Consumer experience with payeeship provided by a community mental health center

Recipients of Representative Payeeship with Mental Illness: Financial Leverage, Conflict, and Satisfaction

This study aimed to examine self-report of financial leverage, conflict, and satisfaction pertaining to representative payeeship for persons with mental illness, which research has not examined in the past decade. Sixty representative payee recipients with mental illness residing across the U.S. completed an online survey, with most (n = 50) receiving representative payeeship by family members/friends. Wilcoxon-Mann-Whitney tests and Spearman correlations were computed. One-third of participants reported experiencing financial leverage and conflict "sometimes" or more often and were dissatisfied with their representative payee arrangement. With the exception of use of alcohol and/or drugs, no participant characteristic was associated with financial leverage, conflict, or satisfaction. Financial leverage was reported to be greater when representative payees were family members/friends. Financial leverage and conflict were positively associated with each other and negatively associated with satisfaction. It is advisable that satisfaction with representative payeeship be increased and conflict resulting from representative payeeship be minimized.

Fiduciary assignment as a potential intervention for substance use disorder: a retrospective chart review

Background: Assignment of fiduciaries to veterans with disability payments is an intervention thought to improve quality of life; however, in veterans who use substances, a proportion of these payments may be misspent on drugs and/or alcohol. While fiduciary assignment may reduce funds available to purchase substances, clinical efficacy of this intervention in the management of substance use disorders has not been rigorously demonstrated.Objectives: The purpose of this study is to evaluate changes in clinical status before and after fiduciary assignment.Methods: This was a retrospective chart review of 50 (44 male, 6 female) veterans who were assigned a fiduciary and determined to have a substance use disorder (SUD). SUD-related data including outpatient and inpatient treatment, toxicology testing, and measures of psychosocial functioning for the three years before and after fiduciary assignment were extracted and compared.Results: Veterans were found to have higher rates of any form of employment after fiduciary assignment (Wilcoxon, Signed Ranked S-statistic = 0.22, pr = 0.02). Two changes in measures of substance use were found after fiduciary assignment. There was a reduction in positive screens for heroin (tstatistic = -2.7, p = .01), but an increase in positive screens for fentanyl (t statistic = 2.53, p = .02). There were some potentially clinically but not statistically significant trends in increased adherence with mental health appointments, number of medical hospitalizations, and rates of employment post-fiduciary assignment.Conclusions: Understanding the clinical impact of fiduciary assignment for veteran's benefits is desirable but still pending at this time.

Unconditional Cash Transfers and Association With Clinical Outcomes Among U.S. Veterans With Psychosis or Recent Homelessness

OBJECTIVE

Three rounds of stimulus checks were distributed to middle- and low-income U.S. adults during the COVID-19 pandemic. This 15-month longitudinal study examined rates of receipt of these stimulus checks, planned expenses, and associations with clinical outcomes among three veteran groups.

METHODS

In total, 158 veterans, consisting of 59 with a psychotic disorder, 49 recently homeless veterans, and a comparison group of 50 veterans without a history of psychosis or homelessness, were assessed five times between May 2020 and July 2021. Bivariate analyses were used to compare receipt of stimulus checks and planned expenses among the groups, and multivariable analyses examined how receipt of checks was related to mental health and substance use over time.

RESULTS

No group difference was found in receipt of stimulus checks, and 74%-84% of veterans reported receipt of more than one check. Most participants reported plans to use their stimulus checks to pay for bills, groceries, credit card debt, and rent or mortgage or to save the money. Over time, participants who received a greater number of stimulus checks reported significantly decreased symptoms of depression (B=-0.48) and anxiety (B=-0.84) and improved social functioning (B=0.24). For the recently homeless group, a greater number of stimulus checks received was associated with decreases in days of alcohol intoxication and drug use, but the reverse was found for the psychosis group.

CONCLUSIONS

Multiple short-term unconditional government cash transfers may improve mental and social functioning among vulnerable populations during major crises, a finding that contributes to the research literature and has policy implications for pandemic and emergency preparedness.

"Support People the Way in Which They Want to Be Supported": Best Practices for Incorporating Client-Centeredness in Representative Payee Programs

Nearly 1 million Social Security beneficiaries have representative payees to manage their funds. Although coercion and paternalism are historically associated with payee services, a recent study showed high satisfaction in a payee program incorporating client-centered practices. Separately we reported ways organizations align payee services with their missions to empower clients and improve outcomes. Here we share results from nine provider qualitative interviews describing client-centered best practices and exploring beliefs regarding their value. We identified four best practices: Shared Decision-Making on Bills and Spending, Non-Paternalistic Substance Use Policies, Client Advocacy, and Additional Service Policies, (changing fee structures, termination policies, incorporating opting in or out, and "graduation"). Results indicate prioritizing clients' goals and agency may improve the quality of life of beneficiaries and reduce the paternalism and coercion historically associated with payee. Creating a client-centered payee toolkit and a payee collaborative may empower organizations to refine their services and provide opportunities for shared learning and support.

