Measuring Money Mismanagement Among Dually Diagnosed Clients

Abstract

Clients dually diagnosed with psychiatric and substance abuse disorders may be adversely affected if they mismanage their Social Security or public support benefits. Assistance managing funds, including assignment of a representative payee, is available but there are no objective assessments of money mismanagement. In this study, a Structured Clinical Interview for Money Mismanagement was administered twice at one-week intervals to 46 clients receiving disability payments and was compared to clinician’s judgment that the client was incapable of managing funds, the frequent basis for payee assignment by the Social Security Administration and Veterans Affairs. Clinician’s judgment and structured interview were concordant on 71% of capability judgments. The interview had high test-retest reliability and was correlated with self-reported money mismanagement and GAF scores, but clinician judgment was not associated with these measures. Results suggest that the interview is sensitive in detecting money mismanagement and raises questions concerning the validity of clinicians’ judgments.

Clients dually diagnosed with severe psychiatric and substance use disorders commonly receive Supplemental Security Income (SSI), Social Security Disability Insurance (SSDI) and/or Veterans Affairs (VA) compensation to help provide for their basic needs. Because of their psychiatric disabilities, these recipients may have trouble managing their funds in their best interests and as a result, may not be able to procure a safe place to live and food to eat (Rosen et al., 2002; Ries and Dyck, 1997). When a beneficiary is judged incapable of managing Social Security benefits, the beneficiary is mandated by the Social Security Administration (SSA) to have a representative payee receive and help manage the beneficiary’s SSI/SSDI payments. The VA follows similar procedures.

The SSA assigns a representative payee to a client based largely on the treating clinician’s response to a single question as part of the application for disability benefits: “In your opinion, is the beneficiary capable of managing his/her funds?” However, no substantial guidelines have been developed by SSA to answer this question as noted in a report to Congress of the Representative Payment Advisory Committee (Representative Payment Advisory Committee, 1996): “Federal regulations do not, however, provide a standard or a process for concluding that a beneficiary is incapable of managing or directing the management of benefit programs.” Currently, SSA provides little guidance on routine applications for SSI or SSDI and provides brief instruction when specific capability evaluations are requested (SSA-787).

If valid, the clinician’s answer to a single question should identify the same people to be incapable of managing their funds as an assessment of standard capability criteria conducted by a third-party. There is considerable literature about money mismanagement and capability that suggests functional criteria for judging someone as incapable. Guidelines concerning which functional impairments render someone incapable of managing funds have been derived from court decisions concerning conservatorship (Anderer, 1990), case manager reports of criteria used for payee assignment (Conrad et al., 1998; Dixon et al., 1999), and the history of payee assignment to drug addicted persons (Rosen and Rosenheck, 1999).

Key criteria for judging someone incapable are that the person either has not been able to meet basic needs for housing and other essentials, or the person has been harmed by substantial spending on drugs and alcohol (Rosen and Rosenheck, 1999). To conduct an objective third-party assessment of money mismanagement, our group developed the Structured Clinical Interview for Money Mismanagement (SCIMM) to rate the extent of a client’s mismanagement of funds, and whether a client is incapable of managing his/her funds.

The goals of this study were as follows: (1) to determine the test-retest reliability of the SCIMM; (2) to assess the level of agreement between the SCIMM and the clinician’s response to the single SSA question concerning whether a beneficiary is capable of managing his/her funds; and (3) to determine the level of agreement between both the SCIMM and clinician SSA judgment with three other validity indicators: a client-rated money mismanagement assessment, GAF scores and money spent on substances during the preceding 28 days.

METHOD

Participants

Participants were 46 clients recruited from units with high proportions of dually diagnosed clients at a large VA hospital (n= 37) and at a local community mental health center (n= 9). Clients were eligible for study participation if they: (a) received VA benefits for a service-connected disability, SSI or SSDI; (b) reported illicit drug or “high risk” alcohol use (Saitz, 2005) in the preceding 12 months, and; (c) were enrolled in psychiatric or substance abuse treatment. During the initial assessments, 28 (61%) of the participants were in a substance detoxification unit, 13 (28%) were in an outpatient setting, and five (11%) were in an inpatient psychiatric unit. A total of 21 clinicians answered the single clinical judgment question describing 34 beneficiaries. No clinician answered the single-item SSA question for more than four clients.

