Introduction

The funding and delivery of mental health services in the United States of America (USA) is fragmented, chronically under-funded, and challenged regarding linguistically and culturally appropriate care for diverse populations. Many system-wide initiatives, both government-sponsored and consumer-driven, have emerged over the past decade to address these pervasive and perplexing issues. Due to a ballot initiative in 2004 (Proposition 63, now known as the Mental Health Services Act), an opportunity arose in California, one of the most population-dense and ethnically diverse states in the USA, to bring an infusion of funds into the public mental health system (Mental Health Services Act, 2004).

While the usual legislative process to enact laws in California is through proposing of bills in the State legislature, voting by the elected representatives, and a signature by the Governor, a ballot initiative qualifies for the ballot by first obtaining the required number of signatures directly from registered voters. Once qualified, the measure can then be placed on the ballot for voting in a regular or special election. A ballot initiative must have language that can be voted on as a “yes” or “no.” If approved by the voters, it is enacted into law. Proposition 63 was the result of one such ballot initiative. The language of Proposition 63 read as follows, “Should a 1% tax on taxable personal income above $1 million to fund expanded health services for mentally ill children, adults, seniors be established?” (http://www.smartvoter.org). The measure passed on November 2, 2004 with 53.7% of the voting public (6,183,119 votes) voting “yes.”

Collaboration For Planning And Implementation Of Services

An intentional consequence of Proposition 63 and the subsequent Mental Health Services Act (MHSA) was the establishment of a process for collaboration to bring about needed changes in the type and delivery of mental health services. A structure for collaboration was provided such that a culturally competent workforce and mental health system will be created. Collaboration to examine current needs has commenced among significant stakeholders such as government agencies, consumers, advocacy groups, mental health professionals, professional organizations, and educational institutions. Stipulated in the Act is the directive to promote web-based technologies and distance learning as a means to support education and training, inclusion of minorities, consumers and family members, and to increase the diversity of the mental health workforce. Regional partnerships with local institutions such as schools and universities will emerge, such that consumers and family members can be prepared academically for active roles in service delivery, as well as the creation of programs for training and re-training of the current workforce.

In addition to regional partnerships, collaboration is further promoted by language regarding planning that will create programs consistent with the Recovery Vision for consumers, increase access to services for underserved populations, and establish oversight and accountability as the planning process unfolds.

Stakeholder Input

One mechanism for inclusion and meaningful collaboration throughout the planning process is the holding of stakeholder meetings in various locations throughout the state. Meeting announcements, minutes, and works in progress are also published on the Internet, so that there is open access to information such as aggregated public comments as the strategic planning and regional partnership processes take shape. Stakeholders are defined as:

a person or an organization that feels they have an active interest in the outcome of an issue or topic. The Department of Mental Health (DMH) uses the term quite broadly to include but not be limited to: clients, family members, country mental health departments, mental health providers, schools, social services, law enforcement and others. (Department of Mental Health, Questions, 2005)

The New Recovery Vision Model

Key elements of the Recovery Vision are explicitly stated in the Act. These elements are hope, personal empowerment, respect, social connections, self-responsibility and self-determination. The recovery model holds at the core of its philosophy that views and goals of consumers of mental health services are to also be incorporated into the treatment planning process. The MHSA requires that consumers and family members are involved in all stages of implementation, as well as the delivery of services in a model true to the Recovery Vision.

To deliver the promise of the Recovery Vision, many changes are needed within the current delivery and reimbursement system as well as the current educational system where curriculum and professional scope of practice may need to be updated or changed. In order to truly help people with chronic mental illness it is absolutely necessary to create an environment where people feel they have control over choices in their own lives (Deegan, 1996; 2003). The recovery process is also more than just about symptoms and behaviors, as recovery holds empowerment and social connection as key elements that foster hope, respect, and self-determination.

According to Anthony (1993a) the recovery process involves a host of systemic issues that interact with the client on a daily basis, where

people with mental illness may have to recover from the stigma they have incorporated into their very being; from the iatrogenic effects of treatment settings; from lack of recent opportunities for self-determination; from the negative side effects of unemployment; and from crushed dreams. (Anthony, 1993a, 14)

The most important element of the recovery movement, of which the Recovery Vision is a product, is the shift in focus for service delivery. Prior to the recovery model, institutions focused on how changes in care would affect the structure of care, not how it would impact consumers (Anthony, 1993b). In contrast, the recovery model emphasizes that the interest of the consumer is paramount over the interests of professionals or institutions. A dramatic shift in the providing of service is the inclusion of consumers as clinicians.

