University of Nebraska Press
  • Participants' Goals, Resources, and BarriersPerson-Centered Assessment and Planning in Self-Directed Care
ABSTRACT

Self-directed care (SDC) is an innovative "money follows the person" approach to community-based mental health service delivery, which affords individuals diagnosed with a severe and persistent mental illness opportunities to engage in person-centered assessment and planning to achieve self-identified recovery goals. A growing body of literature points to the positive impact of SDC; however, existing outcome studies are primarily limited to provider-driven outcome measures. Participants' perspectives and expectations for program participation are largely missing. By examining the self-reported goals, resources, and barriers of 136 SDC participants, this qualitative study provides important insights into participants' individualized and shared aspirations for program participation as well as the resources and barriers they feel impact their goal achievement. These insights illustrate the potential utility and value of various elements of the SDC model and point to more person-centered strategies for outcome assessment. Additional implications for SDC and community-based mental health policy, administration, and practice are explored.

KEYWORDS

self-directed care, person-centered planning, recovery, severe and persistent mental illness

Introduction

Despite recent federal directives to make the public mental health system more person-centered and recovery oriented (i.e., President's New Freedom Commission on Mental Health, 2003), self-directed care (SDC) programs for individuals diagnosed with a severe and persistent mental illness (SPMI) are not widely available in the United States. SDC programs differ from traditional community-based mental health service delivery models [End Page 115] in their "money follows the person" approach. That is, with the support of service brokers or recovery coaches, SDC program participants control the public dollars allotted for their care by purchasing goods and services they feel will help them to achieve mental health recovery. According to Croft, Simon-Rusinowitz, Loughlin, and Mahoney (2013), only 700 individuals were served in 2013 among SDC programs operating in seven states. Although these programs are heterogeneous in size and administration, all integrate the hallmarks of SDC—supports brokerage and flexible spending, allowing program participants to purchase a variety of goods and services to meet their needs (Croft et al., 2013).

The body of literature examining the impact of domestic behavioral health SDC programs is relatively small (Alakeson, 2008; Barcyzk & Lincove, 2010) and limited to a few technical evaluation reports (i.e., Alakeson, 2007; Hall, 2007; Office of Program Policy Analysis and Government Accountability [OPPAGA], 2010; Sullivan, 2006; Teague & Boaz, 2003), one doctoral dissertation (Spaulding-Givens, 2011), and a small number of peer-reviewed journal articles (i.e., Cook, Russell, Grey, & Jonikas, 2008; Cook et al., 2010; Croft & Parish, 2016; Snethen, Bilger, Maula, & Salzer, 2016 ; Spaulding-Givens & Lacasse, 2015). Of these, only a few studies report outcomes of SDC participants in comparison to individuals enrolled in traditional community-based mental health services. In the earliest evaluation of SDC, Teague and Boaz (2003) found that SDC participants (n = 13) felt better able to deal with daily problems and accomplish their goals in comparison to a group of non-SDC clients (n = 8). Hall (2007) reported that SDC participants (n = 131) demonstrated greater residential stability, worked more days, and had lower crisis stabilization and utilization rates than a matched group of non-SDC clients ( n = 131), although these differences were not statistically significant. Using a pre–post design, Cook and colleagues (2008) determined that SDC participants (n = 106) spent significantly more days in the community and scored significantly higher Global Assessment of Functioning scores following enrollment in SDC. Compared to non-SDC clients, SDC participants also appear to be more satisfied with services rendered (Alakeson, 2007; Teague & Boaz, 2003).

Given that flexible spending is a hallmark of the SDC model, much of the SDC literature focuses on the types and amounts of expenditures program participants make. While studies indicate participants commonly [End Page 116] utilized SDC dollars to purchase "traditional" mental health services (e.g., psychiatric assessments, medication, counseling), participants seemingly elected to spend more on "nontraditional" services and goods (Alakeson, 2007; Cook et al., 2008; OPPAGA, 2010; Snethen et al., 2016; Spaulding-Givens, 2011; Spaulding-Givens & Lacasse, 2015). Such purchases included alternative wellness services (e.g., fitness and weight loss programs, massage therapy, smoking cessation) and tangible goods necessary to community participation and goal achievement (e.g., uniform for volunteering, glasses for reading). Most frequently, nontraditional purchases addressed individuals' basic needs (e.g., housing and utilities, food, clothing, and transportation).