The 46 participants were predominantly male (83%) and either Caucasian (46%) or African American (50%). The average age was 50.9 years old (SD = 9.3; range 28 to 75) and most (80%) had not graduated high school. Seventeen percent of the participants were married, 41% were divorced, and 27% were single. Forty-three percent were receiving VA benefits only, 57% were receiving SSDI/SSI benefits only, and none were receiving both VA and Social Security benefits.

Measures

1. Money Mismanagement

Structured Clinical Interview on Money Mismanagement

The SCIMM is a semi-structured clinical interview designed to rate the extent of a client’s mismanagement of funds and can also be scored to rate whether he/she is incapable of managing funds (Rosen and Rosenheck, 1999; Conrad et al., 1998). The SCIMM involves an assessment of the last year’s and last month’s expenditures, living situations and costs, and any periods when there was not enough money for housing. The receipt, storage, and disbursement of the benefit check are determined. If money has been spent on alcohol or illicit drugs, the extent of harm related to these is determined by questions taken from the substance abuse module of the Structured Clinical Interview for DSM-IV (APA Press, Washington DC).

Money mismanagement is rated for the degree to which beneficiaries meet two criteria: (1) whether the beneficiary spent significant funds on something other than basic needs and (2) whether the beneficiary spent significant funds on something that had the potential to harm him/her (e.g., drugs). The SCIMM is scored by summing the ratings of these two criteria.

The interview includes a third criterion, the likelihood that the client’s misspending will continue, that is only scored when the SCIMM is used to answer the SSA’ all-or-none question as to whether someone is capable of managing funds. This prediction of future incapability is judged based on the client’s having a plan to correct the misspending, motivation to do so, and having achieved sustained abstinence in the last five years. In the SCIMM-C (SCIMM-Capability), a client is incapable of managing funds, and thus meets criteria for being assigned a representative payee, if the client is either misspending money needed for basic needs (criterion 1) or spending on something that is harmful (criterion 2). In addition, the client’s misspending must be likely to continue (criterion 3) (Rosen and Rosenheck, 1999).

Client-rated Assessment

The SCIMM was validated by determining its correlation with a client-rated measure of money mismanagement. The client-rated measure consisted of a subset of items derived from a study characterizing clients’ assigned payees (Conrad et al., 1998) and previous surveys of money mismanagement habits (Rosen et al., 2002; Dixon et al., 1999). These items addressed substance use, ability to meet basic needs and spending habits and the measures is available from the corresponding author upon request. Clients were asked to rate the frequency for each of the eighteen items regarding the previous year on a 5-point Likert scale, ranging from never to always. The total score was the sum of the raw scores of each item, and higher scores indicated more severe money mismanagement.

Clinician Summary Judgment

Clinicians were asked virtually the same question SSA and the VBA ask when people apply for disability benefits: “In your opinion, is the beneficiary capable of managing his/her funds?” The choices were “yes” or “no.”

2. Validity Indicators: Money Spent on Substances and Overall Functioning

Participants were assessed on two outcomes that were expected to be correlated with money mismanagement based on prior research (Conrad et al., 1998; Ries and Dyck, 1997): 1) money spent on alcohol and drug use during the previous 28 days using items and; 2) clinician-rated psychiatric and social functioning as measured by the DSM-IV Global Assessment of Functioning Scale (GAF)—Modified.

Procedures

Participants were recruited by advertisement and clinician-initiated referral, and provided written informed consent. At baseline assessment, research staff collected a demographic form, the SCIMM and the clinician summary judgment question and the validity measures, including money spent on alcohol or drugs, GAF scores and a client-rated money mismanagement assessment. Forty-one of the 46 participants were re-assessed on the SCIMM one week later to assess test-retest reliability. Clients and clinicians were reassessed two and six months later.¹ Participants were paid for completing assessments.

Data Analysis

The data analysis involved examining (1) test-retest reliability of the SCIMM, (2) agreement between the SCIMM and clinician summary judgment, (3) the correlation between the SCIMM and validity indicators (client-rated assessment, money spent on substance use and GAF scores) and (4) the correlation between clinician summary judgment and the validity indicators. Pearson correlations (r) were used to characterize the degree of association between two continuous measures, point-biserial correlations (r_pb) characterized the association between continuous and dichotomous variables, and Phi (φ) described the association between two dichotomous variables. All analyses were carried out by SPSS (Version 14).

