Our research group has recently modified and elaborated on the existing conceptual model of financial capacity to apply to persons with schizophrenia and SMI. A number of basic assumptions informed our modification of the model. First, we posited that a majority of individuals with schizophrenia and SMI would be of low SES and would be dependent on entitlement programs for support, in particular Social Security Disability Insurance (SSDI) or Supplemental Security Income (SSI). We note that a smaller number of individuals with personal or family financial support or Veterans Administration Benefits and SMI may enjoy higher income levels than SSDI and SSI beneficiaries. Statistical data from 2003 indicate that more than 2.6 million individuals in the US between age 18 and 65 currently receive SSDI or SSI as a result of psychiatric disability.34
In addition, we assumed that a significant proportion of individuals with psychiatric disability have a representative payee or other proxy managing their funds. As of 2003, it was estimated that as many as 800,000 psychiatric patients receiving Social Security disability were assigned a representative payee.34
A third assumption informing the revised model was that substance use would be a critical variable affecting financial capacity in this population. As noted by Rosen and Rosenheck, “a large amount of money is a well-recognized trigger for substance abuse relapse.”35
The literature has demonstrated a clear temporal connection between receipt of government entitlement checks and substance abuse relapse, psychotic symptoms, and hospitalization.20
Thus any model of financial capacity in the SMI population needs to take into account the effects of substance abuse/dependence on financial judgment and capacity.
Based on these working assumptions, and in consultation with psychiatrists, psychologists, nurses, social workers, and case managers in the Department of Psychiatry and Behavioral Neurobiology, Public Division, at the University of Alabama at Birmingham (UAB), we identified financial skills and issues relevant to individuals of low SES with schizophrenia and SMI. A schematic of the revised model is set forth below in .
Conceptual model of financial capacity for individuals with schizophrenia and SMI
As can be seen, the SMI model shares with the general model (see ) certain core domains, such as basic money skills, cash transactions, and bill payment, although the domain items in the SMI model tend to test more elementary abilities. Additions distinct to the SMI model include domains related to use of money orders, budgeting expenses on a fixed monthly income, and understanding and selecting representative payees. In addition, we have included a domain inquiring about a patient's prior history with money, including prior problems related to substance abuse. Such information may be as relevant as direct performance data in assessing a patient's financial capacity, need for financial supervision, and appropriate community placement.
The preliminary model above represents a first step in identifying and measuring constructs of importance to understanding the financial needs and world of people with schizophrenia and SMI. As discussed, the model is predicated on assumptions that most individuals with schizophrenia and SMI will be of low SES, will receive income through a government entitlement program (usually SSI or SSDI), will have a limited repertoire of basic financial skills, and in many cases will have financial decision-making delegated to a representative payee or a guardian/conservator. Another explicit aspect of the model is the likelihood that many clients' financial skills and decision-making will also be adversely affected by substance use.34
This model provides a backdrop for the section below that discusses specific clinical and research ethics issues related to financial capacity in individuals with schizophrenia and SMI.