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Logo of nihpaAbout Author manuscriptsSubmit a manuscriptHHS Public Access; Author Manuscript; Accepted for publication in peer reviewed journal;
 
Psychol Assess. Author manuscript; available in PMC 2017 April 1.
Published in final edited form as:
PMCID: PMC4703571
NIHMSID: NIHMS696461

All-Data Approach to Assessing Financial Capability in People with Psychiatric Disabilities

Abstract

The goal of this project was to develop an evidence-based method to assess the ability of disabled persons to manage federal disability payments. This paper describes the development of the FISCAL (Financial Incapability Structured Clinical Assessment done Longitudinally) measure of financial capability. The FISCAL was developed by an iterative process of literature review, pilot testing, and expert consultation. Independent assessors used the FISCAL to rate the financial capability of 118 participants (57% female, 57% Caucasian) who: received Social Security disability payments, had recently been treated in acute care facilities for psychiatric disorders, and who did not have representative payees or conservators. Altogether, 48% of participants were determined financially incapable by the FISCAL, of whom 60% were incapable due to unmet basic needs, 91% were incapable due to spending that harmed them (e.g. on illicit drugs or alcohol), 56% were incapable due to both unmet needs and harmful spending, and 5% were incapable due to contextual factors. As expected, incapable individuals scored higher on a measure of money mismanagement (p < .001) compared to capable individuals. Inter-rater reliability for FISCAL capability determinations was very good (Kappa = .77) and inter-rater agreement was 89%. In this population the FISCAL had construct validity; ratings demonstrated good reliability and correlated with a related measure. Potentially, the FISCAL can be used to validate other measures of capability and to help understand how people on limited incomes manage their funds.

Keywords: disability payments, substance abuse, financial capability

Background

In 2011, the Social Security Administration (SSA) administered Social Security Disability Insurance (SSDI) and Supplemental Security Income (SSI) benefits to 3.7 million people with psychiatric disabilities who had been evaluated as being unable to work. In general, these benefits have salutary effects (Rosen, McMahon, Lin, & Rosenheck, 2006), but poor management of Social Security subsistence funds can be associated with negative consequences including homelessness, hospitalization, financial conflict, criminal activity, and drug and alcohol-induced harm (K. J. Conrad, Lutz, et al., 2006; K. J. Conrad, Matters, et al., 2006; Elbogen, Tiegreen, Vaughan, & Bradford, 2011). Money mismanagement is not uncommon in individuals with serious mental illnesses, whose conditions impair their cognitive abilities, judgment (e.g. during mania or psychosis), and ability to resist financial exploitation (Carpenter-Song, 2012; Claycomb et al., 2013; Elbogen et al., 2011; Marson, Savage, & Phillips, 2006; Marc I. Rosen et al., 2002; Sells, Rowe, Fisk, & Davidson, 2003) and is most common in individuals with co-occurring substance use disorders when they are using psychoactive substances (Marc I. Rosen et al., 2002; Shaner et al., 1995).

When people are incapable of managing money in their best interest, conservators, representative payees, or other fiduciaries can be appointed to ensure that funds are used to support clients’ overall health and well-being. The local probate court may appoint a conservator of estate and/or of person to assume all financial decision-making responsibilities, or the SSA may appoint a representative payee to receive and manage Social Security payments.

These life-altering financial capability determinations are made inconsistently. Several studies have found that payee assignment rates vary widely across institutions, suggesting differences in assignment thresholds and procedures, rather than true individual differences in capability to manage finances (Appelbaum & Redlich, 2006; Rosen, McMahon, & Rosenheck, 2007). Responses to the current SSA question used to assess financial capability have been influenced by factors unrelated to financial functioning, such as availability and acceptability of payees (Luchins et al., 1998; Luchins, Roberts, & Hanrahan, 2003; Marson et al., 2006; Marc I. Rosen et al., 2002). An audit by the Office of the Inspector General determined that 23% of reviewed individuals receiving SSI and SSDI payments were likely incapable of managing their own money and estimated that $200 million per year in benefits was being directed to them (Social Security Administration & Office of the Inspector General, 2012). These individuals might benefit from a fiduciary, as assignment of clinically-informed fiduciaries has been associated with significant clinical benefits (K. J. Conrad, Lutz, et al., 2006; Rosen (2011)).