Collectively, the literature provides tentative evidence of positive effects of SDC on individuals diagnosed with an SPMI. The studies cited in the previous paragraph suggest SDC participants fare better than non-SDC participants and that they enjoy access to a wide variety of goods and services that would not likely be available to them in other community-based mental health programs. However, existing outcomes studies are primarily limited to administrative measures (e.g., days in the community, days worked) and do not provide much insight into participants' experiences or expectations other than to assess their satisfaction with SDC. Reports of expenditures provide some understanding of SDC participants' needs and preferences, but this understanding remains incomplete without more direct measures of individuals' expectations and experiences. Overall, SDC participants' perspectives are mostly missing from the available literature. The exception to this is a recent qualitative study by Croft and Parish (2016), which explored participants (N = 30) experiences with SDC and established a "positive relationship between self-direction and recovery" (p. 1). In particular, individuals indicated that SDC made it possible for them to address material needs that undermined their recovery and overall sense of belonging. Participants also attributed to SDC participation increases in self-esteem and self-confidence, which helped to advance their recovery goals. Croft and Parish make an important contribution to the literature by providing a voice to SDC participants and linking SDC participation with mental health recovery. However, more research is needed to better understand the SDC population as well as their experiences with the SDC service delivery model, particularly given that it is a promoted by authorities as a more person-centered, recovery-oriented [End Page 117] alternative to traditional community-based mental health service systems (e.g., Substance Abuse and Mental Health Services Administration, 2005).

Administrative outcome variables, such as days in the community and days worked, may serve necessary contract monitoring purposes, but they do not necessarily capture the preferred outcomes or priorities of program participants (Anthony, 2001; Campbell, 1998). In fact, evidence suggests that consumers' perspectives regarding the efficacy of interventions tend to differ from those of mental health authorities (Windle & Paschal, 1981), and SDC expenditure data strongly suggest that program participants prioritize nontraditional goods and services when they are allowed flexibility in spending mental health service dollars. The purpose of this study is to explore what participants hope to achieve by participating in SDC. By examining SDC participants' self-reported recovery goals written in their own words, it may be possible to better understand how SDC may be improved to help individuals achieve those goals and to identify new ways to conceptualize and assess the impact of SDC. Further, exploring the resources and barriers participants report as impacting their prospective goal achievement may yield new, participant-driven policy and practice implications for policy makers, administrators, and practitioners who wish to implement, improve, or expand SDC programs and other person-centered, community-based mental health initiatives. Last, capturing firsthand accounts of SDC participants' goals, resources, and barriers may begin to fill gaps in the SDC literature by reporting participants' perspectives and providing a more participant-oriented context for existing study findings. Thus, the guiding research questions for this study are: (a) What are SDC participants' recovery goals, and (b) What internal and external resources and barriers do SDC participants identify as impacting their prospective goal achievement?

Methods

Design

The SDC program in this study utilizes a budget authority model of self-direction (Croft et al., 2013). In this model, program participants develop a person-centered recovery plan and manage an individual budget of public dollars allotted for their mental health care. Within the constraints of a purchasing policy approved by the state mental health authority, participants [End Page 118] are free to purchase the goods and services they feel best meet their needs from their preferred vendors and providers. Participants may purchase traditional (e.g., medication management, psychotherapy) as well as nontraditional (e.g., music lessons, yoga or tai chi classes, massage) services to facilitate their recovery. Upon enrollment, participants choose recovery coaches, who are independent contractors and mental health professionals, with whom to collaborate. Coaches provide supports brokerage, which entails helping participants to develop recovery plans, create corresponding budgets, access a variety of services, and make desired purchases (Cook, Terrell, & Jonikas, 2004). The program is administered by a managing entity rather than a community-based mental health provider agency. The role of the managing entity is to process financial transactions much like other third-party payers and to manage a broad provider network of mental health providers from whom SDC participants may elect to obtain services. The elements of this service model—person-centered planning, individualized budgeting, supports brokerage, and financial management services—are consistent with the SDC model endorsed by the Federal Centers for Medicare and Medicaid (Cook et al., 2004).

