategies related to illness and treatment. This perspective reflects broader medical literature suggesting that treatment non-adherence is common across many health conditions (World Health Organization, 2003). Legal and ethical frameworks in many countries further reinforce this individualized perspective by protecting the right of individuals who do not pose an immediate risk to themselves or others to refuse treatment (Shpigelman et al., 2025). Such legislation reflects a shift away from paternalistic care toward person-centered, recovery-oriented approaches emphasizing autonomy, self-determination, and shared decision-making (Roe and Davidson, 2017).

However, coping explanations alone are insufficient to explain treatment disengagement and risk individualizing a broader social problem. Mental conditions such as schizophrenia, post-traumatic stress disorder, or severe depression may impair motivation, judgment, and trust in professionals while increasing treatment avoidance (Amador and David, 2004). At the same time, social stigma and fear of discrimination may discourage individuals from seeking help, particularly among people from ethnic minority backgrounds (Piterman et al., 2025). When individuals withdraw from care, family caregivers often experience increased emotional, social, and economic burden (Shpigelman et al., 2025). Individuals who disengage from care may also face higher risks of homelessness, substance use, repeated hospitalizations, and involvement with the criminal justice system (Girone et al., 2025; Mlay et al., 2025).

These outcomes highlight the need—and the social responsibility—to move beyond explanations that focus solely on individuals and to address the broader social and structural barriers that shape access to mental health services.

Treatment disengagement and social inequality

A growing body of research indicates that treatment disengagement is unevenly distributed across populations. Individuals experiencing social, economic, and cultural disadvantage are both more likely to experience mental illness and less likely to receive adequate treatment (Mlay et al., 2025; Selten et al., 2020). Populations disproportionately affected include people living in poverty, migrants and refugees, ethnic and racial minority groups, individuals experiencing housing instability, and those affected by war or forced displacement. These groups often face multiple barriers to care, including financial constraints, transportation difficulties, language barriers, cultural mismatches with services, and mistrust of institutions.

Structural inequalities shape how people encounter mental health systems and their ability to access care. For example, people living in peripheral areas may struggle to physically access services; individuals with limited financial resources may face transportation or medication costs; and immigrants or ethnic minorities may encounter linguistic, cultural, and institutional barriers, as well as mistrust of services (Knaifel, 2026; Mahajne and Allassad Alhuzail, 2026). Under such conditions, treatment disengagement may reflect not a rejection of care but rather a mismatch between available services and the lived realities of marginalized populations. This creates a troubling paradox: those at greatest risk of mental illness often face the greatest barriers to care. From this perspective, treatment disengagement may reflect systemic limitations in the accessibility, responsiveness, and cultural relevance of mental health services.

Outreach, relational engagement, and structural advocacy as practices of social justice

While psychiatry and psychology often focus primarily on diagnosis and individual therapeutic interventions, social work occupies a distinctive position within mental health care because it operates simultaneously at the individual, family, and structural levels (O’Leary and Tsui, 2023). Its ethical and professional commitments—emphasizing respect for personal autonomy, collaboration with families, and advocacy for equitable social policy—make social work well suited to addressing complex and multidimensional issues such as treatment disengagement. The profession’s ecological micro–meso–macro framework highlights the dynamic interaction between individuals and their environments and recognizes that social conditions play a crucial role in shaping inequality and well-being (Pockett and Beddoe, 2017).

One important practice approach in this context is outreach, or “reaching out,” a core component of social work practice aimed at engaging individuals who remain disconnected from formal service systems (Szeintuch, 2015). Rather than waiting for individuals to seek help, outreach involves proactive and sustained efforts to establish contact with those who remain outside services. Such efforts may include home visits, community meetings, repeated contact attempts, and collaboration with families or community organizations. Evidence suggests that outreach-based interventions can strengthen engagement with services, improve continuity of care, and reduce repeated psychiatric hospitalizations (Hamilton et al., 2015), and are particularly important when working with ethnic minority communities (Mahajne and Allassad Alhuzail, 2026).

Closely related to outreach is relational engagement with families and communities, which focuses on building respectful and trusting relationships with families and caregivers of individuals who may feel disconnected from mental health systems (Knaifel, 2026). Through psychoeducation, consultation, and ongoing dialogue—including efforts to improve family communication patterns and reduce stigma—this approach addresses the relational and socio-cultural conditions shaping engagement with care while fostering trust, flexibility, and respect for lived experience.

A social justice perspective particularly highlights the importance of structural advocacy. Treatment disengagement often reflects barriers embedded within institutional structures and unequal power relations between service users from minority backgrounds and mental health institutions. Such barriers may include privatized services, complex bureaucratic procedures, institutional racism, or culturally unresponsive care (Nadan, 2017). Social workers therefore play a crucial role not only in engaging individuals and families, but also in advocating for structural changes that improve accessibility and equity within mental health systems.

Implications for international social work

Reframing treatment disengagement as an issue of unequal access has several implications for international social work practice. First, it situates mental health engagement within broader debates about social inequality and human rights. Mental health outcomes are strongly influenced by social determinants such as poverty, migration, discrimination, and housing instability (Selten et al., 2020). These barriers disproportionately affect immigrants, refugees, ethnic minorities, and other marginalized populations, who may face linguistic, cultural, and institutional obstacles when accessing mental health services.

Second, this perspective encourages a shift from compliance-based frameworks toward relational and justice-oriented practice. Rather than focusing solely on whether individuals follow treatment recommendations, social workers must also consider whether services are organized in ways that enable meaningful participation and sustained engagement. In culturally diverse societies, this also requires culturally responsive practice, including attention to language, cultural meanings of mental illness, and active collaboration with families and communities in the provision of care (Nadan, 2017).

Third, it underscores the importance of community-based and outreach-oriented mental health services. Systems that respond primarily during acute psychiatric crises may reinforce cycles of psychiatric hospitalization, relapse, and treatment disengagement (Girone et al., 2025). Early community-based engagement strategies can strengthen continuity of care and reduce reliance on coercive interventions. Outreach approaches may be particularly important for immigrant and minority communities, where geographical distance, intersectional stigma, and prior experiences of discrimination may create additional barriers to seeking care (Knaifel, 2026).

Within recovery-oriented mental health systems, attention to structural barriers is essential to ensure that autonomy and choice are supported by accessible services. From this standpoint, social work practice requires balancing respect for individual autonomy, attention to caregivers’ needs, and recognition of—and action to address—structural injustice.

Conclusion

Treatment disengagement in mental health is often interpreted as an individual problem of insight, motivation, or choice. A social justice perspective suggests that patterns of disengagement may instead reflect structural barriers and unequal access to care. In the context of increasing global migration, cultural diversity, and armed conflicts, addressing these inequalities has become an urgent challenge for international social work. Advancing equitable mental health systems requires social work practice that combines outreach, relational engagement, and structural advocacy to reduce barriers to care for vulnerable populations.