A standardized measure of financial incapability is needed to guide what can be a complex, nuanced judgment as to when to file for a fiduciary (Rosen, Ablondi, Black, Serowik, & Rowe, 2014). Articulating operational consensus criteria for evaluating capability can advance research and practice in this field. In this paper, we describe the conceptualization and development of a standardized financial capability instrument called the FISCAL (Financial Incapability Structured Clinical Assessment done Longitudinally). We outline current procedures for determining financial capability and how incapability criteria were developed based on existing procedures and expert review. We then report the inter-rater reliability of FISCAL determinations. Finally, we assessed the convergent and discriminant validity of FISCAL capability determinations by estimating their correlation with measures of money mismanagement, homelessness, and depression. A-priori hypotheses were that FISCAL-assessed capability scores would be moderately correlated with self-rated money mismanagement and recent homelessness (constructs that are closely related to financial mismanagement), and less strongly correlated with depression (a potentially overlapping but distinct construct).

Instrument Development

Principles from Current Practice

Capability determinations rely largely on administrative adjudications, physician opinion, and lay evidence demonstrating inability to manage finances ("The Social Security Representative Payee Program,"). Currently, the SSA uses the “Physician’s/Medical Officer’s Statement of Patient’s Capability to Manage Benefits” form to establish whether beneficiaries' benefits should be paid to a representative payee by asking a single question:

“Do you believe the patient is capable of managing or directing the management of benefits in his or her own best interest? By capable we mean that the patient: is able to understand and act on the ordinary affairs of life, such as providing for own adequate food, housing, clothing, etc., and is able, in spite of physical impairments, to manage funds or direct others how to manage them.” (SSA Form 787, available www.ssa.gov/online/ssa-787.pdf)

Final capability determinations rely heavily on medical evidence from this one question ("The Social Security Representative Payee Program,"), although an SSA claims official can consider evidence from interviews with beneficiaries, relatives, landlords, and others to come to a final capability determination.

There is relative uniformity across state probate courts in the broad principles used to determine financial incapability. Experts assembled by the American Bar Association’s Commissions on Legal Problems of the Elderly and the Mentally Disabled recommended that an incapability determination be based on a functional assessment of skills and behaviors related to a person’s ability to make financial decisions. They concluded that evidence that the person will suffer substantial harm from specific inabilities to manage finances should also be considered (Guardianship: An agenda for reform: Recommendations of the National Guardianship Symposium and Policy of the American Bar Association, 1989). The committee advising Congress also emphasized that incapability should be determined based on the beneficiary’s functioning in his or her living environment. Probably because of the emphasis on real-world functioning, structured assessments of cognitive abilities and of ability to perform financial tasks are rarely dispositive in capability determinations (Social Security Administration & Office of the Inspector General, 2012) and cognitive assessments of financial capacity that have been developed were for people with dementing disorders specifically (Marson et al., 2009; Marson et al., 2000). Appellate courts have upheld findings of financial incapability due to real-world inability to exercise good judgment, as evidenced by needing help paying bills or budgeting funds, and compulsive spending; “… although Appellant has the ability to identify money and count it, she is not capable of managing it.” ("Ryan v. Maddox," 2003).

These legal tenets are consistent with those identified by mental health clinicians. In one mental health center, the criteria health care workers used to recommend payee assignment were based largely on community functioning and likelihood of harm. Substance abuse or dependence (48%) was the most common criterion used for referral to a payee program, followed by history of homelessness (33%), frequent hospitalizations (32%), lack of financial skills (29%), danger at residence (22%), long-term hospitalizations (21%), need for treatment motivation (18%), impulsive spending (16%), and inadequate money for rent (11%) (Luchins et al., 1998). Similar criteria were reported in a survey of several community mental health centers in Illinois (Hanrahan et al., 2002).