The qualitative data reported in this article were collected as a part of a naturalistic descriptive study approved by the Institutional Review Boards (IRBs) of the author's affiliated university and the state mental health authority. Given the research questions posed, this approach is ideal in that it allows for in-depth examination of phenomena not otherwise well understood (Sandelowski, 2000). The clinical and fiscal records of 136 (44%) of the 309 SDC participants served in a southeastern state during one fiscal year were reviewed in two waves. The first wave of data was collected from a convenience sample of 80 participants, who consented in writing to study participation. The second wave was collected from the records of an additional 56 participants, following the IRB's decision to grant a consent waiver in accordance with the Health Insurance Portability and Accountability Act Privacy Rule (U.S. Department of Health & Human Services, 2002) for those participants who were no longer enrolled in the program and could not be contacted to obtain consent. This article examines the qualitative data collected regarding SDC participants' goals, resources, and barriers. Quantitative findings regarding participants' service utilization and outcomes are reported in another article (i.e., Spaulding-Givens & Lacasse, 2015). [End Page 119]

Measures

Demographic data were collected from participants' enrollment documents and Mental Health Outcomes (MHO) forms. The MHO form was developed by the state mental health authority and must be completed for each participant by his or her recovery coach at enrollment and on a quarterly basis thereafter. Qualitative data regarding participants' goals, resources, and barriers were collected from each participant's Life Analysis, a person-centered assessment and planning tool constructed and modified by program staff (Florida Department of Children and Families, 2006 ). Participants are expected to complete a Life Analysis upon enrollment and update it annually in collaboration with their recovery coach. Using this tool, participants describe their histories and identify their goals related to various life domains. In early versions of the Life Analysis, participants were required to identify goals in the domains of mental wellness, physical wellness, and work/productive activities. Additional space was provided to write other goals related to substance abuse/dependence and other "priority components" (e.g., spirituality, relationships), if they wished. In more recent versions, participants are only directed to articulate mental wellness and work/productive activity goals, allowing more flexibility to identify goals in domains of more importance to them. However, it is important to note that the broad categories of goal domains reported herein may be in part an artifact of the program's documentation structure and requirements rather than evidence of participants' priorities.

In addition to using their Life Analysis to articulate recovery goals, participants also use the assessment and planning tool to identify the internal and external resources and barriers that they believe will impact their goal achievement in each domain. Essentially, participants are asked to conduct a SWOT (Strengths, Weaknesses, Opportunities, and Threats) analysis for each goal they wish to achieve. The SWOT analysis is a common strategic planning tool utilized by corporations and nonprofit organizations (Brody, 2005). Participants are directed to identify their strengths or internal resources ("What resources within yourself will help you achieve your goal?"), opportunities or external resources ("What resources in your community will help you achieve your goal?"), internal barriers ("What within yourself may hinder you from achieving your goal?"), and external barriers ("What in the world around you may hinder [End Page 120] you from achieving your goal?") (Florida Department of Children and Families, 2006, p. 6).

Although recovery coaches collaborate with participants in this assessment and planning process, participants are asked to complete the Life Analysis themselves, using their own words to articulate goals, resources, and barriers. Exceptions are made for individuals who have low literacy or are physically unable to write. In such cases, the recovery coach fills in the Life Analysis as the program participant dictates. Therefore, the Life Analysis is the artifact of the person-centered assessment and planning process and theoretically reflects the individual's priorities for program participation (i.e., recovery goals) and perspectives regarding resources and barriers that may impact goal achievement. This document is fundamental to the SDC service delivery model in that it serves as the basis and justification for participants' quarterly plans and budgets in which funds are encumbered for desired goods and services.

Data Analysis

To answer the questions posed in this article, which essentially entails describing phenomena, a generic qualitative approach was taken in accordance with the recommendations of a growing body of literature (Caeilli, Ray, & Mill, 2003; Patton, 1997, 2002; Sandelowski, 2000). Conventional content analysis techniques (Hsieh & Shannon, 2005; Zhang & Wildemuth, 2009) were utilized to code and categorize participants' goal statements, resources, and barriers, which were the units of analysis. After becoming immersed and gaining an understanding of the whole by reading all the participants' statements, the author then reread participants' statements, making notes of recurring themes and emerging categories (Hsieh & Shannon, 2005). A tentative set of categories was created, using labels derived from frequently occurring words or themes. Participants' statements were sorted thematically, utilizing the constant comparative method, which entails the systematic comparison of each statement assigned to a category with those statements already placed in that category (Zhang & Wildemuth, 2009). This process was repeated multiple times. Statements were resorted while combining or refining categories to best capture the intent of participants' statements, and to create categories that reflected a consistent theme. To improve the credibility of these categories, [End Page 121] the author searched for disconfirming evidence—statements that provided evidence contrary to existing themes (Creswell & Miller, 2000). In instances when such evidence was identified, the assignment of the statement was reconsidered, resulting in either reassigning the statement to a new category, relabeling the category to capture more accurately the breadth of participants' statements, or creating a new category. Upon concluding data coding, the consistency of coding was evaluated by reviewing the coding assignments again in their entirety, looking for errors and inconsistencies ( Zhang & Wildemuth, 2009).

