The International Journal of Person Centered Medicine Vol 2 Issue 3 pp 410-420

ARTICLE

The top ten concerns about person-centered care planning in

mental health systems

Janis Tondora PsyDa, Rebecca Miller PhDb and Larry Davidson PhDc
a Assistant Professor, Yale Program for Recovery and Community Health, Yale University School of Medicine, New Haven,
CT, USA
b Instructor, Yale Program for Recovery and Community Health, Yale University School of Medicine, New Haven, CT, USA
c Professor of Psychiatry and Director, Yale Program for Recovery and Community Health, Yale University School of
Medicine, New Haven, CT, USA

Abstract
Person-centered approaches to mental healthcare are at the forefront of behavioral healthcare transformation, yet how to
implement this approach raises questions for practitioners. Based on extensive consultation and systems transformation
work, the following paper describes the top ten concerns frequently raised by those providing services and addresses these
concerns in the context of the provision of recovery-oriented care.

Keywords
Advocates, autonomy, compassion, concerns, ethics, person-centered care planning, person-centered medicine, person-
centered psychiatry, practitioners, recovery, shared decision-making

Correspondence address
Dr. Rebecca Miller, Yale Program for Recovery and Community Health, Yale University School of Medicine, New Haven,
CT, USA. E-mail: [email protected]

Accepted for publication: 20 July 2012

Introduction The convergence of these various factors presents a

unique challenge to a mental health system that is in the
process of transforming to a recovery orientation, but a
“It’s amazing what you can do when you set your
challenge that we cannot afford to avoid. Given that
mind to it … especially when you’re no longer
person-centered care planning is one of the core and
supposed to have one!”
perhaps most basic components of recovery-oriented care
(Woman with a mental illness describing her
[8], we felt compelled to take up this challenge and to
participation in person-centered care planning)
stimulate a dialogue regarding this particularly complex,
but also especially important, aspect of transformation. The
Person-centered care planning (PCCP) has been identified
following discussion of the top 10 concerns about person-
as a cornerstone of a recovery-oriented system of mental
centered care planning is drawn from extensive work
healthcare [1], with well-developed PCCP models used
carried out over the past 5 years in developing and
within the developmental field for over three decades [2-6]
evaluating a culturally responsive approach to psychiatric
and person-centered care itself recently accepted as
care [9-11].
standard practice for all of medicine [7]. Implementation of
Based on training and technical assistance provided to
person-centered care planning in mental health represents a
direct care staff, program managers and administrators
relatively new and relatively controversial challenge. The
who are working to implement such a model of person-
introduction of person-centered care planning has
centered care within the public mental health system in the
provoked an array of contradictory responses in the mental
U.S., we identified the 10 most common concerns raised in
health community, with concerns focused on risk
relation to this work. We describe these concerns below,
management and professional liability, meeting
ranging from the practical (e.g., How do I write a
documentation standards required by fiscal and accrediting
measurable objective?), to the fiscal (e.g., How will we get
bodies, practitioners’ self-image as caring and
paid for person-centered care?) and clinical (e.g., Should
compassionate people, as well as the priority democratic
people with serious mental illnesses be allowed to make
societies place on autonomy and self-determination and the
their own treatment and life choices?), to the ultimately
long history of stigma associated with serious mental
philosophical questions (e.g., How do I work with
illness.
someone who has no goals?). The answers we offer are the
beginning of responses to address these and other