Several published instruments have described financial incapability and assessed related constructs. One clinical group operationalized criteria for needing a payee in the DONReP (Determination of Need for a Representative Payee) questionnaire, which was developed by discussing payee assignment with a focus group of case managers and reviewing the results with an expert panel (Kendon J. Conrad et al., 1998). The client-rated Money Mismanagement Measure (K. J. Conrad, Matters, et al., 2006) was developed to be an outcome measure in studies of the effectiveness of representative payee assignment, and incorporated items from other studies of financial difficulties in people with serious mental illness (Ries & Dyck, 1997; M. I. Rosen et al., 2002).

Development of Financial Capability Criteria and Standardized Assessment

Based on the general consensus about criteria for incapability, we developed a comprehensive assessment of financial capability called the Financial Incapability Structured Clinical Assessment done Longitudinally (FISCAL). The FISCAL assesses financial capability on four global criteria (see Table 1). After pilot use in a published study (R. A. Black et al., 2008), the criteria were reviewed by experts in mental health, representative payeeship, scale development, and competency assessments (authors and the late Bruce Rounsaville, MD), who suggested revisions that were incorporated into a pilot instrument. The FISCAL was tested in a small pilot study, further refined by the experts, and then codified in a codebook (available at http://www.behaviorchange.yale.edu).

Table 1
Financial Capability Criteria

The four criteria for financial incapability are:

(1) Basic needs have not been met AND funds needed for basic needs were spent on something else (criteria A)

Government disability payments are intended to help disabled people meet their basic needs for food, clothing and shelter. If the money is spent for these purposes, the person is not deemed incapable, even if there was some difficulty meeting basic needs (i.e. due to poverty). If basic needs were met through the planned use of public shelters or food kitchens – for example, if an individual is using a public shelter to save money for a security deposit for an apartment – this client’s behavior demonstrates capability, but a client who had to stay at a shelter because he/she spent too much money on non-essentials is incapable.

(2) Substantial funds were spent on something that harmed the client (criterion B)

Historically, substance use has been a criterion for assigning conservators or representative payees according to state statutes and Social Security Administration policy (Rosen & Rosenheck, 1999), and it remains in the statute despite the termination of disability awards based on substance abuse. This policy was grounded on the principle that benefits are intended to help individuals and should not harm them. Criterion B weighs whether a person was harmed by receiving disability payments. Harm from cigarette use was not considered evidence of incapability because its ill effects are delayed well beyond the point of use.

(3) Participant’s misspending (not meeting basic needs or on harmful things) is likely to continue (criterion C)

These criteria assess the likelihood that an individual who has been mismanaging his/her money (as indicated by meeting A or B criteria) will continue to mismanage funds. Prediction of future behavior is already used to assess financial capability by the SSA in that clinicians who judge their client as being incapable are asked on the capability determination form, “Do you expect the patient to be able to manage funds in the future?”

FISCAL raters are asked to weigh – primarily and most heavily – past behavior to predict future behavior, and to consider planned interventions that could affect future spending behaviors. For example, future behaviors may be modified by a new medication regimen that ameliorates symptoms associated with past misspending, or by a substance abuse treatment program that addresses misspending on drugs or alcohol.

(4) Contextual factors

Contextual factors are current conditions that modify the impact or probability of misspending. The algorithm allowed raters to consider factors outside of the primary criteria in making a final determination. Examples of such factors provided to raters in the FISCAL instructions included the client's exhibiting impaired judgment and disorganized behavior, someone else having recommended or opposed payee assignment, a physical limitation compromising capability, and a new intervention being likely to improve the client’s funds management.

FISCAL Capability Determinations

The four criteria were scored using an algorithm to yield a single, dichotomous determination of incapability. Individuals were classified as financially incapable if substantial amounts of their disability payments were spent on things other than basic needs, preventing them from meeting their basic needs (criteria A met) OR substantial amounts were spent on harmful things (criteria B met); AND misspending was at least as likely as not to continue (Criteria C met). Raters had the option to use the contextual factors criterion to further inform capability determinations after considering the results of the algorithm.

