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Chapter 1
INTRODUTION
California is facing significant changes regarding mental health treatment and
funding for mental health programs. The passing of the Mental Health Services
Act(MHSA) in 2004 provided a new source of funding for mental health providers
that were willing to provide treatment approaches specified in MHSA. In order to
meet criteria set forth by MHSA, many programs will have to change or modify their
treatment approaches and aspects of their organizational culture. Transitioning to a
new treatment approach is no small task for any service provider. This project will
examine some of the challenges and influencing factors that were faced by mental
health service providers participating in MHSA.
Background of the Problem
Mental health services have changed considerably over the past hundred years
in the United States. These changes have been influenced by funding sources,
availability of funds, technology, and shifts in societal values regarding people living
with chronic mental illness. These changes have impacted the service providers and
consumers of mental health services considerably. California is in the midst of
another shift in funding and service delivery for mental health programs that will
impact both consumers and service providers.
In 2004 California passed proposition 63 or the Mental Health Services Act.
This act created a new source of funding for mental health programs by placing a one
percent tax on individuals living in California with a taxable net income of over one
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million dollars (Feldman, 2009). This tax would create another additional source of
funds for mental health service providers that were willing to create or modify
programs that were congruent with the types of services set forth in the act. These
types of services are commonly referred to as, “Wellness and Recovery.”
One of the specific criteria set forth by MHSA is that mental health services be
congruent with the Wellness and Recovery model. One of the key values of the
Wellness and Recovery Model is that consumers be provided with a choice in the type
of treatment they receive and the consumer be empowered to define what wellness
means to them. The recovery model emphasizes that there are many paths to recovery
and encourages service providers to work with consumers to help them recognize their
own personal strengths in order to work towards wellness. An in depth analysis of this
model is presented in chapter 2.
Statement of Research Problem
Though not specifically stated in the legislation, the MHSA is, on paper, a
transformative piece of legislation. It attempts to complete transform the current mode
of mental health services: from expert driven treatments to consumer driven
treatments; from deficit models of treatment to strength based models of treatment.
The question addressed in this research is whether or not this transformation is
occurring and, if so, how and why.
Purpose of Study
This study will examine the factors that influenced mental health service
providers to transition to a Wellness and Recovery model, while also examining some
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of the barriers that were faced during this transition. This exploratory case study will
examine the influencing factors and barriers to transition that were faced by two
county mental health service providers and two private non profit service providers.
This study may help to identify how a successful transition can be made and help
identify factors that influence changes in the treatment offered by mental health
service providers.
Definitions of Terms
Barrier- Any factor that would be perceived as limiting the mental health providers
ability to implement the Wellness and Recovery model or meet other criteria set forth
by MHSA.
Consumer- An individual that is provided services by a mental health treatment
provider.
Full Service Partnerships- A mental health service provider that offers housing,
psychiatric services and case management services under contract to a county.
Influencing Factor- Any factor that would be perceived as contributing to a mental
health service provider utilizing a recovery model for treatment as opposed to other
treatment models.
Mental Health Service Provider- An agency that provides specific mental health
services to people living with chronic mental illness.
Realignment funds- Funding for mental health services that is primarily generated
through sales tax and vehicle license fees.
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Social Rehabilitation Model- A treatment approach that emphasizes consumer
strengths and environmental influences on wellness. This approach is recovery
oriented but not necessarily recovery focused. Consumers do not necessarily take the
lead role in developing treatment plans and leading treatment.
Mental Health Service Provider- An agency that provides specific mental health
services to people living with chronic mental illness.
Wellness and Recovery model- Treatment model that presents the opportunity for
consumers to define wellness in their own terms and emphasizes the importance of
increasing overall quality of life rather than reducing or eliminating symptoms. This
approach is client driven in that the consumer plays a significant role in developing
and leading the treatment plan. This model emphasizes client strengths and the role
that environmental factors have on wellness.
Assumptions
The fundamental assumption underlying this case study is that the provision of
mental health service are driven by budgets.