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frequently asked questions for systems engaged in Practitioners assess, evaluate, diagnose, educate, inform
transformation to recovery-oriented and, therefore, by and advise the patient and his or her supporters about the
necessity, person-centered, mental healthcare. We hope possible courses of treatment and rehabilitation available
that others will join the dialogue. for whatever ails the person, including the relative benefits
and drawbacks of each approach. Practitioners then deliver
whatever treatments and rehabilitation strategies they are
What is person-centered care? competent to provide based on the nature of the ailment
and the person’s informed consent. The person, in
conjunction with his or her supporters (to whatever degree
We define person-centered care planning as involving a he or she wishes) makes decisions about what treatments,
collaborative process between the person and his or her interventions, services and supports make the most sense
supporters (including the clinical practitioner) that results within his or her life context, given his or her values,
in the development and implementation of an action plan needs, preferences and goals. It is no more appropriate for
to assist the person in achieving his or her unique, personal the person to assume the role of practitioner than it is for
goals along the journey of recovery. We suggest that this the practitioner to assume the authority to make the
plan can meet the rigorous documentation elements person’s decisions for him or her.
required by accrediting and funding bodies (such as CMS) While it is not appropriate for patients to tell
and can be attentive to the specific mental health and/or practitioners what to do, it also is not appropriate for
substance use barriers interfering with goal achievement. practitioners to tell patients what to do. It is the right and
In addition, for the plan to be considered person-centered it ethical responsibility of practitioners to offer the best
needs to: 1) be oriented toward promoting recovery rather mental healthcare that they can. Yet it is also the patient’s
than only minimizing illness; 2) be based on the person’s right, except in few exceptional circumstances (see
own goals and aspirations; 3) articulate the person’s own Concern 1 below), to make his or her own decisions about
role and the role of both paid and natural supports in what treatment recommendations, interventions, services
assisting the person to achieve his or her own goals; 4) or supports he or she will use in his or her recovery [12].
focus and build on the person’s capacities, strengths, and
interests; 5) emphasize the use of natural community
settings rather than segregated program settings and 6) Concern 9. Person-centered care planning
allow for uncertainty, setbacks and disagreements as is important, but it is the responsibility of
inevitable steps on the path to greater self-determination non-clinical practitioners
[6]. To expand on this definition, we offer the following
table that contrasts person-centered care from traditional “Personal goals are best served at the clubhouse,
practitioner-driven models of care. with the rehab’ staff or at the peer-run program. My
role is to provide treatment to reduce symptoms. That
The top ten concerns about person- is what I was trained to do. Other practitioners have
centered care planning responsibility for helping people to find housing or
jobs or hobbies.”
Below we address the top 10 concerns that have been
raised by direct care staff, program managers and It is certainly true that not every mental health practitioner
administrators as we have worked with them to implement can or should be proficient in every aspect of the care of
the model of person-centered care planning described persons with serious mental illnesses. Some practitioners
above. We discuss each in turn. were trained to diagnose disease and treat illness, while
others may have been trained in job and community
resource development or in cognitive-behavioral
Concern 10. Emphasizing patient choice psychotherapy. The question is not so much one of what
inevitably devalues clinical knowledge and any given practitioner was trained in, however, as much as
expertise what the person receiving care needs, wants and can
benefit from. Person-centered care planning provides the
“Why did I go to school for all these years if I’m just overarching framework within which any of these specific
going to do whatever the patient wants? When a interventions or treatments becomes relevant to the
person is mentally ill, his judgment is impaired. How person’s life. Otherwise, the practitioner is trying to
could he know what he needs?” provide services to someone who may have no interest in
or reason for, receiving them.
Person-centered care planning for mental illness no more Offering people services they do not want has often
requires practitioners to do whatever the patient wants than occurred in mental health where the attainment of “clinical
does person-centered care for any other medical condition. stability” has been framed as the ultimate goal rather than
Ideally, person-centered care planning evolves within a as a means to an end. For example, a man living with
collaborative relationship in which decision-making is bipolar disorder may wish to be the best father he can be,
viewed as shared between healthcare practitioners, patients yet symptoms of mania may have led him to behave in a
and their supporters. Within the context of such a manner that frightened his children and alienated his wife.
partnership, each party has its respective role to play.

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Table 1 Comparison of Traditional and Person-Centered Approaches to Care

Traditional Approaches Person-Centered Approaches

Self-determination comes after individuals have successfully used Self-determination and community inclusion are viewed as
treatment to achieve clinical stability fundamental civil rights of all people
Compliance with practitioner’s instructions and recommendations is Active participation and empowerment is vital
valued
Only professionals have access to information (e.g., plans, All parties have access to the same information and information is
assessments, records, etc.) shared readily between them
Disabilities, deficits, dysfunction and problems drive treatment. Interests, abilities and personal choices define supports. Focus is on
Focus is on illness. promoting health.
Lower expectations of patient. High expectations of person.
Clinical stability is valued Quality of life is valued
Linear progress and movement through an established continuum of Person chooses from a flexible array of supports and/or creates new
services is expected support options with team
Primary emphasis is on professional services Diverse supports (professional services, non-traditional services and
natural supports)
Facility-based settings and professional supporters Integrated settings and natural supporters are also valued
Avoidance of risk; protection of person and community Responsible risk-taking and growth