OVERSIGHT AND ACCOUNTABILITY

Oversight and Accountability Commission

The state of California has a number of agencies that provide oversight for mental health services. The Department of Mental Health (DMH) has a federally mandated oversight body, the California Mental Health Planning Council (CMHPC). The CMHPC oversees the master plan for mental health services in the public mental health system. The meetings are open to the public, and the Master Plan is also available at the CMHPC website (http://www.dmh.ca.gov/MHPC/default.asp). The MHSA has another oversight body, specifically designed to aide in implementing the Act. Part 3.7 of MHSA requires that an oversight and accountability commission, Mental Health Services Oversight and Accountability Commission (MHSAOC), be established for the new law. The DMH, MHSAOC, and the CMHPC are working collaboratively to stay current on each other’s progress, roles, recommendations, and collected data.

Mental Health Services Oversight and Accountability Commission (MHSOAC)

The primary responsibility of MHSOAC is as follows: to provide support, oversight, and accountability for the implementation of MHSA, to ensure that the direction of the new law will stress prevention and early intervention, to ensure that the needs and voices of people with serious mental illness will be taken into consideration when planning for the implementation of MHSA. Further, MHSOAC will promote a systemic approach to mental health services, develop public education programs to reduce stigma, promote programs that maximize MHSA funding, and will keep the public informed of the progress of MHSA (Department of Mental Health, 2006). The MHSOAC meets at least once at least quarterly in a location that will be as accessible to the public as possible. All meetings of MHSOAC are to be open to the public (MSOAC, 2006).

The California Mental Health Planning Council (CMHPC)

The California Mental Health Planning Council provides a very special role in relation to implementation of MHSA. The Planning Council is an autonomous body that operates independently of DMH. The Planning Council is a federal and state mandated organization that advocates for the needs of seriously mentally ill persons in the state of California (CMHPC 2006). As outlined by section 1911 of federal statute 106-310, any state that receives federal grant dollars must have a Mental Health Planning Council to provide oversight of policy and implementation.

The Planning Council has a number of committees and task forces that are aligned according to process and topic in specific areas relating to mental health services. The Planning Council has four standing committees: the Human Resource committee, the Quality Improvement Committee, the Policy and System Development Committee, and the System of Care Committee (CMHPC, 2006). Currently the main focus for the Policy and System Development Committee is the implementation of MHSA. The Planning Council will ultimately issue recommendations to the state based on the information gathered at the stakeholder meetings and the plans that have been submitted for funding. Because the CMHPC has so much influence on DMH procedures most of what the CMHPC recommends will be implemented into their system of care procedures.

SUCCESSFUL INCLUSION OF MARGINALIZED COMMUNITIES

The Department of Mental Health (DMH) Master Plan has identified underserved areas of need, such as linguistic and ethnic minorities, rural versus urban dwellers, severely emotionally disturbed children and transition age (17-25) youth, and individuals with co-occurring disorders, such as chemical dependency and mental illness. In fiscal year 1999-2000, in California the unmet need for mental health services was estimated to be 600,000 persons, where 300,000 of this figure are children and youth, and 100,000 are adults over the age of 65 (http://www.dmh.ca.gov/MHPC/masterplan.asp). In 1997-98 the total number of persons served through the State of California public mental health system was 460,000, so the need for capacity-building to meet current need in addition to capacity expansion to meet growing needs and case-finding is apparent (CMHPC Master Plan).

In both California state and US federal sources, it is estimated that at best only one in two individuals in need of services actually receive care, and for ethnic and linguistic minorities, the estimate for service delivery is even lower. The US Government report “Mental Health: Culture, Race, and Ethnicity” (2001) mentions that minorities receive treatment at a rate lower than the general population and the impact of overall loss to productivity and health is disproportionately greater as well (CMHPC Master Plan). Further, the socio-economic mix of individuals receiving mental health services through the public mental health system from 1990-2000 consisted of between 30-55% indigent, depending on location of service (CMHPC Master Plan), which is a disproportionately higher utilization by this lowest socio-economic group when compared to the population of California as a whole.