Methods

Study Design

The study design was a cross-sectional evaluation of client-participants’ money mismanagement and related characteristics. In order to evaluate beneficiaries at high risk for needing a fiduciary, participants were enrolled from an inpatient psychiatric unit and two intensive outpatient programs in Connecticut. Enrollment was conducted between February 2011 and August 2012. This study was approved by the Yale University Institutional Review Board.

Participants

Eligible participants were between the ages of 18 and 65, spoke English, received at least $600 from SSI or SSDI each month, had a current or past adult DSM-IV substance use diagnosis, and did not have a representative payee or conservator. After written informed consent was obtained, participants identified a clinician who would fill out a Social Security form for them. Participation was limited to those who had a clinician who agreed to participate in the study. Client-participants were paid $100 for participating.

Altogether, 138 individuals were consented and enrolled in the study. Of those, 4 were lost to follow-up, 8 did not meet inclusion criteria, 2 were withdrawn (one for instability and one who was determined to have a payee), and 6 had incomplete data, leaving 118 participants for analysis (eFigure1).

FISCAL Assessment

The FISCAL assessment is used to determine financial incapability, using a comprehensive, all-data procedure (Griffin, Weiss, Mirin, Wilson, & Bouchard-Voelk, 1987; Kranzler, Kadden, Babor, & Rounsaville, 1994; Kranzler, Tennen, Babor, Kadden, & Rounsaville, 1997; Pilkonis, Heape, Ruddy, & Serrao, 1991; Spitzer, 1983; Torrens, Serrano, Astals, Pérez-Domínguez, & Martín-Santos, 2004; Wilberg, Dammen, & Friis, 2000; Zanarini, Gunderson, Frankenburg, Chauncey, & Glutting, 1991).

FISCAL assessments were completed by four trained clinicians with masters or doctoral degrees. Assessors used a comprehensive manual outlining how to administer the FISCAL, the criteria used for determining capability and the background behind the criteria, and guidelines for hard-to-evaluate scenarios and how to rate them. Training consisted of conducting at least two FISCAL assessments with a trainer during which each assessor independently rated criteria and discrepancies were discussed until consensus was reached.

FISCAL raters were instructed to integrate all information available to rate client-participants on the four capability criteria. For the purpose of this study, data were collected from three different sources: participants, treating clinicians, and medical charts (see Figure 1):

Figure 1
FISCAL Sources of Information and Procedures

(1) Data from Participant Self-Report

Client-participants completed a pen-and-paper assessment battery with a research assistant. The following measures were collected:

  • A structured questionnaire was used to determine participants’ personal characteristics, education, employment, psychiatric, and legal history.
  • Substance use and housing stability were assessed with a timeline follow-back interview technique (Sobell & Sobell, 1992) that uses a calendar with memory aids (key and anchor dates) to cue accurate recall of daily occurrence of events. Participants provided retrospective estimates of their drinking over each of the past 90 days and housing situation over each of the past 60 days. The six-week test-retest reliability of self-reported daily drinking using this method was r = .79 (Sobell, Maisto, Sobell, & Cooper, 1979). In another study, substance use data recorded with the timeline follow-back technique strongly correlated (r = .65) with another measure of monthly drinking in a sample of psychiatric outpatients (Carey, 1997).
  • Personal income and financial transactions were assessed using the Timeline Historical Review of Income and Financial Transactions (THRIFT) (A. C. Black, Serowik, Ablondi, & Rosen, 2013). The THRIFT is a semi-structured interview that collects information about past month expenses and debts using a calendar that respondents fill in with recent events in their lives to help them better remember their financial transactions (i.e. timeline follow-back method). The interviewer elicits information about amounts of income from different sources, in-kind transactions, expenses, debt and account balances over the past 28 days. One week test-retest reliability of the THRIFT in people with serious mental illness was r = .77 for income, r = .91 for expenses, and r = .99 for debt, and the reliability of each domain was significantly higher than values from a personal budgeting questionnaire (A. C. Black et al., 2013).
  • Money mismanagement was assessed using the client-rated Money Mismanagement Measure (K. J. Conrad, Matters, et al., 2006). The Money Mismanagement Measure is a 28-item, self-reported screening assessment of money mismanagement for people with serious mental illnesses. Questions ask about the participant’s difficulties meeting basic needs, budgeting, paying bills, and keeping track of funds over the past month. This assessment had a Rasch person reliability of .85, and good construct validity in that it is has a logical item hierarchy and expected correlations with other measures (K. J. Conrad, Matters, et al., 2006).
  • The 21-item Beck Depression Inventory II (BDI-II) (Beck, 1996) is a self-report assessment of depression symptom severity over the past two weeks. Items are scored on a four-point Likert scale (0–3); the sum of all items ranges from 0–63, with scores interpreted as minimal depression through severe depression. The BDI-II has demonstrated high internal consistency (α = .92 among outpatients) and “adequate” content and factorial validity (Beck, 1996; Dozois, Dobson, & Ahnberg, 1998).