A traditional care plan might focus exclusively on the in his or her daily life. Failing to address the person’s
clinical goal (e.g., compliance with medications and everyday life concerns and continuing to treat the illness as
reduction of mania) with little, or no, mention of the man’s if it took place in a vacuum, perpetuates the narrowly
ultimate goal of reunification with his family. We suggest defined, practitioner-driven model of care that people with
that this lack of connection between treatment and mental illnesses routinely identify as a major barrier in
personally valued life goals is one reason why attrition and their recovery and their ability to benefit from the services
drop out rates are so high in outpatient mental healthcare being offered [18].
[13-15].
For mental health practitioners to offer more Concern 8. We do it already; our care is
responsive and individualized care, the care planning
already person-centered
process needs to be shaped by the person’s life goals rather
than by the practitioner’s specific training or professional
“Are you suggesting that we don’t take the person
discipline. Simply put, in a person-centered system, we no
into consideration?”
longer have a clinical or treatment goal that exists
independent of a meaningful outcome in a person’s life.
We readily agree that caring and compassionate
The goal on the treatment plan – whether one is a
practitioners do already make concerted efforts to take the
supported employment specialist or a psychiatrist – is the
person into consideration. This is not the same, however,
same, for example, Nathan wants to get a job. Each
as offering person-centered care planning. In addition to
professional then assists Nathan based on his or her unique
listening empathically to the person and tailoring the care
skills and training, with a supported employment specialist
one provides to each individual, person-centered care
offering job development and coaching and the psychiatrist
planning involves the use of new tools and strategies that
prescribing effective medications at a suitable dosage to
practitioners may have some familiarity with, but which
control the psychotic symptoms that interfere with
generally are not employed routinely in practice. These
Nathan’s job performance without making it impossible for
include comprehensive and structured interests and
him to get out of bed in the morning [16].
strengths assessments; the inclusion of the person’s natural
In order to create these types of person-centered care
supporters and legal advocates in the care planning
plans, clinical and medical professionals will need to know
process; articulation of clearly defined short- and long-
more about the person’s overall life context and everyday
term personal goals with measurable objectives;
experiences and will need to place treatment and other
assignment of responsibility for different tasks and action
interventions within this context [17]. For a psychiatrist,
steps to different members of the care team, including the
for example, to expect a patient to accept being diagnosed
person in recovery; prioritization of natural, integrated
with a psychotic disorder, it will be incumbent upon the
settings over those designed solely for persons labeled with
psychiatrist to explain how this diagnosis helps the person
serious mental illnesses; and the use of tools such as
to make sense of his or her own experience and how it
psychiatric advanced directives, shared decision-making
accounts for some of what has gone wrong in the person’s
aids and supported employment, housing, socialization and
life. Similarly, to expect a patient to take prescribed
education coaches.
medication, it will be useful for the prescriber to connect
Thus, while many practitioners strive to attend to each
the taking of these medications to potential improvements
person as a unique individual, there are many strategies