A Systematic Review of Health Outcomes Associated With Provision of Representative Payee Services

OBJECTIVE

The Social Security Administration's Representative Payment Program appoints payees as financial managers for individuals determined incapable of managing their funds. The aim is to afford stability and increase clients' ability to meet health and behavioral priorities. This systematic review examined literature on the effect of representative payee services on identified outcomes.

METHODS

A search of academic databases and gray literature was conducted in November 2015 and repeated in December 2017. Included studies had a comparison group; excluded studies examined services other than representative payee. Primary outcomes included substance use, symptoms of mental illness, housing stability, quality of life, and other health-specific outcomes. Secondary outcomes included the client-payee relationship and client satisfaction with services.

RESULTS

Eighteen articles met inclusion criteria. Studies assessing primary outcomes found several positive and few negative effects of representative payee services. Studies examining secondary outcomes indicated that receipt of such services may affect the client-provider relationship, increase conflict and violence, and increase clients' perceptions of financial leverage (i.e., a payee's use of control over funds to encourage, incentivize, or otherwise coerce certain behaviors). Most studies were of poor or moderate quality. Studies spanned nearly two decades, and results may have been confounded by the evolution of service delivery modalities.

CONCLUSIONS

Representative payee services are largely beneficial or neutral in terms of health and behavior outcomes. Negative findings mainly involved the client-payee relationship. Given that more than five million individuals have a representative payee, assessing the impact of these services with more rigorous research designs is worthwhile.

Common Factors in Community Mental Health Intervention: A Scoping Review

While there is considerable research and commentary devoted to common factors in psychotherapy, their implications for community mental health interventions are much less clear. In response, a scoping review was conducted to answer the question, 'What is the evidence base for common factors in community mental health intervention?' A comprehensive search of MEDLINE, PsycINFO, and Google Scholar was completed. A total of 60 publications were identified in this review with a focus primarily upon therapeutic alliance. Though methodologically diverse, this review supports the likely importance of alliance in the outcomes of community mental health interventions.

Pathways to assignment of payees

How clients come to be assigned representative payees and/or conservators to manage their funds is not well understood. We compared clients assigned a payee during a clinical trial of a money management-based intervention to those not assigned payees and examined antecedents to payee assignment. One year after randomization, significantly more clients assigned to the advisor teller money manager (ATM) money management intervention were assigned payees than participants in the control condition (10 of 47 vs. 2 of 43; p = .02); those assigned payees had lower baseline GAF scores and participated more in study therapies. Several ATM clients were assigned payees after third parties paid more attention to clients' finances, and others after having negotiated storage of their funds with the ATM money manager during the study. Assignment of payees appears to be influenced by whether third parties critically attend to how clients' manage funds and by clients' receptiveness to having a payee.

Subjective Experiences of Clients in a Voluntary Money Management Program

A large proportion of people diagnosed with mental illnesses have difficulty managing their money, and therefore many psychiatric treatments involve providing money management assistance. However, little is known about the subjective experience of having a money manager, and extant literature is restricted to people forced to work with a representative payee or conservator. In this study, fifteen people were interviewed about their experience receiving a voluntary money management intervention designed to minimize substance use. Clients emphasized the importance of trusting the money manager, financial mindfulness (an enhanced awareness of the financial transactions in clients' day-to-day lives), agency over their own affairs, and addiction. In contrast to evaluations of people assigned representative payees and/or conservators, there was little mention of feeling coerced. These findings suggest that money management programs can address client concerns by building trust, relating budgeting to clients' day-to-day lives, and encouraging clients' control over their own affairs.

The 'check effect' reconsidered

AIMS

The 'check effect' refers to the use of disability payments to purchase illegal drugs or alcohol. This paper describes subsequent research concerning three interrelated issues: the check effect, whether receipt of disability payments is associated with more overall substance use, and potential policy responses to misuse of disability payments for substances.

METHODS

Review and synthesis of published papers.

RESULTS

Increased substance use at the beginning of the month has been described in a variety of settings. The tendency to purchase substances at the beginning of the month is impacted by household wealth, the tendency to discount future rewards and cyclical economic activity. However, in naturalistic observational cohort studies, beneficiaries who receive disability payments had no greater substance use than those without disability payments. Potential policy responses to mis-spending of disability checks include financial counseling that discourages spending on drugs and the assignment of a representative payee to prevent misuse of benefits for substances. Assignment of a representative payee per se has not been associated with reduced substance use, but payeeship administered by agencies that integrate payee practice into treatment has been.

CONCLUSION

Disability payments impact the timing of substance use, but receipt of disability payments is not associated with more overall substance use than unalleviated poverty. Money management-based clinical interventions, which may involve assignment of a representative payee, can minimize the purchase of substances with disability payments.