Further data from participants was obtained by FISCAL assessors, who conducted a semi-structured interview with each participant.

  • The interview consisted of questions about the participant’s last month’s expenditures, and recent history of living situations, and periods when the participant did not have enough money for basic needs. Participants were also asked about money spent on harmful things and about their plans for the future. The interview had a one week test retest reliability of r = .82 and scores correlated positively with another client-rated assessment of money mismanagement (r = .44) (R. A. Black et al., 2008) (instrument available at www.behaviorchange.yale.edu).

(2) Data from Treating Clinician’s Rating of Client

Client-participants’ clinicians completed a clinician-rated assessment of capability.

  • The Clinician Assessment of Financial Incapability (CAFI) (A. C. Black et al., 2014)(instrument available online) is a 32-item clinician-rated assessment of their client’s spending, bill-paying, management of funds, psychiatric symptoms, and ability to avoid financial victimization. While the instrument is still undergoing validity testing, factor analysis supported conceptual groupings by content experts in a published study (A. C. Black et al., 2014).

(3) Data from Client Psychiatric Records

FISCAL assessors reviewed each client-participant’s psychiatric chart (including intake forms, progress notes, DSM diagnoses, substance abuse evaluations, urine toxicology results, and other records in the chart) and extracted information related to the four capability criteria.

Integration of Data from Three Sources

FISCAL assessors combined information about each participant collected from the three sources. Assessors then reconciled discrepancies between the sources of information to rate the four FISCAL criteria. The algorithm was applied to derive a dichotomous capability determination (capable vs. incapable). In addition, assessors rated financial capability on a six point continuous scale, from “completely incapable” to “completely capable”.

On a 5-point scale anchored by 0, “not at all certain” and 4, “completely certain”, FISCAL assessors also rated how certain they were that they had sufficient data to make a capability determination and how certain they were that their capability determination was accurate.

Data Analysis

Statistical analyses were conducted using IBM SPSS Statistics 19 software ("SPSS Statistics," 2010) and R 3.1.1 ("R Project 3.1.1," 2014). We used the Bonferroni correction to reduce the chance of type 1 error (Rice, 1989). Statistics with a p value less than or equal to .0036 (.05 / 14 = .0036) were considered statistically significant.

Descriptive statistics summarized participant characteristics and the proportion of participants rated incapable of managing their funds by the FISCAL procedure.

Inter-Rater Reliability

Every third case evaluated by each rater was included in the reliability analysis. In total, 44 (34%) participants’ FISCAL assessments were rated by a second trained FISCAL assessor blind to the original ratings. To compare ratings of assessors, holding constant the information available to each one, second FISCAL assessors made capability determinations based on the initial assessment battery, interview notes documented by the first assessor and data transcribed from the first assessor’s chart review. Interview notes reviewed by the second assessor included participants' answers to questions about their funds (e.g. how much money do you receive from Social Security? Where else do you get money from?), how and to what extent they had met basic needs (e.g. were there times you lived in a shelter? were there times you were hungry because you didn’t have enough to eat?), whether they had spent money on harmful things (e.g. how did you pay for alcohol?), and plans to change spending patterns (e.g. do you think you will make different spending decisions in the next year?). The second rater did not have access to the sections of the structured interview that asked the first rater to give opinions and make judgments about the participant.