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and tools (some new, some long-standing) that are under- As depicted below, a quality person-centered plan
utilized and whose consistent use in practice could not only depicts the short and long-term destinations, but
significantly advance the implementation of a more also explicitly identifies the role of all team members in
person-centered model of care planning. Examples of this contributing to the process. Interventions are thought of
model are implied in such questions as: How do you broadly and include specific action steps for the
determine what interests the person has that he or she practitioners involved as well as for the person in recovery
might like to pursue? Does the person have the option of and his or her natural supports. Thus, the person-centered
running the care planning meeting? Do you automatically plan is an important tool that promotes accountability
offer a copy of the plan to the person you’re working with? among all stakeholders as both tasks and timelines are
How often are natural supporters included in the meeting clearly spelled out. The potential impact and value of the
when desired by the person in recovery? How often are the written planning document is further magnified when this
person’s roles and responsibilities articulated in the plan document is offered in hard copy to the person in recovery
along with the services to be provided by mental health (an essential practice in person-centered planning). This is
practitioners? [10,19]. not only an important symbolic gesture offered in the spirit
of partnership and transparency; it also serves to activate
Concern 7. The care plan is not that the person in the day-to-day work of his or her recovery
important and does not really drive care. It process. The written care plan, while a valuable tool for
setting a course and reflecting on progress, is only one
is more for accreditation and piece of the picture. Equally, if not more, important is the
reimbursement purposes process behind the development of the plan, which we
discuss in other sections of this paper.
“Why are you focusing on a piece of paper that has
little to do with the quality of care I provide? It is for Concern 6. Person-centered care planning
the chart… not the person. Does it really matter?”
is based on people’s own goals, but people
Often in practice, the treatment plan is a technical with serious mental illnesses sometimes
document that has to be completed to satisfy accrediting or give up on life goals. They are doing their
reimbursement bodies and is useful neither to the best just to get through each day, to
practitioner nor to the person receiving services. In such survive and may not want to make changes
cases, the plan is completed and filed in the medical record
and plays little, if any, role in actually guiding care. It is
“What if my patients don’t have goals? When I ask
doubtful whether anyone involved would argue that this is
them what their goals are, they give me a blank stare.
an ideal way of providing care or occupying the time and
What if they are just comfortable with where they are
talents of dedicated mental health practitioners. While we
at?”
recognize this is the unfortunate reality of most treatment
plans written in today’s mental health systems, we propose
Most people do not live their lives explicitly in terms of
that the truly person-centered plan - one created through a
“goals”. We may have dreams and aspirations, but often
process of partnership and shared discovery - has the
we do not take the time to break these down into the
potential to be a powerful transformative tool. Rather than
various steps that will be required for us to pursue them.
being a bureaucratic document that takes time away from
So, while many people with serious mental illnesses
the real work of direct patient care, creation of the person-
similarly will not have explicit goals and may well not
centered care plan is an intervention in and of itself, as it
know how to answer questions that ask them about goals,
becomes the very heart of the work and the therapeutic
they nonetheless will have ideas about what could make
process.
their lives better. Do they, for example, want to work and
Person-centered care planning emphasizes the need for
make money? Would they perhaps like to have a better
the practitioner and patient to enter into a collaborative
place to live? How would they prefer to spend their time
process of exploring and identifying the goals and
on a day-to-day basis? What gives them pleasure or a sense
objectives that will promote the person’s recovery and
of success? This type of dialogue differs significantly from
increase his or her quality of life. The person-centered care
the more restrictive conversation in which the patient is
plan is a road-map for pursuing valued life goals and the
expected to merely report on symptoms and side effects or
milestones which are achieved along the way (i.e., short-
patterns of eating, sleeping and taking medications. Using
term objectives) serve to give both the practitioner and the
strength-based inquiry to inspire hope and to support
individual the critical experiences of success and forward
people in goal-setting is a process that requires both
momentum needed to continue on the road ahead. In this
clinical skill and perhaps a willingness to step outside the
sense, the plan becomes a useful tool that has direct
comfort zone of our inherited professional discourse.
relevance in guiding the work of the team over time. It can
For many people receiving public mental health
be consulted as needed in order to ensure that all parties
services, it may also at first feel dangerous to allow
stay on course and revised as often as needed if the person
themselves to dream once again - with so many of their
encounters roadblocks along the way or reaches certain
previous dreams having been abruptly interrupted by
landmarks and wants to set a new destination. An example
illness or dashed by the legacy of the low expectations we
of such a plan is depicted in Figure 1 below.

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Tondora, Miller and Davidson Person-centered care planning concerns and mental health

Figure 1 A person-centered Care Plan

Adapted from Adams & Greider (2004) [33]

have had for persons with serious mental illnesses. Based Change model developed by Prochaska and Diclemente
on these experiences, individuals living with prolonged [20], which breaks down behavioral changes into several
conditions may initially report that they have no goals or incremental stages beginning with pre-contemplation and
aspirations. Such a response should not be taken at face progressing through contemplation and persuasion to
value, but rather to represent the years of difficulties and action. This model offers a useful framework for thinking
failures they may have endured and the degree of through what the planning process might look like for a
demoralization which has resulted. Over time, it is not particular person at a particular point in his or her life,
uncommon for people to lose touch with the healthier and given such issues as apathy, an apparent lack of
more positive aspects of themselves and become unable to motivation, overwhelming symptoms, learned helplessness
see a future beyond the “patient” role. When facing such or demoralization. For some people in the pre-
circumstances, practitioners need to conceptualize one of contemplative stage in relation to treatment adherence or
their first steps as assisting the person to get back in touch medication use, for example, goals might at first be
with his or her previous interests and talents and to draw oriented toward addressing basic needs such as housing
upon these to imagine a brighter tomorrow. and income [21-23]. It is important to remember in this
This goal-setting dimension of person-centered care regard that someone may be pre-contemplative in one part
planning may benefit from incorporating the Stages of of his or her life, such as the use of medications or

