Who Has the Money to Do That?: Supporting Mental Health Recovery with Non-Treatment Goods and Services Purchased through Self-Directed Care

Background and Purpose: Individuals with serious mental illness (SMI) experience significant financial constraints that create inequities in access to recovery-promoting resources. Several states have implemented Self-Directed Care (SDC) programs that help people with SMI identify recovery goals and access dedicated public funds to purchase needed goods and services, outside of formal mental health treatment, to help achieve these goals. This project sought to evaluate participant and stakeholder experiences with SDC as part of a pilot program implemented at two behavioral health provider organizations in New York state. The SDC program offered individuals with SMI the support of a resource consultant and control over funds to purchase recovery-promoting resources, with approval of purchases and oversight provided by the Office of Mental Health.

Methods: Semi-structured qualitative interviews were conducted with 14 SDC participants and 12 staff across the two SDC provider sites, as well as 8 leadership and staff from the state mental health agency and a provider/advocacy association. Interviews explored participants and other stakeholders’ perspectives on how the SDC program was being implemented, its perceived impact, and factors that might impact program expansion and scale-up. Interviews were audio recorded, transcribed, and analyzed using modified grounded theory.

Results: Participants described the process of identifying goals and needed resources within SDC as personalized and client-driven. Both participants and stakeholders highlighted the broad flexibility afforded in the types of goods and resources that participants could purchase with SDC funds to promote recovery goals and that misuse of funds was very rare. Participants described how access to specific non-traditional goods (e.g., furniture, cellphone, bicycle, clothing) and services (e.g., yoga, acupuncture, martial arts, writing class) was connected to improvements in physical health, community participation, and social relationships, as well as enhanced housing stability and recovery from substance use. SDC-funded resources such as school books, computers, and transportation also facilitated progress along education and employment/career goals, including graduation from college and launching income-generating entrepreneurial activities. Overall, participants credited SDC with facilitating a shift in perspective from basic survival toward higher-level recovery pursuits and with increasing their sense of purpose, independence, confidence, and self-esteem, while reducing stress, anxiety, and depression. When considering program scale-up, areas to be addressed included: expanding tracking of program referrals and enrollment, clarifying factors that should be considered in decision-making regarding purchase approvals, expanding communication regarding approval timeframes and request denials, clarifying duration of participant tenure in the program, ensuring fit between provider/organizational philosophies and the person-centered approach of SDC, increasing administrative efficiency, and clarifying definitions of program success.

Conclusions and Implications: Descriptions of SDC aligned with key program components and client-driven principles. Participants consistently reported positive impacts along multiple life domains, often referencing how the impact of accessing one resource rippled across multiple goals. Interviews shed light on the mechanisms underlying progress towards recovery goals in SDC and highlight key areas that inform future implementation and program expansion.