Although doing so is not strictly qualitative, the frequency with which participants used particular words or expressed key themes was counted. Sandelowski (2000) argued that counting is appropriate in descriptive qualitative content analysis, but that it "is a means to an end, not the end itself" (p. 338). The purpose in counting and reporting frequencies of recurring themes is to demonstrate the degree to which goals, strengths, or barriers are shared by SDC participants and to increase the rigor and transparency of this study.

Theoretical Positioning

The credibility and transparency of generic qualitative studies are enhanced by the disclosure of a researcher's theoretical positioning (e.g., motives, personal history) (Caeilli et al., 2003; Creswell & Miller, 2000). As Caeilli et al. (2003) explained, a researcher's decision to conduct a study is "never a naïve choice" (p. 9). The author has extensive involvement with SDC, serving initially as a program coordinator and later as an advisory board member. She has also conducted trainings and workshops for SDC recovery coaches and board members. The author's involvement with SDC as a practitioner and educator sparked her interest in examining the SDC model and participants' experiences, increased the feasibility of this study, and likely informed her understanding and interpretation of study findings.

Results

Sample

Ranging in age from 29 to 83 (M = 50.5, SD = 9.44), a majority of study participants (N = 136) were White (n = 103, 75.7%), female ( n = 80, 58.8%), [End Page 122] divorced (n = 59, 43.4%) or single (n = 56, 41.2%), and living alone (n = 60, 44.1%). Most had earned a high school diploma (n = 36, 26.5%) or attended college without completing a degree ( n = 35, 25.7%). Although a substantial number of participants (n = 92, 67.6%) were classified as disabled at the time of the study, nearly all reported having an employment history (n = 114, 83.8%). Only a small percentage (n = 14, 10.3%) were military veterans. Participants' mean annual family income ranged from $0 to $48,000 (M = $10,560, SD = $6,165). Most (n = 92, 67.6%) relied upon federal disability insurance as their primary source of income. No statistically significant differences were detected between the demographic characteristics of active and discharged program participants.

Most study participants were diagnosed with a mood disorder (n = 91, 66.9%) or a psychotic disorder (n = 34, 25%); others were diagnosed with anxiety (n = 7, 5.1%) or somatoform (n = 1, 0.7%) disorders. Nearly half (n = 62, 45.6%) also had a substance abuse history. Individuals (n = 76, 55.9%) enrolled in SDC at the time of the study had been participants for an average of 3.19 years ( SD = 1.56), while those discharged (n = 45, 33.1%) remained in SDC an average of 2.76 years (SD = 1.46).

Recovery Goals

The majority of SDC participants (n = 117, 86.0 %) reported having goals related to mental wellness. Many (n = 91, 66.9%) also identified physical wellness goals, and 90 (66.2%) articulated goals in the area of work and productive activity. Only 17 (12.5%) individuals noted goals pertaining to sobriety. As a caveat, these goal domains are an artifact of the life domains included in the Life Analysis that participants are required to use for self-assessment and planning purposes. However, content analyses of each domain revealed categories that point to participants' shared hopes, yet individualized recovery goals. For example, analysis of 152 mental wellness goals revealed seven categories: stability, balance, and wellness ; independent living; symptom management; functioning and skills; access services; health, happiness, and quality of life; and family and relationships. Table 1 details the categories and frequencies of goal statements by domain (e.g., mental wellness, physical wellness) and provides example goal statements for each category. Please note that the number of goal statements often exceeds the number of participants who identified goals in the corresponding domain. This is because individuals frequently reported multiple goals [End Page 123] for each domain. Given that the goal was the unit of analysis, each goal statement was coded and categorized independently.