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abstinence from substance use, for example, but in the evidence-based practices (those interventions which have
action stage in another area, such as getting a job or having been shown to be effective), leading some in the field to
a girlfriend. Helping people to figure out what is possible suggest broad-scale and indiscriminate adoption of
in relation to these different areas of life at any given time evidence-based practices for everyone with a select
and how to negotiate or make compromises among various condition (regardless of other evidence and other relevant
goals, is another task for which clinical skill and factors). This has led to criticisms of evidence-based
experience can be extremely useful. practice as “cookbook” medicine, to which Sackett, one of
the foremost developers and proponents of evidence-based
Concern 5. Does not the emphasis on using medicine and his colleagues have responded:
evidence-based practices contradict the
“Evidence-based medicine is not ‘cookbook’
principles of person-centered care? medicine. Because it requires a bottom up approach
that integrates the best external evidence with
“Am I supposed to follow evidence-based guidelines individual clinical expertise and patients' choice, it
and provide evidence-based practices or am I cannot result in slavish, cookbook approaches to
supposed to do what the patient wants? I can’t do individual patient care” [26].
both.”
Within this context, person-centered care planning can
As already noted in Concern 10 above, person-centered be viewed as a technology and strategy for maximizing the
care planning does not mean simply giving a patient effectiveness of the role of patient choice in this “bottom
whatever he or she wants. Instead, it requires practitioners up approach.”
to take into account and to base the services they provide,
on a collaborative decision-making process in which the
Concern 4. Person-centered care makes
person plays a central role. Rather than being in conflict
with evidence-based practice, this emphasis on the sense once the person is in recovery, once
person’s own values, goals and preferences is perfectly in active treatment has been administered
accordance with the principles of evidence-based and been effective. But most patients seen
medicine, that all adults have the right to make their own in public sector settings have severe
healthcare decisions. It is for this reason that evidence-
based medicine explicitly includes the person’s role as illnesses and are too disabled to pursue
decision-maker (including his or her needs, cultural values recovery goals. The first step is getting
and preferences, including the right to defer decision- their clinical issues under control
making to others) as one of the three components that the
practitioner has to consider (the other two being the “Person-centered care sounds great for people who
available scientific evidence and the practitioner’s are well on their way to recovery, but the people I
accumulated knowledge base and clinical experience; see serve are so ill, they are not ready for that. First,
[24]). Since the person is free to (and in one way or they need to be stabilized, then we can revisit the job,
another, will, except in very limited situations) ultimately the classes and the new apartment.”
make his or her own decisions, it behooves healthcare
practitioners to accept this fact and to communicate with There are undoubtedly times when people with serious
the person and his or her family in as accurate, mental illnesses want to be taken care of, just as there are
informative, culturally and personally responsive and times when people who do not have serious mental
perhaps even persuasive, a way as possible so as to illnesses want to be taken care of. In the case of individuals
maximize outcomes. with serious mental illnesses, such times may likely be
The apparent contradiction between person-centered when they are experiencing acute episodes of illness and/or
care and evidence-based practice is due to a confusion, when they are in extreme distress. Based on first-person
currently prevalent in the field, between evidence-based accounts of people in recovery and on the wisdom of
medicine or practice on the one hand and evidence-based various accrediting bodies and laws, however, we are not
practices on the other. As described above, evidence-based to take this preference for being taken care of during acute
medicine or practice is based on the available scientific episodes to generalize to the remainder of the person’s life.
evidence, the practitioner’s accumulated knowledge and The majority of individuals with serious mental illnesses
experience and the patient’s choice [25]. Evidence-based will spend only about 5% of their adult lives in acute
practices, on the other hand, are those interventions for episodes, the remaining 95% of the time being spent in
which scientific evidence exists attesting to their periods of relative symptomatic and functional stability
effectiveness for certain conditions or patient populations. [27]. It is during this 95% of the time that person-centered
Evidence-based practices may (or may not) be used within care planning is best carried out, including planning,
the context of evidence-based medicine, depending on the through the use of a psychiatric advance directive, for how
practitioner’s clinical judgment, the patient’s particular the person would like to be treated and supported during
conditions and circumstances and the patient’s informed that 5% of the time that he or she may be too disabled to
choice. Somewhere along the way, evidence-based practice make his or her own decisions.
(i.e., what practitioners do) became confused with