RESULTS

Clinical Description of Participants

With regard to psychiatric diagnoses, 48% (n = 22) of the sample had a Depressive Disorder, 46% (n = 21) had PTSD, 30% (n = 14) had a Bipolar Spectrum Disorder, 24% (n = 11) had a Personality Disorder, 11 % (n = 5) had a Schizophrenic Spectrum Disorder, and 4% (n = 2) had an Anxiety Disorder. As expected in a study requiring recent self-reported substance use for enrollment, chart reviews revealed that 85% (n = 39) abused alcohol, 52% (n = 24) abused cocaine, 20% (n = 9) abused marijuana, and 17% (n = 8) abused opioids.

With regard to the SCIMM, the mean money mismanagement score was 4.7 (SD = 1.2, SEM = 1.7) on a scale from 0 to 6. Thirty-two percent of beneficiaries were rated as incapable of managing funds according to the SCIMM-C. Twenty-four percent of the beneficiaries without a current payee were rated as incapable of managing funds according to their clinicians’ summary judgments.

Reliability and Agreement of the SCIMM

The SCIMM (r = .82) and SCIMM-C (φ = .90) demonstrated excellent one-week test-retest reliability. The SCIMM, scored as a continuous measure, was not significantly correlated with the clinician’s summary judgment of client’s incapability to manage funds (r = .23, p = .24, n = 34). Approximately 40% of the beneficiaries (13/34) were rated as incapable of managing their funds by one of the instruments, but the SCIMM-C and clinician summary judgment were fairly discrepant. Six participants (18%) rated as capable of managing their own money according to clinicians were rated as incapable by the SCIMM-C, and four rated (12%) incapable by their clinicians were rated capable by the SCIMM-C.

Validity of the SCIMM and Clinician summary judgment

There were significant correlations between the client-rated assessment of money mismanagement and the SCIMM (r = .44, p <.01, n = 46) and between the client-rated assessment and the SCIMM-C (r_pb = .37, p = .01, n = 46). The SCIMM (r = −.30, p = .04, n = 46) and SCIMM-C (r_pb = −.28, p = .07, n = 46) were correlated with the GAF, but were not significantly correlated with the amount spent on drugs and alcohol.

In contrast, clinician summary judgment was not correlated with client-rated money mismanagement (r_pb = .01, p = .97, n = 34), substance expenditures (Alcohol: r_pb = .12, p = .60, n = 34; Cocaine: r_pb = .15, p = .51, n = 34) or GAF scores (r_pb = −.21, p = .24, n = 34).

DISCUSSION

This is the first study to compare clinician summary judgment to a criteria-based, semi-structured interview to rate money mismanagement. The findings suggest that the semi-structured clinical interview was reliable and valid, but raised questions about whether clinician summary judgment was. The semi-structured clinical interview demonstrated excellent test-retest reliability and, as expected, was correlated with client-rated money mismanagement and with the GAF, providing evidence for its validity. One reason for its high reliability may be that the interview assessed two concrete measurable behaviors: homelessness and substance-related harm.

However, the SCIMM did not correlate with amount spent on substances in the last 28 days. This may reflect the interview’s review of substance purchases over a one-year time frame instead of a 28-day time frame or that the exact amount spent on drugs and alcohol may not necessarily relate to the extent of harm experienced by the beneficiary. There is evidence that people with disabling mental illnesses use relatively small amounts of drugs but incur substantial harm from this use (Lehman et al., 1996).

Two limitations of this study were the small sample size (n = 46) and the convenience sample enrolled. The convenience sample in this study was selected from various settings, including substance detoxification units and psychiatric inpatient and outpatient units, and represents a heterogeneous population. Capability measures may have different psychometric characteristics in other client populations and clinicians at other institutions. Other limitations to be addressed in future research include a very short test-retest interval and a limited range of validity indicators.

It is a significant concern that the widely-used SSA question of capability, clinician judgment, was not correlated with any money mismanagement or clinical measure. Clinician judgments have far-reaching implications for clients’ autonomy to manage their funds. The lack of convergent validity is perhaps not surprising given that term “capable” in the SSA question is not defined, leaving its meaning open to different interpretations. One implication of these findings is that clinician summary judgment of capability to manage funds may be of limited value in determining the need for a payee when no guidelines are provided. For example, SSA might instruct clinicians to assess functional capability to meet basic needs and avoid harmful purchases, using guidelines like those from the SCIMM.

CONCLUSION

The structured clinical interview to measure money mismanagement and capability to manage funds demonstrated excellent test-retest reliability. It was correlated with a client-rated money mismanagement measure and GAF scores. Clinician’s judgment, the frequent basis for payee assignment, was not correlated with the structured clinical interview, client-rated money mismanagement measure or GAF scores.