Agreement between first and second raters’ capability determinations was calculated using the Cohen’s Kappa statistic and percent agreement.

Validity Testing

In order to determine procedural validity, incapable participants were compared to capable participants to ascertain the extent to which differences in capability appropriately reflected criteria-relevant information (e.g. money mismanagement measure) versus construct-irrelevant information (e.g. gender or age).

Point-biserial correlations were used to quantify convergent and discriminant validity. We assessed the strength of the correlation between the FISCAL determination and theoretically similar and different measures.

Results

Altogether, 118 patient-participants completed initial assessments. A slight majority of participants were female (57%). The participants’ average age was 46 ± 10.5 years. Participants were primarily Caucasian (non-Hispanic) (57%), African American (non-Hispanic) (27%) or Hispanic (14%). Participants had working clinical diagnoses of Depressive Disorder (n = 52, 44%), Personality Disorders (n = 37, 31%), Schizophrenia-spectrum Disorders (n = 36, 30%), Bipolar Disorder (n = 25, 21%), and Anxiety Disorder (n = 8, 7%), with 48 (40%) participants having more than one diagnosis. There was no documented diagnosis in 5 (4%) participants.

For the 15-item Money Mismanagement Measure and the 21 BDI-II items, internal consistency reliability was estimated by ordinal alpha (Gadermann, Guhn, & Zumbo, 2012). For this sample, ordinal alpha was .87 for Money Mismanagement and .93 for BDI-II.

Overall Capability and Specific Capability Criteria

According to the FISCAL algorithm, 57 (48%) participants were financially incapable. Of these, 34 (60%) were incapable due to unmet basic needs criteria, 52 (91%) were incapable due to the harmful spending criteria, and 32 (56%) were incapable due to both unmet basic needs and harmful spending. Three (5.3%) participants were incapable due to contextual factors (Table 2).

Table 2
Incapability by Criteria (n = 57)

Six participants who met the criteria for not meeting basic needs or harmful spending were ultimately determined capable based on contextual factors. Four of these capable determinations involved raters’ judgments that harmful spending on substances of abuse was less determinative than otherwise effective money management by the participant, and two participants had new plans that indicated capable money management in the next six months.

Characteristics of Individuals Found Incapable by the FISCAL

To elucidate how FISCAL assessors rated concepts such as failing to meet basic needs and substantial spending on harmful substances, relevant indicators were used to describe beneficiaries rated as incapable. Of the 57 participants found incapable, 13 participants had been homeless for a month or more in the preceding six months. In the preceding 60 days, 9 participants had been homeless, 5 of whom were homeless for more than two weeks. Despite having a median monthly income of only $886, individuals rated incapable spent a substantial amount of money on alcohol and drugs. In the month with the most use in the preceding six months, 13 participants spent $100 or more on alcohol and 29 participants spent $100 or more on drugs.

Inter-Rater Reliability

The inter-rater reliability of capability determinations by the FISCAL was very good, as indicated by Kappa = .77. Percent agreement between raters was 89% (Table 5). Agreement between raters was higher when raters were more certain of their determinations. In cases when either rater was less certain (<2 on the 0–4 scale) about the accuracy of determinations, percent agreement between first and second raters was only 25%. Percent agreement was 100% when both raters were more certain (3 or 4 on the 0–4 scale) they had made an accurate capability determination.

Table 5
Inter-Rater Reliability of Final Capability Determination

Procedural Validity

Capable participants did not differ from participants rated incapable on any tested demographic measures (Table 3).

Table 3
Demographics and Clinical Characteristics

Convergent and Discriminant Validity

As predicted a-priori, incapability ratings had a significant and medium correlation (Cohen, 1992) with the money mismanagement measure (r = .46, p < .000), and a weaker, non-significant correlation with the BDI-II (r = .24, p = .008). Incapability ratings had a non-significant, smaller association with recent homelessness (r = .21, p = .021) and with number of psychiatric hospitalizations (r = .18, p = .048). (See Table 4).