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For those patients who appear to violate the 95% rule winning political economist Amartya Sen [29-30]; see also
and/or who may appear to be too disabled to make their [31].
own decisions on an ongoing basis, we suggest that there
remains a significant amount of latitude for practitioners to Concern 3. Person-centered care planning
elicit and be guided by the person’s own values, needs and
is time and labor intensive and
preferences. It is equally important for persons with
significant disabilities to live with as much choice as practitioners have case loads that are too
possible, even if that choice is based on a restricted range high to allow them the time needed
of options due to the individual circumstances. Simple
examples of how this principle can be honored in practice “I have to complete paperwork on a timeline and we
are in asking people in institutional settings how they don’t have the luxury of discussing everything first –
would like to spend their time, what and with whom they especially when the client doesn’t show up half the
would like to eat and what activities would give them some time! How can I satisfy my supervisor and still do
degree of pleasure, rather than insisting they first person-centered care planning?”
participate in treatment and other activities which have
proven not to be effective for them in the past. Even if Mental health practice in today’s fiscal climate balances on
these core treatment activities did have a proven razor-thin margins. Budget deficits around the country
effectiveness, to expect all patients to rigidly move through often lead to stretching of resources, making this seem like
a pre-determined continuum of care is, we suggest, a subtle an ill-advised moment to advocate for the expansion of
yet pernicious form of coercion. person-centered planning which further taxes the time of
Unfortunately, despite the positive changes brought practitioners. While we acknowledge that conversations
about by recovery-oriented system transformation, it is still regarding goals, dreams, strengths and aspirations may
not uncommon for individuals to be expected to jump take more time up front, these conversations are an
through “clinical hoops” and demonstrate stability before investment in a collaboration that stands to be timesaving
moving on to pursue broader life goals (e.g., requiring 6 in the long run. With the focus on patient responsibility
months of medication compliance as a pre-requisite for and action, practitioners can shift from a “do for” the
referral to supported employment or dictating a certain person perspective to a “do with,” fostering increased
compliance level with unit groups before a patient is independence on the part of the patient and a shift toward
allowed to participate in a hospital’s treatment mall maximizing natural community connections rather than
rehabilitation programming). Ironically, engagement in relying on institutional ones.
these personally preferred activities is often the factor that Program evaluation findings on person-centered
ultimately increases individuals’ desire to acknowledge planning models suggest that this approach to care may
and begin to work on, the core clinical issues that interfere also serve to interrupt the reactive cycle of crisis response,
with progress. leading to reductions in hospitalizations, incarcerations and
Finally, the consumer/survivor literature has argued assaultive or self-injurious behavior [32]. One could argue
that much of what practitioners view as apathy, passivity that the management of these crisis-oriented situations
or a lack of motivation to engage in person-centered stretches systems and practitioners far more than the
planning is actually due to “learned helplessness” [28] additional time needed to engage in collaborative person-
stemming from years of having other people take over centered planning. Ultimately, person-centered planning
one’s control and decision-making authority for one’s own may take more time to create than the cookie-cutter
life. Just as the process of sharing power and responsibility documents that still populate many charts in mental health
in care planning is a sometimes disconcerting role-shift systems around the country. However, we view this as time
among mental health practitioners, many persons with well spent and suggest it is a prudent investment in
serious mental illnesses may truly want to exert greater improving the quality of the partnership and, ultimately,
control over their lives but feel unprepared to do so. To the the quality of life among persons in recovery.
degree that this is a contributor to a person not wanting to
make his or her own decisions or to take a backseat in care Concern 2. Person-centered care is not
planning, the process of re-instilling a sense of control,
consistent with the concept of “medical
competence and confidence in one’s own decision-making
capacity will require time, incremental successes and the necessity” and therefore won’t be
provision of mentoring and skill-building opportunities reimbursed. Also, it doesn’t fit with the
specific to the process of person-centered planning. regulations of the Joint Commission, CARF
Regardless of how long such a process takes, however, and other accrediting bodies
it is most likely true that such a process will not even begin
as long as people continue to have others make their
“We can’t lose our accreditation and our income.
decisions for them in the context of a professional-knows-
Our funders and regulators don’t allow us to focus
best model of service planning. For more on the
on recovery goals. We have to focus on treatment
importance of assisting people to make their own decisions
issues.”
so that they can get better at making their own decisions
and on the failure of good intentions alone to foster
autonomy, the reader is referred to the work of Nobel Prize

