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Rethinking the Causes and Consequences of Financial Wellness for People With Serious Mental Illnesses

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Crystal Brandow at clb strategies llc
Crystal Brandow
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Margaret Swarbrick
Margaret Swarbrick
Margaret Swarbrick
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Patricia B Nemec
Patricia B Nemec
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Abstract

Many people with serious mental illnesses live in poverty, which can worsen mental and overall health. The authors suggest strategies to improve health outcomes through behavioral health services and supports that directly target financial wellness while reducing dependence on public benefits. Although some services focus on financial education, this effort is likely insufficient for addressing poverty and its accompanying financial hopelessness. A social-ecological approach with the core goal of financial wellness may improve outcomes. Financial wellness is a social justice issue that must be elevated to a high-priority area of intervention in behavioral health services.
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Rethinking the Causes and Consequences of Financial
Wellness for People With Serious Mental Illnesses
Crystal L. Brandow, Ph.D., Margaret Swarbrick, Ph.D., Patricia B. Nemec, Psy.D.
Many people with serious mental illnesses live in poverty,
which can worsen mental and overall health. The authors
suggest strategies to improve health outcomes through
behavioral health services and supports that directly target
financial wellness while reducing dependence on public
benefits. Although some services focus on financial educa-
tion, this effort is likely insufficient for addressing poverty
and its accompanying financial hopelessness. A social-
ecological approach with the core goal of financial wellness
may improve outcomes. Financial wellness is a social jus-
tice issue that must be elevated to a high-priority area of
intervention in behavioral health services.
Psychiatric Services 2020; 71:89–91; doi: 10.1176/appi.ps.201900323
Social determinants of health, of which poverty is a sig-
nificant example, can contribute to poor health outcomes as
well as to increased risk for developing a mental illness (1).
Poverty is complex and multidimensional and is discussed in
the literature as being connected to overall health, psychi-
atric symptoms, self-efficacy, and general quality of life (2).
Poverty can become a vicious cycle that traps individuals,
ensnares families in generational poverty, and contributes
to historically impoverished communities over many years.
Persistent poverty is a particularly salient challenge facing
individuals with serious mental illnesses, who are more
likely than the general population to experience poverty,
unemployment, and low salaries and are at a higher risk of
homelessness and involvement in the criminal justice system
(3). These experiences are compounded by settings that
propagate other negative social determinants—including
discrimination, food insecurity, and limited access to health
care (4)—that further perpetuate a poverty trap among in-
dividuals and communities.
Individuals experiencing poverty are relegated to living
in inadequate built environments—the human-made, phy-
sical aspects of the places where people live and work.
These environments restrict opportunities to exit poverty
for people using behavioral health services, leaving them
trapped in circumstances that increase stress, exacerbate
symptoms of many mental illnesses, contribute to risks of
addiction, and compromise general medical health. In fact,
living in neighborhoods with inadequate built environments
is associated with an increased likelihood of depression (5),
which is connected to increased risk for cardiovascular
events. Furthermore, in low-income communities, inadequate
housing is prevalent, and studies indicate associations between
poor housing and both mental health and substance use
conditions (6). Both the built and social environments of
urban areas can contribute to isolation. People residing in
socially isolated communities often have difficulties man-
aging crises and experience the onset of mental health
conditions; furthermore, higher risks of mental health con-
cerns and premature mortality are associated with a lack of
social networks (6). The structures of the local neighbor-
hoods and communities where individuals live in poverty
are not designed to promote upward mobility, and this cir-
cumstance creates stress that can have a further negative
impact on both mental health and overall health.
Living in poverty also contributes to general lack of well-
being through undesirable consequences across the eight
dimensions of wellness (7). Most clearly, financial wellness,
which involves the possession of financial resources to meet
HIGHLIGHTS
•Poverty is prevalent among individuals with mental health
conditions, especially serious mental illnesses.
•By engaging in financial literacy activities rather than
focusing solely on financial education, behavioral health
service agencies have the potential to improve well-
being outcomes, including financial wellness, for indi-
viduals with mental health conditions.
•Behavioral health service agencies—in partnership with
other stakeholders, including individuals with lived expe-
rience with mental illnesses and poverty—have the op-
portunity to take a social-ecological approach to poverty
reduction among individuals with mental health conditions.
