A key purpose of the SDC approach is to increase consumers' control of decisions relating to their care, and thereby increase their independence and free them from coercion in mental health treatment. Although consumers' degree of involvement in decisions about their own treatment varies,23 many consumers experience mental health care as a coercive process, one which regularly forces them to adhere to interventions they may not believe are beneficial or do not want.22 Mental health providers, family members, police, and judges can also apply leverage to compel receipt of mental health treatment, and consumers' awareness of this leverage colors their perceptions of care.49 SDC programs give participants the authority to separate themselves from services that they do not find beneficial and to find new providers when they so choose, and this ability would be expected to result in less perceived coercion.
Even with SDC, persons with mental health disabilities may remain vulnerable to coercion. One concern is SDC participants' choices regarding services and providers may be used by persons outside the program as a basis for coercion or competency challenges.34 Another concern is that persons who are more severely ill, who have not previously been offered the opportunity to direct their own care, or who have a conservator or representative payee will be vulnerable to pressure from providers, SDC coaches, or their representatives. Such concerns create a nexus of legal, ethical, and logistical issues, which may be resolved differently in different programs. However, in designing rules and procedures for their programs, program officials may need to balance the goal of protecting participants against coercion with other important program goals, such as maintaining program integrity and sustainability and ensuring participants' safety.
In relation to maintaining program integrity and sustainability, some participants may need guidance to ensure that their spending priorities (i.e., the amounts of money being allocated to different categories of spending) purposefully reflect their health care needs. For example, persons who expect to have out-of-pocket expenses related to a frequent need for outpatient therapy should consider these expenses when planning their individual budgets. Although this guidance could come from a SDC coach, participants with more severe limitations in cognitive functioning have the assistance of a legally authorized representative, such as a conservator or representative payee. SDC programs should consequently be prepared to provide such representatives education about the SDC approach and to communicate their program's expectations around participant self-direction.
Problems with coercion could also arise if fiscal intermediaries are not made accountable to the SDC program that they serve. For example, in Washington County, Maryland, the local mental health care services agency, which is an administrative branch of the state public mental health system, serves as the fiscal intermediary of the SDC program. Although this arrangement is thought to work well in Washington County, it could raise concern because the Washington County SDC program is accountable to the core services agency. This arrangement could result in a sense of coercion, because the SDC program may fear that its funding could be jeopardized if participants make too many requests for purchases.
Protecting SDC participants from victimization by providers of services and other vendors should also be considered in the design of SDC programs. Certain behaviors, health problems, and other personal characteristics that are associated with having a SMI may increase participants' risk of being victimized. These would include illicit drug use and heavy alcohol use, impaired decision-making, low educational attainment, low self-efficacy, and poverty. SDC programs must be vigilant for and be prepared to respond to situations involving participant victimization, such as acts of financial fraud or theft, and also must monitor for unethical or unfair treatment by providers. Some SDC programs apply a vetting process to service providers, to check professional licensing and to run criminal background checks. This may help reduce outright fraud. However, SDC programs could also have procedures for administratively tracking and investigating cases of participant victimization and for designing response plans that reduce the likelihood of re-occurrences.