Resources and Barriers

Just as participants identified more than one recovery goal for each goal domain, participants also listed multiple internal and external resources and barriers for each domain. Given that the resources and barriers were the units of analysis, Tables 2 and 3 detail the frequencies with which the resources and barriers were identified rather than the numbers of SDC participants who identified them. In many cases, participants seemed to struggle with differentiating between "internal" and "external" when describing their resources and barriers impacting prospective goal achievement. In these instances, the units were coded using the definitions provided in the Life Analysis. For example, if a participant identified "neighborhood gym" as an internal resource for achieving a physical wellness goal, "neighborhood gym" was coded as an external resource.

Internal resources

As shown in Table 2, participants' internal resources typically fell within one of five categories, although the frequency of resources within each category varied from one domain to the next. Participants commonly reported internal resources related to desire and motivation, stating they were "determined" and "willing to try." Participants also pointed to their knowledge, skills, and abilities and behaviors, which were often domain specific. For example, participants described behaviors for achieving mental wellness goals, such as "I keep appointments" and "I take my meds as directed." Participants also frequently included personal characteristics (e.g., "intelligence," "tenacity") as internal resources for goal achievement. Finally, the theme of spirituality emerged across domains. A small number of participants identified their "belief in God" or "faith" as internal resources for goal achievement.

In the work and productive activity goal domain, another category of internal resources emerged. Many participants included their employment and volunteer history as internal resources that might help them to achieve their goals related to obtaining a job or engaging in some other type of productive activity. Examples of these resources ranged from "long retail history" to "painting experience" to "volunteer at homeless shelter."

External resources

SDC participants identified a wide variety of external resources, from which eight categories emerged. Categories, examples, [End Page 124]

Table 1. Categories, Frequencies, and Examples of Goal Statements by Domain
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Table 1.

Categories, Frequencies, and Examples of Goal Statements by Domain

[End Page 125]

and frequencies of these external resources are detailed in Table 2. Although some of these categories crossed several domains, others were more domain specific. Across all four goal domains, participants described community resources (e.g., "library," "church") that would help them to achieve their goals. Participants also frequently identified their support network (e.g., "my mother," "friends in recovery") as external resources. This category emerged among three goal domains: mental wellness, physical wellness, and sobriety. Other major categories of external resources, which emerged among the mental wellness, physical wellness, and work/productive activity goal domains, included other services and benefits (e.g., "Medicaid," "Voc Rehab") and employment and volunteer opportunities (e.g., "walking dogs at animal clinic"). To help achieve their mental wellness and work/productive activity goals, SDC participants mentioned their mental health providers and services (e.g., "SDC coach") and a variety of educational opportunities and materials (e.g., "night schools," "books/computer"). The housing and transportation (e.g., "I got my own apartment," "public transportation") category crossed the domains of mental wellness and physical wellness, and participants identified medical providers and services (e.g., "dentist," "eye doctor") as helpful to achieving their physical wellness goals.

Internal barriers

As demonstrated in Table 3, SDC participants identified internal barriers within five categories across goal domains with the exception of sobriety. For most domains, the majority of the internal barriers were psychological or emotional in nature. Participants described having "fear of failure," "self-doubt," or "lack of trust." Participants also frequently identified behaviors as internal barriers. Examples of such behaviors included "staying out of bad places" and "going off my medicine." Mental illness and symptoms (e.g., "depression," "mood swings") and physical conditions (e.g., "back injury," "migraines") comprised other major categories of internal barriers to goal achievement. Finally, a few SDC participants pointed to limitations in knowledge, skills, and abilities (e.g., "need computer skills") that created barriers for achieving their recovery goals.

External barriers

Three categories of external barriers emerged consistently across goals domains. Participants most commonly reported barriers related to financial insecurity (e.g., "money," "cost of living"). Participants also frequently mentioned barriers related to lack of transportation (e.g., "no car") and an adequate support network (e.g., "family," "poor social [End Page 126] life"). In addition, external barriers categorized as environment and society were reported across most domains. Examples of such barriers included "stigma," "discrimination," and the "job market." Other external barriers were more domain specific. For example, participants described other resources (e.g., "not have clothes need to go job seeking") that were barriers to achieving their work and productive activity goals. Finally, SDC participants identified barriers accessing mental health or healthcare providers and services (e.g., "inadequate insurance"), which impact their ability to meet their mental wellness and physical wellness goals.