Psychiatric Services 71:1, January 2020 ps.psychiatryonline.org 89
SOCIAL DETERMINANTS OF MENTAL HEALTH
practical needs and a sense of control and knowledge about
personal finances (7), is negatively affected when individuals
live in poverty and lack a sense of control over their financial
status. Poverty and lack of economic opportunity also have
emotional consequences, such as low self-esteem, low self-
efficacy, self-stigma, and feelings of hopelessness, depres-
sion, and anxiety. Limited access to medical and dental care
can thwart the use of preventive and lifesaving services,
thereby affecting an individual’s overall health. In addition,
medical supplies such as glasses, hearing aids, and medica-
tions can be too expensive for individuals experiencing
poverty or can be inaccessible as a result of the inadequate
built environment in communities where low-income pop-
ulations reside. These environments also may prevent safe
physical activity, like walking. This situation is directly
connected with environmental wellness, in that areas with
high crime, substandard housing, and lack of green spaces
can prevent outdoor physical activity and contribute to a
sense of feeling demoralized. This circumstance has conse-
quences for spiritual wellness, because individuals living
with low incomes in these environments may experience a
sense of purposelessness. Furthermore, intellectual wellness
can be affected by a lack of available educational opportu-
nities or a lack of accessibility because of costs associated
with acquiring further education. Occupational conse-
quences result when individuals with a serious mental ill-
ness and/or other behavioral health conditions experience
periods of underemployment or unemployment; the latter
creates a gap in a resume that is unappealing to employers.
Finally, poverty can influence social wellness and may lead to
social isolation if any individual lacks affordable trans-
portation or sustains decreased social networks resulting
from lack of employment, volunteer, or educational oppor-
tunities. Although not exhaustive, these examples illustrate
the constellation of life experiences and areas of well-being
affected by living in poverty and highlight the importance of
expanding behavioral health system programming to bring
financial skills training to individuals who use behavioral
health services. Supporting the rise out of poverty will have
positive consequences that affect the whole person, whole
communities, and future generations.
Longstanding norms in behavioral health services can be
changed, improved, and redesigned to become antipoverty
practices. Although some behavioral health services agen-
cies have included financial education for the people they
serve, this effort is likely insufficient for overcoming poverty.
Services also need to address financial literacy—the knowl-
edge and skills needed to find, evaluate, understand, and use
information to manage personal funds and financial prod-
ucts. Financial literacy has the potential to improve access,
skills, abilities, and connection across various dimensions of
wellness and well-being, promoting positive health out-
comes while helping to combat the vicious cycle of poverty.
Similarly, the focus of services provided to individuals
with serious mental illnesses generally should be broadened
from money management to financial wellness, which can be
examined with multiple indicators. Objective indicators of
financial wellness may include measures such as income, debt,
credit rating, and savings, as well as aspects of financial ca-
pability, such as knowledge of credit terms, financial products
and services, financial planning, and budgeting. Subjective
indicators of financial wellness may include financial self-
efficacy, a sense of control, satisfaction with one’scurrentfi-
nancial situation, and hope for the future, including a belief in
one’s ability to reach personal financial wellness goals (8).
Transforming existing practices to move beyond financial
education to include programs and services that promote fi-
nancial literacy and financial wellness has the potential to
improve financial self-sufficiency and independence among
individuals with behavioral health conditions. People who
live with a mental illness, a substance use disorder, or
co-occurring disorders have the right to participate in the
economic marketplace like other citizens (9) and to make
decisions, including financial decisions, that affect their own
lives. This right is an issue of socialjustice that remains largely
unaddressed in current behavioral health services.
Many individuals with mental illnesses are encouraged to
apply for supplemental income programs to increase cash
flow for basic needs—a factor that contributes to the cyclical
poverty experienced by individuals in this population. It is
not uncommon for individuals with disabilities related to
mental health conditions to receive Supplemental Security
Income or Social Security Disability Insurance. These ben-
efits may, in some instances, allow an individual to meet
basic needs, but they will not provide an individual with the
resources necessary to attain financial self-sufficiency. These
benefits may address “absolute poverty”—having inadequate
income to meet basic needs—but do not sufficiently elimi-
nate relative poverty, where limited resources restrict the
ability to share the same living standards, inclusion, and
access as others. One study found that 95% of individuals
with a serious mental illness (N5114) did not believe they
had the funds to meet their needs through the next month
(10). Supplemental income programs do not effectively
support sustaining and growing finances.
Employment is one avenue to acquire the funds to meet
basic needs, yet the safety net of government benefits often
proves to be a disincentive to work. Many programs rely on
evidence-based supported employment to facilitate a return to,
or entry into, the workplace. Although this approach may help
with securing work, including competitive and regular em-
ployment, it is not inherently beneficial for asset building and
poverty reduction. These services and supports, without proper
efforts to promote financial literacy and financial wellness, may
fail to help individuals with serious mental illnesses and other
behavioral health conditions improve their financial status and
participate in their own economic outcomes.