The efficacy of assertive community treatment to treat substance use

BACKGROUND

Assertive Community Treatment (ACT) has been studied extensively in people with severe mental illness, but there have only been a few clinical trials in which substance use was one of the measured outcomes.

OBJECTIVE

The goal of this article was to describe the efficacy of ACT in treating co-occurring substance use disorders and suggest approaches to make it more efficacious.

DESIGN

A literature review was conducted and randomized clinical trials describing ACT's impact on substance use were reviewed.

RESULTS

Four randomized clinical trials of ACT that measured substance abuse adequately were identified, all of which showed small to no effect on substance abuse compared with control conditions. Methodological issues might account for the small effects. ACT might further reduce substance use by being paired with evidenced-based substance abuse treatment, helping clients become housed or helping them manage their money better.

CONCLUSION

Integrated ACT, in which the ACT team provides substance abuse counseling, has the potential to reduce substance use by several mechanisms, but this has been difficult to demonstrate in clinical trials when participants in control groups receive similar interventions.

Money management, mental health, and psychiatric disability: a recovery-oriented model for improving financial skills

TOPIC

Although money management skills are essential for independent functioning in the community, when viewed from the framework of psychosocial rehabilitation, there have been few systematic models for teaching money management skills to consumers with psychiatric disabilities based on a recovery orientation.

PURPOSE

For those diagnosed with psychiatric disabilities, better money management has consistently been shown to be associated with superior quality of life, fewer hospitalizations, and greater self-efficacy. Consumers frequently indicate that learning how to budget and staying out of debt are among their top goals for recovery with mental illness. The current paper reviews the issues of money management and mental health among people with psychiatric disabilities and proposes a recovery-oriented approach to increasing money management skills to increase community functioning among consumers.

SOURCES USED

Published literature, clinical cases, and financial literacy resources.

CONCLUSIONS AND IMPLICATIONS FOR PRACTICE

Improving money management can lead to a number of benefits by helping consumers with psychiatric disabilities: 1) gain more knowledge about disability benefits, 2) improve basic financial skills, and 3) reduce vulnerability to financial exploitation. Future work on incorporating this model into psychiatric rehabilitation programs would address skills consumers can use in living, working, and social environments in a way that enhances consumer choice and promotes recovery.

The therapeutic relationship in secondary mental health care: a conceptual review of measures

OBJECTIVE

The study aimed to determine the conceptual basis of measures of the patient-professional relationship used in routine mental health services research by reviewing their face, content and construct validity.

METHOD

A comprehensive literature search identified measures of the relationship used in mental health services research. The conceptual basis of each identified measure was identified by a review of measures' authors assessments of face, content and construct validity plus item analysis of the measures themselves.

RESULTS

The search identified 15 measures. The seven developed in psychotherapy were likely to be better validated conceptually; most were based on therapeutic alliance models. Measures developed specifically for mental health services were based on a wider range of models including global assessments of the relationship.

CONCLUSION

Most of the better validated measures originate in psychotherapy, but there is limited evidence for their validity in general mental health services. Four measures are recommended.

Use of leverage over patients' money to promote adherence to psychiatric treatment

Persons who handle money for patients with mental disabilities often use access to funds as leverage to promote adherence to treatment. Drawing on data from a five-site study involving interviews of 1011 patients at community mental health centers, this paper explores who provides money assistance, the predictors of leverage use, and its impact on patients. A substantial minority of patients reported having experienced leverage. Substance abuse and frequent hospitalization were the strongest clinical predictors, suggesting that functional impairment is a key determinant. Patients experiencing money leverage were also likely to experience other forms of leverage, and although they were more likely to feel coerced, they were also more likely to believe that money leverage was effective. Family members seemed to provoke fewer negative feelings as money managers. The frequency with which money leverage is used suggests attention is needed to both the fairness of leverage and the means of minimizing negative effects.

A comparison of satisfaction with clinician, family members/friends and attorneys as payees

Clients disabled by psychiatric illness may be assigned mental health clinicians as payees. We compared client-payee interactions among 42 clients with clinician-payees, 20 whose payees were family or friends and nine with attorney-payees. Compared to clients with attorney-payees, clients with clinician-payees felt more satisfied and more involved in their money management, and had had more contacts with their payees in the previous month. Clients' satisfaction with family/friend payees was similar to that with clinician payees. In multivariate analyses, whether or not the payee had had training about mental illness accounted for 33% of the variance in satisfaction with the payee.

Payee relationships: institutional payees versus personal acquaintances

Most patients' payees are friends or family members, but quantitative evaluations of patients' experience of payeeship published thus far have involved patients whose payees were mental health staff. We compared ratings of different aspects of payeeship among veterans whose payees were family or friends (n = 27) and among those with institutional payees (lawyers, accountants, or clinic-affiliates, n = 22). After adjusting for differences in sociodemographic characteristics, the two groups had small and statistically non-significant differences on measures of their interaction with their payees. Overall satisfaction with payees and trust in them was high.