Discussion

This study entailed content analysis of 136 SDC participants' self-reported recovery goals, resources, and barriers. In addition to documenting one approach to person-centered assessment and planning utilized within a SDC program, study results contribute to a growing body of literature highlighting the utility and value of such person-centered approaches, which have yet to be widely implemented among public mental health service systems (Adams & Grieder, 2013). Data also offer new insights into SDC participants' goals, resources, and barriers, which help to address existing gaps in the available SDC research and indicate avenues for future program planning, evaluation, and policy-making efforts.

Analysis of SDC participants' goal statements revealed individualized visions of recovery as well as shared hopes and aspirations. For example, participants articulated very specific goals (e.g., "get my CDL license," "lose 20 pounds," "increase volunteer hours to 20 a week"), but also described more general desires to "get a part time job and have a few friends" and "to be able to live on my own again and gain some control of my life." This finding is consistent with the recovery literature, which demonstrates that while recovery is an individual process, most people diagnosed with an SPMI share the same aspirations as those without diagnoses. They wish to live independently, have meaningful work, and enjoy fulfilling relationships with family, friends, and partners ( Spaniol, Gagne, & Koehler, 1997).

Participants' goals clustered around the domains of mental wellness, physical wellness, work and productive activity, and sobriety. This is not surprising given the structure of the required self-assessment tool. However, across these domains, other themes emerged. Participants frequently expressed goals related to independence and self-sufficiency. They aspired [End Page 127]

Table 2. Categories, Frequencies, and Examples of Participants' Internal and External Resources by Domain
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Table 2.

Categories, Frequencies, and Examples of Participants' Internal and External Resources by Domain

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Table 3. Categories, Frequencies, and Examples of Participants' Internal and External Barriers by Domain
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Table 3.

Categories, Frequencies, and Examples of Participants' Internal and External Barriers by Domain

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to "truly get off disability," "have my own place to live," "become self-sufficient," and "be successful out of [the] mental health system." They also described wanting to access providers and services (e.g., therapists, dentists, eye doctors) that were presumably inaccessible prior to enrolling in SDC. Together these themes reveal the degree to which poverty may impact individuals' lives and mental health recovery by limiting their autonomy and access to resources. They also offer insight into people's priorities for program participation, which reinforces the relative importance of the flexible spending characteristic of SDC models in conjunction with person-centered assessment and planning, and provides context for expenditure data published to date. This context is discussed further below.

It is also noteworthy that SDC participants did not express any goals that might be considered "delusional" or "grandiose." In fact, their goals were fairly ordinary. Participants wanted to have their own home, go to school, find a job or volunteer, or be closer to their families. This is significant given prevailing beliefs that individuals diagnosed with an SPMI "lack insight" or have "distorted" perceptions of reality as well as their problems and needs, requiring mental health professionals to design and manage their treatment plan. Study findings suggest that individuals diagnosed with an SPMI articulate clear and realistic visions of and goals for their recovery when allowed to engage in person-centered assessment and planning. They are also adept at identifying the internal and external resources and barriers that impact their goal achievement.

Interestingly, participants identified a greater number and variety of internal and external resources to support their goal achievement than barriers. Internal resources ranged from desire and motivation (e.g., "desire to stay alive for me and my family"), personal characteristics (e.g., "great sense of humor"), behaviors (e.g., "take meds, see doctor"), and spirituality (e.g., "I got faith") to a fascinating array of knowledge, skills, and abilities (e.g., "electrical knowledge"). Participants also identified a wide range of external resources, including the family, friends, and sponsors they count among their support network; the various mental health and healthcare providers and services that they recognize as integral to their well-being; other benefits and services and available housing and transportation that meet their needs; and a multitude of employment and volunteer opportunities as well as educational opportunities and materials. This demonstrated ability to identify resources for goal achievement illustrates the principles of the strengths [End Page 132] perspective, which contend that all individuals and environments are rich with strengths and resources (Saleebey, 1997), and reinforces the clinical utility of strengths-based, person-centered assessment and planning.

In addition to demonstrating broad awareness of internal and external resources that might support their recovery goals, SDC participants displayed keen insight into the internal barriers that impede their goal achievement. Participants were particularly astute in describing the symptoms, behaviors , and psychological and emotional traits that inhibit the change process. These candid observations regarding their challenges and limitations further debunk conventional wisdom that individuals diagnosed with an SPMI "lack insight." Moreover, the types of internal barriers identified exemplify a possible gap in community-based mental health service provision. In particular, individual psychotherapy is rarely available to public mental health clients outside of SDC programs with flexible funding and private provider networks; yet there is a growing body of research that demonstrates the efficacy of psychological intervention, particularly for the mood disorders with which most SDC participants are diagnosed (Hunsley, Elliott, & Therrien, 2014).