Various additional strategies can be used, based on a holistic,
social-ecological approach to addressing the issue of poverty
among individuals with serious mental illnesses and other be-
havioral health conditions. On an individual level, behavioral
health providers can provide training on financial literacy and
90 ps.psychiatryonline.org Psychiatric Services 71:1, January 2020
SOCIAL DETERMINANTS OF MENTAL HEALTH
financial wellness to increase knowledge and skills (e.g.,
“Building Financial Wellness,”developed by P. Nemec, M.
Swarbrick, J. Cook, et al., 2019). Behavioral health service
agencies can establish savings programs and incentives for em-
ployees and for the people they serve (9) as one way of dem-
onstrating the value of financial wellness. These programs give
individuals the opportunity to contribute to their own savings
while developing and using financial knowledge and skills.
On an interpersonal level, helping to build strong social
networks, identifying financial predators in a person’s life,
and offering peer support around financial wellness can
assist with reducing risk and enhancing economic oppor-
tunity. Financial wellness coaching can provide education,
guidance, practical skills, application procedures, and peer
support around financial wellness and money management.
Efforts to foster safety and resiliency on the community
level can include outreach to the places people work, learn,
and play in order to convene conversations about poverty and
create strategies for improving social norms in the community.
On the community level, agreements with local financial in-
stitutions, services, and supports can be made to create a re-
ferral network for helping individuals with mental illnesses or
co-occurring disorders receive financial counseling and credit
advice, establish bank accounts, and build their credit.
On a societal or policy level, behavioral health services,
along with their community partners, can seek to transform
public policy to improve social determinants in low-income
communities. Advocacy may be needed to maintain existing
policies that provide financial advantages to people living
in poverty, such as the earned income tax credit and Social
Security work incentive programs. Conversations with com-
munity members can drive a plan to address negative social
determinants and adverse community experiences, further
changing social norms by backing those changes with policy,
such as mental health parity legislation or the creation of a
task force to address social determinants. Advocating for im-
proved features of the built environment, such as safe, walk-
able sidewalks that community members can use to walk to
work or to local transit, or educating policy makers on the
relationship among mental illnesses, substance use, and pov-
erty may help lay the groundwork for improving outcomes
and creating the structures necessary to end the cycle of
poverty among individuals with serious mental illnesses.
This list is not exhaustive. Instead, it is illustrative of
sample strategies with a social-ecological approach that
behavioral health service agencies can take—alone or in
collaboration with key stakeholders, including community
leaders and individuals with lived experience with poverty
and mental health conditions—to combat poverty, improve
financial security, and promote asset building for individu-
als with mental illnesses. By viewing poverty as a social-
ecological problem, financial wellness can be considered a
social justice issue, an elevated designation that may clarify
that poverty is an issue of collective concern and not the
responsibility solely of individuals experiencing it. Poverty is
a significant social determinant of health, and behavioral
health service agencies can engage in prevention efforts and
support individuals who have behavioral health condi-
tions in building financial literacy and financial wellness
skills in order to improve their socioeconomic conditions.
The authors urge service providers, agency administra-
tors, funders, and policy makers invested in prevention, in-
tervention, and treatment for mental illnesses and substance
use disorders to recognize that an added focus on financial
wellness can benefit people with mental illnesses. Behavioral
health service agencies have an important role in educating
the people they serve and the people they employ about the
importance of financial literacy and financial wellness. Be-
havioral health services need to help promote the develop-
ment of money management skills; offer encouragement,
tools, resources, and peer support for developing goals and
plans for financial wellness; and help individuals access fi-
nancial services and asset development programs. Although
expanding and refocusing services is not necessarily quick
or easy to achieve, doing so will make financial wellness more
accessible for people with mental illnesses who live in poverty.
As the saying goes, “A hand up is better than a handout”—
behavioral health services would do well to remember that.
AUTHOR AND ARTICLE INFORMATION
Policy Research Associates, Delmar, New York (Brandow); Collaborative
Support Programs of New Jersey, Freehold (Swarbrick, Nemec); Rutgers
University Behavioral Health Care, Piscataway, New Jersey (Swarbrick).
Ruth S. Shim, M.D., M.P.H., and Michael T. Compton, M.D., M.P.H., are
editors of this column. Send correspondence to Dr. Brandow
(cbrandow@prainc.com).
The authors report no financial relationships with commercial interests.
Received June 27, 2019; revision received August 12, 2019; accepted
August 23, 2019; published online October 8, 2019.
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SOCIAL DETERMINANTS OF MENTAL HEALTH
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Full-text available
  • Jun 2002
Research on mental illness in relation to social problems such as crime, unemployment, and homelessness often ignores the broader social context in which mental illness is embedded. Policy, research, and practice will be improved if greater attention is given to social context. The authors critically analyze the approach used in much of the psychiatric services literature to infer links between mental illness and social problems. They compare these studies with studies that have been more validly conceptualized to account for social context. With this broader perspective, the impact of mental illness on crime, unemployment, and homelessness appears to be much smaller than that implied by much of the psychiatric services literature. Poverty moderates the relationship between serious mental illness and social problems. Factors related to poverty include lack of education, problems with employment, substance abuse, and a low likelihood of prosocial attachments. This relationship is often complicated and is not amenable to simple explanations. Research and policy that take this complexity into account may lead to greater effectiveness in interventions for persons with serious mental illness.