Table 4
Capable vs. Incapable Participants

Discussion

This study describes the development and preliminary validation of the FISCAL measure of financial capability. The FISCAL found a high percentage (48%) of beneficiaries to be financially incapable. An audit by the Office of the Inspector General similarly found that 23% of a sample of beneficiaries with mental health conditions without an assigned payee may have been incapable of managing or directing the management of their benefits (Social Security Administration & Office of the Inspector General, 2012). There have been few other studies with any large populations of people with serious mental illness. In one study of psychiatric inpatients at four VA hospitals, clinicians indicated that 27 patients (11% of the sample) were in need of a payee (Marc I. Rosen et al., 2002). Other studies, not focused specifically on payee assignment, have described frequent difficulty managing their funds among people with mental health conditions (Elbogen, Sullivan, Wolfe, Wagner, & Beckham, 2013; Marson et al., 2006).

The FISCAL had acceptable psychometric properties. FISCAL inter-rater reliability ratings (kappa = .77) were in the “very good” range (Regier et al., 2013), and are substantially better than kappa for most DSM-5 diagnoses (Freedman et al., 2013; Regier et al., 2013). In the infrequent instances when two people rating the same participant disagreed on a participant’s capability, it was disproportionately when raters felt they had insufficient information to make a determination or when raters felt less certain about their determinations; inter-rater agreement increased as certainty about sufficient data and certainty about assessor capability determinations increased.

The FISCAL also had convergent validity in that FISCAL-rated capability was positively and significantly correlated with client-reported money mismanagement, a construct that is closely related to financial incapability. Determinations also demonstrated fair discriminant validity in that correlations with constructs such as depression were less strong. Importantly, we found that capable and incapable individuals, as determined by the FISCAL, did not significantly differ on most demographic characteristics, suggesting the instrument leads to determinations that are unbiased with respect to those variables.

We had predicted a-priori that the FISCAL would be moderately correlated with recent homelessness, but in fact the effect size was small(Cohen, 1992). One explanation for this finding is that homelessness may be caused by factors other than financial incapability, such as poverty. For example, a woman who reported 60 days of recent homelessness was determined to be financially capable by the FISCAL rater. She had not spent much money on nonessential items or harmful substances. She had been evicted from her apartment because she had incurred expenses from a fire in her prior apartment and had been living in a shelter and saving the majority of her monthly income for a new apartment. Such complexities diluted the relationship we expected to find between financial capability and a measure of recent homelessness.

The FISCAL operationalizes the construct of financial capability; its primary criteria were sufficient to classify 95% of clients. Contextual factors were only invoked for the remaining 5%. In most cases, the contextual factors criterion appeared to reflect extrapolation of the other criteria rather than a repudiation of them. Of the three cases determined incapable by contextual factors, all three described a participant with disorganized behavior and impaired judgment. Although these participants had not demonstrated incapability (as defined by the primary criteria) in the preceding six months, they all had plans to leave supports that were in place and were thus unlikely to meet their basic needs or avoid harmful spending in the next six months. Overall, the misspending and functional difficulties among individuals rated incapable by the FISCAL suggest that incapability was not rated for only minor concerns.

Incapability to manage one’s funds due to psychiatric or substance use disorders is a potentially transient state, and not necessarily a permanent trait. Expert panels have emphasized that a person’s capability or incapability to manage funds should be considered in the context of his/her home or social environment (R. A. Black et al., 2008). This emphasis on the home environment is sometimes meant to allow people with severe impairments, but with “street smarts,” or extensive natural supports, to be considered capable. However, it requires considerable skills to manage the challenging environments many participants live in. One difficult challenge to overcome is poverty—a person living in poverty has less leeway to spend money on non-essentials and remain clothed and housed than a wealthier person whose purchases do not compete with funds for essential sustenance. The high rate of financial incapability among participants in this study is likely related to the fact that participants were in crisis, as they were recruited from inpatient or intensive outpatient treatment programs. Thus, they were assessed when they were clinically unstable and had often managed their funds suboptimally.