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The response to this concern builds directly on the interventions which spell out who is doing what on what
response given above to Concern 9 about person-centered timeline and for what purpose [33]. Based on hundreds of
care planning violating professional roles and identities. chart reviews done by the authors and our colleagues, we
Here, the concern is that person-centered care planning is suggest that these standards for person-centered care
not consistent with the traditional medical model and the planning documentation are on par with, if not superior to,
regulatory, accrediting and reimbursing bodies that govern the level of rigor which actually exists in most treatment
mental healthcare. Our response to this concern is plans around the country.
complex, as the issues involved are themselves complex. Second, the belief that funders will not pay for non-
In the first place, such regulatory and accrediting clinical life goals is actually a correct one, but not because
bodies as the Joint Commission and CARF (Commission of the nature of the goal itself but the fact that funders do
on Accreditation of Rehabilitation Facilities) are actually not pay for goals at all. Rather, funders pay mental health
ahead of everyday clinical practice regarding the practitioners for the interventions/professional services we
importance placed on person-centered and goal-directed provide to help people overcome the mental health barriers
care. Individually responsive care oriented to the that are interfering with their functioning and the
achievement of each person’s unique situation and goals attainment of valued recovery goals. This is admittedly a
has been the mandate for many years, prior to the advent of broad-brush review and the authors acknowledge that each
person-centered care in mental health per se. Care is state and locality is subject to its own unique funding and
expected to be strength-based, culturally competent and regulatory expectations, a full discussion of which is
responsive to each individual’s life context and that all of beyond the scope of this paper. However, we maintain that
this be documented adequately in the person’s medical medical necessity and person-centered care are not
record. Funding for work on which this article is in part incompatible constructs and service plans can be created in
based was awarded by the U.S. Centers for Medicare and partnership with persons in recovery while also
Medicaid, the bastion of American healthcare that is maintaining rigorous standards around treatment planning
responsible for the very notion of “medical necessity.” and documentation.
These consistencies do not negate the fact, however,
that person-centered care planning principles do not Concern 1. Allowing people to set their
translate readily into the categories and concepts of
own goals and make their own decisions
conventional care plans. Were they to do so, it would be
questionable how much their introduction actually effects increases risk and exposes the
change in the way we provide care. Efforts must therefore practitioner to increased liability
be made to reconceptualize care plans and documentation
tools to become person-centered, strength-based and goal- “Isn’t impaired judgment one of the core
directed. Doing so does not minimize the importance of characteristics of serious mental illness? If given
illness, deficits and problems, but does reframe them choices, and people make bad ones, will I be the one
within the context of the person’s overall life. That said, it held responsible?”
is still true that Medicaid, for instance, currently will not
provide reimbursement for certain services or supports that Person-centered care planning does not override a
people with serious mental illnesses desire and will find practitioner’s ethical and societal obligation to intervene on
useful. For the time being - until, that is, these regulatory a person’s or the community’s behalf should someone pose
and funding bodies move further in the direction of self- a serious and imminent threat to self or others. In such
directed care and flexible funding - other sources of cases, just as in the case of an automobile accident or
funding will need to be identified for these kinds of traumatic brain injury, healthcare practitioners are
services (e.g., transportation or job coaching) or they will sanctioned to intervene on the person’s behalf without
need to be secured beyond the parameters of the formal getting prior consent. In psychiatry, as in most other
mental health system in the community at large - a solution branches of medicine, however, such cases are the
that may ultimately be both cost-effective and consistent extremes and the exceptions, not the norm. Consistent with
with the desire of persons in recovery our response to Concern 4 above, the literature suggests
Even at the current time, it is common for practitioners that most people with most mental illnesses pose few if
to view regulatory and funding bodies as more formidable any risks most of the time. Risk can be exacerbated by
barriers to providing person-centered care than they in fact substance use and by non-adherence to medication, but
need to be. We believe this derives from two fundamental even then the risk posed by people with serious mental
misconceptions. First is the belief that person-centered illnesses pales in comparison to the risks they face from
planning is somehow “soft.” Second is the belief that others, as it is much more common for a person with a
funders will not pay for life goals such as helping someone serious mental illness to be the victim of a crime than to be
to finish school or return to work. a perpetrator [34,35].
Contrary to the common myth that person-centered What this suggests is that heightened concerns about
planning is “soft,” emerging practice guidelines explicitly increased risk and liability are misplaced when applied to
call for the documentation of a) comprehensive clinical most people most of the time. In the circumstances in
formulations; b) mental health-related barriers that which they are warranted, prudent risk assessment and
interfere with functioning; c) strengths and resources; d) management are central and crucial aspects of effective
short-term, measurable objectives and e) clearly articulated care. When not warranted, though, they place undue