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Creating Healthy Communities, Healthy Homes, Healthy People: Initiating a Research Agenda on the Built Environment and Public Health
Article
Full-text available
  • Oct 2003
Mounting evidence suggests physical and mental health problems relate to the built environment, including human-modified places such as homes, schools, workplaces, parks, industrial areas, farms, roads and highways. The public health relevance of the built environment requires examination. Preliminary research demonstrates the health benefits of sustainable communities. However, the impact of mediating and moderating factors within the built environment on health must be explored further. Given the complexity of the built environment, understanding its influence on human health requires a community-based, multilevel, interdisciplinary research approach. The authors offer recommendations, based upon a recent conference sponsored by the National Institute of Environmental Health Sciences (NIEHS), for research and policy approaches, and suggest interagency research alliances for greater public health impact.
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Urban built environment and depression: A multilevel analysis
Article
Full-text available
  • Nov 2005
To assess the relations between characteristics of the neighbourhood internal and external built environment and past six month and lifetime depression. Depression and sociodemographic information were assessed in a cross sectional survey of residents of New York City (NYC). All respondents were geocoded to neighbourhood of residence. Data on the quality of the built environment in 59 NYC neighbourhoods were collected from the United Status census, the New York City housing and vacancy survey, and the fiscal 2002 New York City mayor's management report. Among 1355 respondents, residence in neighbourhoods characterised by a poor quality built environment was associated with greater individual likelihood of past six month and lifetime depression in multilevel models adjusting for individual age, race/ethnicity, sex, and income and for neighbourhood level income. In adjusted models, persons living in neighbourhoods characterised by poorer features of the built environment were 29%-58% more likely to report past six month depression and 36%-64% more likely to report lifetime depression than respondents living in neighbourhoods characterised by better features of the built environment. Living in neighbourhoods characterised by a poor quality built environment is associated with a greater likelihood of depression. Future prospective work designed to assess potential mechanisms underlying these associations may guide public health and urban planning efforts aimed at improving population mental health.
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A Wellness Approach
Article
Full-text available
  • Apr 2006
There is a significant paradigm in the field of public mental health practice that encompasses a wellness approach. This paper will present a wellness approach by comparing it to the traditional medical model. A personal application of the wellness approach will be discussed.
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Swarbrick, M. (2010). Peer Wellness Coaching Supervisor Manual. Freehold, NJ: Collaborative Support Programs of New Jersey, Institute for Wellness and Recovery Initiatives.
Chapter
  • Sep 2010
Overview According to Gates and Akabas , practices conducive to effectively integrating peer providers as staff of mental health agencies include: clearly defined job structure, adequate training, support and guidance regarding disclosure of peer status, and opportunities for networking and social support. Practices that seem to undermine successful integration include subtle discrimination based upon lingering stigma, role conflict, and role confusion among peer and non- peer staff. This manual contains information, resources, and strategies that we believe can help mental health agencies to successfully introduce the peer wellness coach role into the array of services offered. Although this manual is designed for direct supervisors, the strategies described may also help managers and administrators to effectively integrate the peer wellness coach role. Practical strategies for supervisors to effectively supervise the wellness coach are highlighted. The first section defines the key wellness coach principles and core concepts (wellness and coaching), and presents key wellness coach tasks and ethical principles. The next describes the purpose of supervision, and outlines the process for setting up a supervisor-wellness coach relationship. Strategies for integrating a wellness coach into the team/agency culture and special supervision issues are highlighted. Section three outlines strategies for assisting the wellness coach in developing and refining core competencies. This section specifically addresses wellness assessment, responding to barriers, the coaching session plan, and a format for helping the wellness coach to selectively use self disclosure (known as wellness narratives). Section four explores special issues. The final section highlights the importance and benefits of assisting wellness coaches in terms of career development.
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The Social Determinants of Mental Health
Article
  • Nov 2015
  • PSYCHIAT SERV
Ninety percent of the determinants of our health derive from our lifetime social and physical environment-not from the provision of health care. The author describes behaviors, such as poor eating, excessive drinking and abuse of drugs, smoking, and physical inactivity, and social factors, such as adverse childhood experiences, poor education, food insecurity, poor housing quality, unemployment, and discrimination, that contribute to ill health and early demise. Better health and mental health can be achieved by understanding and responding to these determinants of health.
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