Assigning a payee to clients judged incapable may benefit them. However, the state of FISCAL-rated incapability does not necessitate the assignment of a fiduciary if a less restrictive alternative is available. A recent clinical trial found that patients with co-occurring psychiatric and substance use disorders assigned to voluntary money management-based therapy had significantly more negative toxicologies for cocaine metabolite (Rosen, Rounsaville, Ablondi, Black, & Rosenheck, 2010) and greater preference for larger, delayed rewards (A. C. Black & Rosen, 2011) than patients in the control group. Another study found that, in individuals diagnosed with psychiatric disabilities, better money management was consistently associated with better quality of life, greater self-efficacy, and fewer hospitalizations (Borras et al., 2007; Elbogen et al., 2011).

This study had several limitations. First, participants were enrolled from acute care facilities and the incapability rates were likely higher than among clinically stable beneficiaries. This was a convenience sample with uncertain generalizability to other acute care sites. For example, FISCAL-rated incapability might be less prevalent among people without fiduciaries at sites with more services like subsidized housing that allow people to misspend some money and still meet their basic needs. Within sites involved in the study, not all eligible individuals were enrolled in the research. It is possible that a disproportionate number of incapable individuals enrolled in the study because they were motivated to receive payments for study participation. However, it is equally possible that individuals with more severe incapability were not engaged because of prolonged hospitalization, no reliable means of contact, or unwillingness to divulge financial information. Finally, inter-rater reliability estimates were based on non-independent ratings, as second raters used notes collected by first raters to make capability determinations. This was done to hold constant the data reviewed for capability determinations so that any disagreements would reflect differences in interpretation of the rating criteria, rather than differences in interviewing skills that affect available data. Before the FISCAL can be used more widely, inter-rater reliability should be assessed with raters collecting data independently.

Financial capability determinations are complex and nuanced judgments and there is some subjectivity in evaluating the four FISCAL criteria—e.g. how much homelessness reflects failure to meet basic needs, how much purchasing harmful drugs indicates harmful incapability, and whether a planned change is likely to improve management of funds. This paper describes the results of the first phase of an ongoing project to better describe and measure financial capability in persons with serious mental illness who are receiving SSI and SSDI benefits. In a second phase, our research group is assessing the FISCAL’s predictive validity. Specifically, this ongoing study is investigating whether people assessed as incapable by the FISCAL have more homelessness, money mismanagement, and substance use twenty-four weeks later. Subsequent analyses might also consider more broadly what factors other than those tested might be associated with financial capability in this population.

If replicated, our findings have important clinical implications. Our finding that a substantial proportion of study participants were rated incapable suggests a need for further support and screening of this population to identify individuals who need assistance managing their benefits. Routine screening might facilitate getting clients the help they need earlier, prevent the deleterious consequences of financial mismanagement and preclude their need for a fiduciary at a later time. In clinical practice, the FISCAL potentially provides both clinicians and beneficiaries with guidelines for capability assessments, and might facilitate a recovery orientation if completed collaboratively with the client(Rosen et al., 2006). Use of the FISCAL has the potential to make the capability assessment process fairer and more likely to identify people who need assistance managing their finances.

Supplementary Material

Acknowledgements

This research was supported by grants from the National Institutes of Health (R01DA025613 and R01DA12952). The authors would like to thank Kendon Conrad, PhD, Professor Emeritus at the University of Illinois at Chicago for his reading and comments on an earlier draft of this article.

Contributor Information

Christina M. Lazar, Yale University School of Medicine, New Haven, CT.

Anne C. Black, Yale University School of Medicine, New Haven, CT, Department of Veterans Affairs, West Haven, CT.

Thomas J. McMahon, Yale University School of Medicine, New Haven, CT.

Robert A. Rosenheck, Yale University School of Medicine, New Haven, CT.

Richard Ries, University of Washington School of Medicine, Seattle, WA.

Donna Ames, University of California Los Angeles School of Medicine, Los Angeles, CA.

Marc I. Rosen, Yale University School of Medicine, New Haven, CT, Department of Veterans Affairs, West Haven, CT.

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