When asked to identify external barriers, participants consistently pointed to lack of money, transportation, and access to mental health and healthcare providers and services. Given that most study participants rely on federal disability as their primary source of income and have an average annual family income of $10,560, it is no wonder that poverty is the overwhelming barrier to their recovery and prospective goal achievement. It is well known that there is an inverse relationship between the prevalence of mental illness and socioeconomic status (Hudson, 2005 ) and that lack of basic necessities, including clothing, housing, and transportation, undermines recovery (Perese, 2007). However, study participants' reported barriers are important in that they provide additional context for their SDC expenditures and service utilization, which are reported in a related study (i.e., Spaulding-Givens & Lacasse, 2015). This related study demonstrated that individuals elected to spend a substantial amount of their annual budgets on nontraditional goods and services (e.g., transportation, housing assistance, dental services) ( Spaulding-Givens & Lacasse, 2015). These purchases suggest attempts to ameliorate barriers identified by SDC participants in the present study. These self-identified barriers also provide additional evidence to contextualize Croft and Parish's (2016) study [End Page 133] of 30 SDC participants, in which meeting basic needs as an initial step toward goal achievement and recovery emerged as a major theme. Critics might argue that such spending is inconsistent with the mission of a mental health recovery program and might express concerns regarding dependency. These findings regarding participants' goals of self-sufficiency and barriers related to poverty, in relation to other recent studies (i.e., Croft & Parish, 2016; Snethen et al., 2016; Spaulding-Givens & Lacasse, 2015), suggest that SDC participants likely make such purchases to address their reported barriers in an effort to attain and maintain their recovery goals. Not only does this reflect rational budgeting and spending; it also demonstrates the value of person-centered assessment and planning, and flexible funding streams and purchasing mechanisms, in helping individuals diagnosed with an SPMI to address simultaneously their material and mental health needs.

This study is limited by its reliance upon a nonprobability sample of SDC participants served in a single state. The study participants' demographic characteristics are consistent with those reported by other recent SDC studies that examined the population of SDC participants (i.e., Cook et al., 2008; Hall, 2007; OPPAGA, 2010), suggesting that the study sample may be fairly representative of the SDC population served in the state in which the study was conducted. However, as Croft and Parish (2016) noted, SDC programs vary from state to state given the lack of "widely accepted fidelity standards for self-direction in behavioral health" (p. 10). Study findings may not be generalizable to other SDC populations or programs. There is also a possibility that data collected from individuals' Life Analyses documents may be biased by participants who are more educated or otherwise inclined to provide more detailed responses. Despite these limitations, this study makes an important contribution to the SDC literature by affording new insight into participants' self-reported recovery goals and their resources and barriers to goal achievement. It is the first known study of its kind to examine the goals individuals hope to achieve through their participation in SDC, the internal and external resources individuals perceive as being available to help realize those goals, and the internal and external barriers that individuals recognize as impediments or threats to their goal achievement. Findings offer implications for SDC and community-based mental health policy and service provision, particularly with respect to person-centered assessment and planning and budgeting. [End Page 134]

Implications for Policy, Practice, and Research

Study findings point to a number of important implications for SDC and community-based mental health policy, practice, and program evaluation. Although SDC participants frequently shared a vision of well-being, stability, and self-sufficiency, their notions of how to realize this vision were unique. Participants were also adept at identifying a wide range of internal and external resources and barriers that could advance or impede the achievement of their recovery goals. Often, these resources and barriers are domain specific, demonstrating participants' keen insights to inform the assessment, planning, and change processes. Not only do these findings debunk misguided assumptions that individuals diagnosed with an SPMI "lack insight" and necessarily depend on mental health professionals to design and manage their treatment plans, they also underscore the real potential for participants to collaborate meaningfully in, if not direct, their recovery. The breadth of resources and barriers reported in this study illustrates that participants are indeed their own experts and bring substantive knowledge of themselves and their environments to the assessment, planning, and treatment processes. The individualized nature of many participants' self-reported goals, resources, and barriers reflects the utility and value of person-centered assessment and planning for recovery in conjunction with individualized budgeting and flexible spending characteristic of SDC. Study findings, which contextualize reported SDC expenditure and service utilization data, reveal consistency between participants' goals of independence and self-sufficiency with their purchases of nontraditional goods to meet basic materials needs. This consistency may help to alleviate the concerns of state mental health authorities or community-based mental health providers that are reluctant to allow individuals diagnosed with an SPMI to control public mental health services dollars.

