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How the Ballot Brought About Funding and Changes for Mental Health Services Dale Mueller, California State University at Dominguez Hills, College of Health and Human Services, School of Nursing Abstract
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 While the usual legislative process
to enact laws in 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 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 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 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 In both 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 Table 1 Comparison of
Utilization by Ethnicity to Population and Workforce: Mental Health Services in
*** 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
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. 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. 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 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
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