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The Contribution of Self-Direction to Improving the Quality of Mental Health Services

Publication Date
Oct 31, 2007

U.S. Department of Health and Human Services

The Contribution of Self-Direction to Improving the Quality of Mental Health Services

Executive Summary

Vidhya Alakeson

2006/2007 Harkness Fellow
Office of the Assistant Secretary for Planning and Evaluation

November 2007

The final report of the President’s New Freedom Commission on Mental Health identified two principles that should underpin reform of the mental health system: “services and treatments must be consumer and family centered;” and “care must focus on increasing consumers ability to successfully cope with life’s challenges, on facilitating recovery, and on building resilience.”1 Self-direction is identified as one possible means by which to achieve these goals.

There are currently five states with self-directed care (SDC) pilots or established programs for adults with serious mental illness (SMI): Florida, Iowa, Maryland, Michigan and Oregon, with a pilot under development in Texas. For the purposes of this report, SDC programs are considered to be ones that include person-centered planning, individual budgeting and provide participants with access to support services. While programs share a philosophical approach and the core components of self-direction, there is significant variation in the design across states.

Self-direction for adults with SMI is in the early stages of development and currently serves a very small number of consumers. Therefore, it is not possible to draw any firm conclusions about its potential to meet the goals of the New Freedom Commission. However, evidence from existing SDC programs indicates that it is a promising approach, worthy of further investigation. Self-direction has been shown to improve consumer satisfaction with services compared to traditional community mental health services. According to interviews with consumers, this is in large part due to the focus on recovery rather than symptoms; the flexibility of the approach in meeting individual needs; and the support provided by counselors and peers in articulating goals and developing spending plans.

Despite fears about the capacity of individuals with SMI to make informed choices about their care, there is no evidence that outcomes are worse under SDC than under professionally-controlled services. On the contrary, early evidence is that outcomes improve, with participants in SDC making less use of crisis stabilization units and crisis support compared to non-participants and greater use of routine care and supported employment. The most significant savings from SDC will be brought about if these early findings indicating a shift to greater prevention and early intervention are sustained over the long term, reducing the need for costly, acute services.

While initial findings from SDC are promising, the report discusses some of the issues that need to be addressed if self-direction is to successfully expand and make a significant contribution to improving the quality and outcomes of the public mental health system. These include: extending the scope of SDC to include traditional mental health services; finding ways of integrating self-direction for adults with SMI with Medicaid regulations and funding streams; and developing an active peer movement as a source of advocacy for self-direction and as a source of alternative services to provide consumers with choice and flexibility.


  1. President's New Freedom Commission (2003). Achieving the Promise: Transforming Mental Health Care in America: Final Report.

The Full Report is also available from the DALTCP website ( or directly at
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