Letter

In Reply: We appreciate the willingness of Psychiatric Services to provide a venue for discussing the application of consumer-directed approaches to people in need of behavioral health care. Power and del Vecchio's comments about our discussion draw from their experience with the cash and counseling (C&C) program to question our "characterization that mental health consumers lack adequate decision-making and self-care abilities." They suggest that "the true barrier remains the stigma" that is associated with behavioral health problems.

As noted in our column, we agree with Power and del Vecchio that stigma is a fundamental problem. However, it is unlikely that we will soon eradicate the stigma associated with behavioral health treatment. For example, the Institute of Medicine ( 1 ) report cited by Power and del Vecchio noted that "the proportion of Americans who associated mental illness with 'violent or dangerous behavior' in 1996 was nearly double that found in the 1950 General Social Survey" ( 2 ). Although the relationship between violence and mental illness is weak, the public perception of this association is strong, leading to unnecessary stigma.

Although it is important to deal with stigma, there are other barriers or problems that need to be addressed or, at the very least, taken into account when moving in the direction of self-directed care, including neuropsychological complications; poor self-efficacy; cognitive deficits associated with illnesses such as schizophrenia, major depression, and substance abuse; low motivation; hopelessness; and compromised compliance with medication regimens. It would be incorrect to infer, however, that behavioral health consumers necessarily lack adequate decision-making skills. Whether they do or not depends upon both the particular person and his or her particular problems or limitations. It might also depend upon the particular context. As we noted in our column, even behavioral health consumers with intact decision-making capacities—one who can access and understand information about treatment alternatives—might still be unable, for example, to make difficult decisions (we used low motivation to illustrate one such barrier). Capacity is static, whereas decision-making is dynamic and may vary with the circumstances.

In sum, we agree with Power and del Vecchio that consumer-directed health care has promise in the area of behavioral health. In their letter they mention how, within the C&C program, Medicaid recipients benefit from the use of in-house supportive services. (One feature of the C&C program allows consumers to enlist a representative to assist in decision making.) The use of such an enhanced service component actually underscores the very point that we were attempting to make in our article: some patients—in particular, those with behavioral health problems—might be unable on their own to manage the challenges of consumer-directed care. That is precisely why we suggested that the care coordinator role be adopted in behavioral health care.