Justification
The MHSA is an attempt, in California, to institutionalize a treatment
approach. To date, there has been little research on the success or failure of this
attempt. This research can help determine how agencies and clinicians have
successfully (or unsuccessfully) transitioned to using the Wellness and Recovery
model. This research will also help expose other relevant aspects of transitioning to
new treatment models which can aid the direction of further research.
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Chapter 2
LITERATURE REVIEW
Introduction
Mental health treatment philosophy in the United States has changed
considerably since the 1900’s. The only constant in the mental health treatment field
has been change. Legislation, funding, shifts in societal values, changes in treatment
philosophies, technology, and the pharmaceutical industry have all had their place in
influencing what type of mental health treatment and services were offered to people
with chronic mental illness. Some of these changes were purposeful, while others a by
product of some other changes, but few of the changes were the product of a consumer
movement. California is in the midst of another shift in regards to the type of mental
health services provided to consumers. This shift in treatment philosophy shares some
aspects with treatment philosophies that have been popular in the past. This shift,
however, was made possible by changes in legislation initiated by consumers. This
shift seeks to move mental health treatment and the definition of wellness away from
the Medical Model, which has dominated mental health treatment philosophy, towards
a very different approach to treatment: a Wellness and Recovery Model. This
Chapter sets a context for this research. It is a review of the history of mental health
treatment and a description of the various treatment models used by the mental health
services system.
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Historical Perspective
Between 1890 and 1950, American mental health treatment primarily took
place in state funded psychiatric hospitals or asylums. Many patients in psychiatric
hospitals received occupational therapy as a form of treatment (Bell, 1989).
Occupational therapy consisted of consumers completing tasks that aided in keeping
the hospital self sufficient such as repair work, services in the kitchen, laundry and
minor construction jobs. Hydrotherapy was used between 1910 and 1940 as a way to
calm patients (Bell, 1989). Hydrotherapy consisted of steam and whirlpool baths,
continuous bath, cold packs and needle spray showers. Experimental therapy utilized
during this time period included fever therapy, organ removal, vasectomy, electro
shock therapy and lobotomy (Bell, 1989).
As the number of long term care patients increased from 1890 to 1950, state
legislatures provided funding to expand existing hospitals and build new facilities,
while local communities were responsible to pay for the actual cost of admitting and
treating the individual patients (Grob, n.d.). Generally speaking, only individuals with
psychiatric disorders who were considered to be dangerous were required to be placed
in a state run hospital. Because of the financial responsibilities placed on local
communities, it was not uncommon for local officials to keep non dangerous, indigent,
“insane” members of the community in almshouses where costs of care were much
lower (Grob, n.d.). As the population of patients within the hospital rose and the
financial burden placed on local communities to provide care rose, hospital
administrators received pressure from local communities to discharge patients
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regardless of their condition (Grob, n.d.). The shared financial responsibility for
indigent community members who were considered “insane” led to the passing of
legislation in 1905 which placed financial responsibility for the care of patients in state
psychiatric facilities, solely on the state governments (Bell, 1989).
New York and Massachusetts passed legislation in 1905 that relieved local
communities from any financial obligation in providing care to mentally ill patients
(Grob, n.d.). This shift in financial responsibility was justified by the belief that local
care provided to the mentally ill was substandard in that it was not capable of
rehabilitating patients and ultimately encouraged patients to be dependent on services
provided (Grob n.d.). Supporters of this legislation also argued that the treatment
provided by hospitals, although more expensive than community care counterparts,
would increase the likely hood of recovery while providing more humane care, which
would ultimately lower costs (Grob, n.d.). Humane care referred to a shift away from
the primary intervention of locking up people with chronic mental illness towards
providing other forms of treatment. The type of treatment provided by psychiatric
hospitals included, occupational therapy, hydrotherapy, organ removal, vasectomy,
electro shock therapy, lobotomy and in some cases “normal living therapy” which
encouraged the establishment of a steady schedule of rest, sleep, proper nutrition and
recreation for the person being treated. Ideally, this legislation would have allowed
people in need of long term care to be able to receive long term care, as hospital
administration would no longer be pressured by local communities to release patients
who were in need of treatment. This legislation actually ended up allowing local
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communities to cut costs spent on treating indigent elderly in almshouses, by allowing
local communities to transfer them to State run psychiatric facilities.