Mental health clients are also underserved in terms of cultural and linguistic context for services. There is a shortage of mental health workers overall, and this shortage is especially acute when examined against client ethnicity. The need for culturally and linguistically competent services is apparent. Table 1 compares the percentage of clients served to the population of California as a whole, Los Angeles County which is the most population-dense geographic region of California, and the composition of mental health personnel who are currently delivering services.

Table 1

Comparison of Utilization by Ethnicity to Population and Workforce: Mental Health Services in California

*** California Mental Health Planning Council, personal communication

****US Census obtained from http://quickfacts.census.gov/qfd/states/06000.html

*****US Census obtained from http://quickfacts.census.gov/qfd/states/06037.html

Marginalization and Inclusion

The Mental Health Services Act seeks to address the marginalization of mental health clients in several ways [MHSA, Section 5813.5 (d)] The Recovery Vision named in the Act promotes hope, personal empowerment, respect, social connections, self-responsibility, and self-determination [MHSA, Section 5813.5 (d)(1)]. Further, the Act states that planning for services will reflect the cultural, ethnic and racial diversity of mental health consumers [MHSA, Section 5813.5 (d)(3)]. The Act includes dedicated funding to address the overall shortfall of service providers in the field of mental health [MHSA WIC Section 5820 (a)], where this planning will include a needs assessment [MHSA, Section 5820 (b,c)] by occupational category along with a 5-year education and training development plan. The plan will include many aspects of community and client collaboration, including inclusion and employment of mental health consumers and family members in the mental health system [MHSA, Section 5822 (d, g, h)]. Curriculum to train existing staff and to provide initial training for new jobs will commence [MHSA, Section 5822 (f)] and the use of web-based technologies and distance learning techniques will be used [MHSA, Section 5822 (d)].

Even for marginalized populations and communities, availability of computers and the Internet is a feasible means of communication and a way to sustain communication and educational endeavors, since many public buildings such as libraries have computers with Internet access available to the public (Table 2).

Table 2

Internet usage by Age and Household in the United States 2003

US Census Bureau, Current Population Survey, September 2001. Internet Release Date: October 27, 2005. Retrieved from http://www.census.gov/

Constructivism, Distance Education and the Recovery Vision

The Recovery Vision that is infused throughout the Mental Health Services Act transformation of services, including the education and training component, emphasizes the importance and value of individual experience and context of the human experience. Interestingly, and perhaps not so coincidentally, this world view also describes constructivist conceptions of learning, whereby knowledge is individually and socially constructed by each learner, based on their own interpretations and experiences. Constructivist curriculum design, therefore, is highly compatible with the aims of the Act and can serve as a basis, at least in part, for new curriculum to be developed.

Constructivist components (Jonassen, in Riegeluth, ed., 1999) are especially relevant for training programs that build upon experiences of consumers and family members, and for elements of cultural relevance for populations, sub-groups, and groups with special needs based on culture, language, socioeconomic variables, lifestyle, and many other aspects that express individuality and group affinities in daily life. Using the framework of problem-based learning and instructional strategies such as exploration through modeling, articulation and creation of context through coaching, and reflection as a synthesis to create meaning through scaffolding, an engaging program for diverse groups of learners can be created. The element of authenticity, an important factor in therapeutic relationships as well as educational contexts, is important in the constructivist approach – real problems or personally relevant issues can be incorporated into constructivist learning activities and is also congruent with a core value in mental health support systems.

Mental Health Services Act – Special Topics Workgroups

As part of the development process for short- and long-term education and training options, a series of planning sessions are being held. Leadership from stakeholder groups and individuals who have interest and expertise in the specialized areas are invited, and consumer and family member participation is incorporated as part of the recruitment. These special topics are needs assessment, training and technical assistance, consumer/Family member employment, regional partnerships, stipends and scholarships, distance learning, human service academies, post secondary education and training, and licensing and certification. Subject matter experts are invited, as well as representatives from populations with special needs, and contributions from the California Pan-Ethnic Health Network to assist in ensuring a culturally diverse working group (personal communication, Human Resources Committee, CMHPC).

