Money Matters: Participants' Purchasing Experiences in a Budget Authority Model of Self-Directed Care

Background and Purpose: Self-directed care (SDC) is a service delivery model in which individuals diagnosed with a severe and persistent mental illness direct their behavioral healthcare by managing an individual budget and purchasing the goods and services they deem most helpful. Participants may purchase conventional mental health services as well as alternative goods and services (e.g., clothes, fitness classes) to support their recovery. Although the literature provides insight into how participants elect to spend service dollars allocated for their care, little is known about the decision-making process that informs their purchase choices or experiences using individual budgets. Given that individual budgets are regarded as an essential component of SDC and are theorized to enhance participants’ choice and control, it may be helpful to better understand not just what participants buy, but why. Participants’ qualitative accounts of their purchasing decisions and experiences may provide insight into the degree to which individual budgets and flexible spending enhance participants’ perceived self-determination and recovery. Their personal reports may also help identify potential barriers to self-determination within the purchasing process that may not be immediately evident in post-hoc quantitative analyses of expenditures. To this end, this study explores the factors that influence participants’ purchasing decisions, the benefits they derive from SDC purchases, and the perceived barriers experienced in making desired purchases.

Methods: Semi-structured interviews were conducted in person with a purposive sample of 18 SDC participants, including 11 females and seven males with a mean age of 54 (SD = 11.8). Of those interviewed, eight were white, six were black, and four identified as being biracial; 16 reported being diagnosed with a mood disorder. A schedule was used for consistency. Recorded interviews were transcribed, and data were analyzed using the constant comparative method.

Results: Participants reported recovery-related purchases in five categories: basic needs; mental health; physical fitness; education and technology; and miscellaneous supplies (e.g., office, craft). The largest and most frequently reported category included those related to basic needs. Analysis of the benefits that individuals associated with these purchases revealed five themes: financial help; mental wellness and stability; tools and opportunities; self-esteem; and physical well-being. Participants reported that their financial needs, the SDC program’s purchasing policies and procedures, and their recovery goals influenced their purchases decisions. Finally, participants described barriers experienced in making desired purchases. These barriers clustered in the following categories: lack of clarity and flexibility in purchasing guidelines, technicalities in purchasing procedures, perceived disconnect between purchases and goals, and participants’ struggles with symptoms.

Conclusions and Implications: Participants regard SDC purchases as integral to their mental health recovery as well as to their daily survival. Flexible purchasing guidelines afford participants the freedom to make purchases to subsidize their living expenses and to pursue recovery goals otherwise unaffordable. Findings reveal the extent to which money matters in mental health recovery and suggest that individualized budgeting and purchasing contribute to SDC participants’ mental wellness and stability, enhance their control over service choices, and, most notably, provide some material relief in ongoing struggles with chronic poverty.