Study findings also highlight the necessity of person-centered, recovery-oriented program evaluation. The administrative measures (e.g., days in the community, days worked) used to assess SDC participants' outcomes in a related study (Spaulding-Givens & Lacasse, 2015 ) as well as other previous studies do not necessarily capture the priorities articulated by study participants. Ideally, program outcomes should be linked to individuals' achievement of their self-reported recovery goals, which drive individualized planning, budgeting, and purchasing in the SDC [End Page 135] model. However, it is important to note that most study participants did not articulate their recovery goals in measurable ways, which may make it difficult for practitioners and administrators to assess progress and report outcomes. This concern was also raised in a state-mandated evaluation of SDC (OPPAGA, 2010). Practitioners assisting individuals with the development of person-centered plans may need to model how to conceptualize and articulate measurable, time-limited goals with discrete objectives and tasks. Otherwise, participants may find it more difficult to achieve their goals, and administrators may struggle to demonstrate unique programmatic outcomes of SDC beyond the more traditional utilization measures. SDC participants' self-reported recovery goals also point to the potential utility of integrating standardized measures of personal recovery (Shanks et al., 2013) in future outcomes studies of SDC. This approach is supported by existing studies that reveal disconnect between providers' clinical outcomes measures and more participant-oriented understandings of recovery (Andresen, Caputi, & Oades, 2010).

SDC participants' desire to be autonomous and self-sufficient is a common theme throughout study findings. However, findings also reveal a hint of participants' belief in the necessity of compliance with the instructions of mental health authorities. This may reflect some degree of institutionalization and marginalization that may ultimately undermine their confidence and ability to self-direct. For example, among their internal resources, participants often described themselves as "compliant" and reported that they "follow orders given to me by my doctor" and are "compliant with doctor's orders." Certainly, all individuals may benefit from following their doctors' advice in many cases. However, participants' choice of words (e.g., "compliant," "follow," "orders") does not reflect a collaborative relationship with their providers and may indicate that participants do not recognize that they do indeed have choices regarding their treatment regimen. Practitioners working in SDC programs may need to coach participants in how to advocate for themselves with other providers, so that they can exercise real autonomy and self-determination in their recovery process. This finding also points to the importance of carefully vetting providers to confirm that they share and practice the philosophy and principles of self-direction prior to inviting them to join a SDC provider network. [End Page 136]

The barriers identified by study participants illustrate the degree to which poverty impacts the lives and recovery of SDC participants and provides additional context for other recent research findings, which demonstrate that participants frequently utilize available service dollars to subsidize their living expenses and meet their basic needs (Croft & Parish, 2016 ; Spaulding-Givens & Lacasse, 2015). These findings further demonstrate the degree to which participants perceive poverty as undermining their recovery, and show the potential utility of flexible funding streams characteristic of SDC programs that allow individuals to address both their material and mental health needs. In fact, research suggests that SDC participants must first address their basic needs prior to making progress toward their other more clinical, functional, and existential recovery goals (Croft & Parish, 2016). One caveat is that practitioners collaborating with SDC participants may need to assist them with securing other types of public assistance, and support their efforts to achieve financial self-sufficiency through employment. Policy makers and program administrators may help to advance participants' long-term independence by linking recovery coaching or brokerage services with other types of supported employment and vocational rehabilitation services (Spaulding-Givens & Lacasse, 2015).

Finally, more research is needed to evaluate the experiences and outcomes of SDC program participants as well as the impact of the model's key clinical components: person-centered planning, individualized budgeting, and supports brokerage. While randomized controlled trials will provide the most clarity regarding the effects of SDC on individuals diagnosed with an SPMI, further qualitative inquiries will provide greater insight into the ways individuals experience SDC as compared to other service delivery approaches. Specifically, this study points to a need to examine SDC participants' achievement of their self-identified recovery goals, as well as the degree to which SDC participation helps individuals to address barriers to goal achievement. Other prospective studies might examine program participants' perceptions regarding the role recovery coaches play in the person-centered assessment and planning processes characteristic of SDC. [End Page 137]

Jennifer Spaulding-Givens
jennifer spaulding-givens, PhD, MSW, University of North Florida

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