The operating principles of the special topic workgroups include that recommendations be applicable and available to local mental health programs and agencies that will be assisting in delivery of services according to the MHSA. In this way, no one agency or group will dominate the development in their own interests, and all stakeholders will be able to participate as far as feasibility of implementation. All viewpoints and experiences of mental health consumers and family members are to be incorporated, and principles and practices of cultural competency be incorporated (personal communication, Special Topic Workgroup, 2006).

CMHPC Plans for Distance Education Curricula

There are several curricula that are being adapted for distance delivery under the direction of the CMHPC’s Distance Education subcommittee. The five-year plan for education and training is intended to include distance learning as a means to train or re-train existing workers in the mental health professions, as well as construct new programs to train new workers, including consumers and family members, for new positions in the mental health system.

A kick-off curriculum planning meeting was held with the CMHPC’s Distance Education subcommittee in February of 2006 to establish the target populations for the four online curricula to be developed as the first offerings for all Californians. Information gathering and project direction, including learner capabilities and intended course outcomes was established at this kick-off meeting (personal communication, HR subcommittee February 2006)

Subsequent meetings will be held with each of the sponsoring agencies and their stakeholders to further develop the curriculum. The California Association of Social Rehabilitation Agencies (CASRA) has a psychosocial rehabilitation counselor certificate curriculum that will be adapted for online delivery. The Department of Mental Health/Department of Rehabilitation Cooperative Program is based on a model designed to retrain disabled individuals to return to the workforce in productive jobs, and this cooperative program will be used as a prototype to expand to mental health and dual-diagnosis clients. Pacific Clinics is a not-for-profit community based agency that has developed a paraprofessional mental health certificate program that will be expanded and made available via distance delivery. United Advocates for Children of California (UACC) is a community network organization that has developed a curriculum for mental health advocates and an introduction to mental health services. All of these programs are being reviewed for conversion to distance delivery under the auspices of the CMHPC’s Distance Education subcommittee, which is a collaborative endeavor to support the longer-range planning that is occurring under the auspices of the Special Topics Workgroups of the Mental Health Services Act.

References

Anthony, W. (1993a) Recovery from mental illness: the guiding vision of the mental health service system in the 1990s. Psychological Rehabilitation Journal. Apr 16(4), 11 – 24.

Anthony, W. (1993b) The decade of recovery. Psychosocial Rehabilitation Journal. Apr, 16(4), 1.

California Mental Health Planning Council (CMHPC). MHPC Home Page. Retrieved from http://www.dmh.ca.gov/MHPC/default.asp

California Mental Health Planning Council (CMHPC). Retrieved from http://www.dmh.ca.gov/MHPC/masterplan.asp

Deegan, G. (2003) Discovering recovery. Psychiatric Rehabilitation Journal. Sp 26(4), 368 – 376.

Deegan, P. (1996) Recovery as a journey of the heart. Psychiatric Rehabilitation Journal. Win 19(3), 91 – 98.

Jonassen, D. Designing constructivist learning environments. In Riegeluth, C., ed. (1999) Instructional-design theories and models, volume II: A new paradigm of instructional theory. Mahwah, New Jersey: Lawrence Erlbaum Associates

Mental Health Oversight and Accountability Commission (MSOAC) (2006). Goals, Procedures and Rules of Operation. Retrieved from http://www.dmh.ca.gov/MHSOAC/docs/CommRulesOper_Adopted1-27-06.pdf

Mental Health: Culture, Race and Ethnicity: A Report to the Surgeon General. (2001). Retrieved from http://www.surgeongeneral.gov/library/mentalhealth/cre/

Mental Health Services Act (2004). retrieved from

http://www.dmh.cahwnet.gov/MHSA/default.asp

Smartervoter.org (2004). Language of Proposition 63 and summary of arguments for and against. Retrieved from http://www.smartvoter.org/2004/11/02/ca/state/prop/63/

Stakeholder Input Process. California Department of Mental Health April 19, 2005. retrieved from http://www.dmh.cahwnet.gov/MHSA/meetings.asp

Questions about MHSA and Implementation. Frequently Asked Questions. California Department of Mental Health February 2005. Retrieved from http://www.dmh.ca.gov/mhsa/FAQs.asp

US Census Bureau, Current Population Survey, September 2001. Internet Release Date: October 27, 2005. Retrieved from http://www.census.gov/