417
Tondora, Miller and Davidson Person-centered care planning concerns and mental health

restrictions on the liberty of persons with serious mental medication non-compliance, etc.), the practitioner is
illnesses. encouraged to document fully the conversation in the
Issues of risk and liability put aside for the moment, medical record, capturing both perspectives in writing in
how do we respond to the concern that people with serious the plan, making clear the service user’s position as well as
mental illnesses will still make bad decisions if left up to the practitioner’s own efforts to communicate these
their own devices? Initial studies in shared decision- concerns and to provide necessary support and
making in fact point to the opposite and indicate that information. While each and every situation must be
people with schizophrenia, for example, make decisions in evaluated on a case-by-case basis, we believe that this
similar ways as those with other medical disorders. Simply represents a balanced approach which both respects the
put, some people with mental illnesses make good individual’s right to make decisions and practitioners’
decisions most of the time, some make good decisions desires to ensure they have done their due diligence and
some of the time and some make good decisions only upheld their professional obligations.
rarely; but the same is true of the general population [36].
At this time, the only legal or statutorily-justified way to
interfere with an individual’s personal sovereignty (other
Conclusion
than based on serious and imminent risk) is when the
person has been determined to be incapable of making his
or her own decisions by a judge and therefore has been We hope that this discussion has helped to clarify some of
assigned a legal guardian or conservator of person. Even in the more confusing aspects of person-centered care
these cases, in many states a judge’s decision needs to planning for persons with serious mental illnesses. For
outline those specific areas in which the person is unable to readers who find general principles easier to follow than
make his or her own decisions. Short of this, the vast specific examples, we suggest that there is one general
majority of individuals with serious mental illnesses have principle at the heart of person-centered care planning
both the right and the responsibility of making their own from which the responses offered above can all be derived.
decisions and of dealing with and learning from the This principle is itself derived from the fundamental
consequences of these decisions. assumption of the mental health recovery movement,
Where then does all this leave the compassionate which is that people with serious mental illnesses have
practitioner who wishes to support someone in his or her been, are and will remain people first and foremost, just
personal choice but fears the person is making potentially like everyone else [28].
detrimental decisions that will jeopardize his or her If people with serious mental illnesses are first and
recovery and wellbeing; for example, a person is choosing foremost people, then it follows that person-centered care
not to take medications that seem to be helpful or is planning for people with serious mental illnesses is first
spending time with someone who has physically abused and foremost similar to, if not exactly the same as, person-
them or provided them drugs? In these situations, we centered care planning for other people. We need only
would not suggest that practitioners sit silently on the depart from this approach when required by specific
sidelines in the name of being person-centered or in the challenges posed by the illness or by other aspects of the
hope the individual will ultimately learn from suffering the person’s life history, such as a history of demoralization
“natural consequences” of an apparent self-defeating and despair. Any adaptations or additions that need to be
choice. Rather, in keeping with emerging best-practices in made to the basic process of identifying the person’s goals,
recovery-oriented care [37], we suggest that the role of the the barriers to those goals and an action plan to pursue the
practitioner in such situations is to remain fully engaged goals and overcome the barriers, need not fundamentally
with the person to explore what the choice means and why alter the nature of the approach itself. Rather, we suggest
it is important to him or her; to identify potential pros and beginning with an approach to person-centered care
cons; to brainstorm alternative choices and to ensure the planning that would be relevant and applicable to anyone
person has all the information necessary in order to make at all and then make the adaptations and additions required
an informed decision. But, in the end, barring any by the nature of the specific mental illness this specific
immediate safety concerns, it is the person’s decision to person is experiencing and its specific impact on his or her
make, just as it is in any other healthcare arena. ability to participate fully in the process. Developing
Following the type of collaborative dialogue described strategies and tools that can assist people in these specific
above, the person, in fact, might arrive at a different tasks of identifying and setting goals and making their
decision that both parties are comfortable with. However, decisions remains an important area for development in the
there also will be circumstances in which the person and future.
the practitioner may need to “agree to disagree” moving
forward. In these circumstances, some practitioners have
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