Elderly people without financial resources who were cared for in local
almshouses were transferred to psychiatric facilities when senility was redefined,
largely by local officials, in psychiatric terms (Grob, n.d.). This redefinition of
senility helped to decrease the number of admissions to almshouses from 99.5 per
100,000 in 1904 to 58.4 per 100,000 in 1920 (Grob, n.d.). The legislation that was
intended to be cheaper by providing better care and increase the likelihood for patient
rehabilitation proved to be expensive as the total patient population that had been
hospitalized for twelve months or less fell from 27.8 percent in 1904 to 12.7 percent in
1910 (Grob, n.d.). The number of patients receiving long term care was clearly rising.
In 1904, 39.2 percent of patients were hospitalized for five years or more compared to
52 percent in 1910. By 1922 the number of patients admitted to state hospitals with
identifiable somatic conditions such as cerebral arteriosclerosis, paresis, Hunington’s
Chorea, brain tumors and other somatic conditions accounted for one third of the
patient population in state psychiatric hospitals (Grob, n.d). By 1940 this percentage
increased to 42.4 percent (Grob, n.d.).
It seems that the general philosophy between 1900 and 1940 concerning
mental health treatment was largely focused on funds and what to do with indigent
people in need. Legislation was passed under the guise of increasing availability of
services and allowing people to receive the treatment they needed. What actually
happened was that local officials took advantage of the situation in order to save
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money. Their motive for increasing the likelihood of recovery for people in need
seems questionable when they clearly seized an opportunity to save money by
decreasing the number of people that their community was responsible for supporting.
It seems these patients were eagerly pushed into the hospitals and out of local
government official’s minds. An argument can be made that Almshouses were not
providing the level of treatment that patients were receiving in the psychiatric
hospitals. However, the massive shift of people from Almshouses to hospitals belies
the argument. Almshouses could only encourage patients to participate in
occupational therapy and aspects of normal living therapy but did not have the
resources to provide the treatments provided in psychiatric hospitals such as
electroshock therapy and hydro therapy etc, but not everyone in Almshouses needed
hospital treatment.
Patient populations in State psychiatric hospitals began to change drastically
by the mid 1940’s and ultimately influenced psychiatrists to transfer out of hospitals
toward community settings. As long term patients increased, the role of the State
hospitals shifted towards custodial care. Many psychiatrists were interested in
providing therapeutic interventions and moved out of the State psychiatric hospitals to
pursue an environment where the patient population allowed for therapeutic
interventions. The interventions provided by psychiatrists included talk therapy which
was centered in psychoanalysis, and the use of psychotropic medications later in the
1950’s (Frank & Glied, 2006). Career opportunities for psychiatrists outside of state
hospitals began to increase during the 1940’s as outpatient mental health facilities and
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community care centers began to be viewed as effective. Psychiatry also began
moving towards a psychodynamic and psychoanalytical model which emphasized life
experiences and the role of socioenvironmental impact on a person’s mental health
(Grob, n.d.). The movement toward community mental health clinics as a primary
mental health provider was strengthened by the 1946 National Mental Health Act
which provided funding for States to establish new facilities and increase support for
existing facilities (Grob, n.d.). The National Mental Health Act had a significant
impact on the number of outpatient clinics available to the public. By 1949 all but five
states had one or more clinic, where as before 1948 half of the all States did not have
any outpatient clinics. The number of people receiving services from outpatient
mental health clinics increased from 233 per 100,000 in 1955 to 901 per 100,000 in
1968.
As mental health services shifted away from State run psychiatric hospitals,
new programs were developed that helped support people who were living in the
community who would have otherwise been locked up in institutions. Outpatient
mental health clinics employed psychiatrists, psychologists and social workers who
provided multiple treatment approaches including medications, therapy, and
community living support (Bell, 1989). The treatment philosophy was still
predominantly centered in the Medical Model: defining wellness in terms of
alleviating symptoms.
Medicaid was one form of support provided by the state and federal
governments that enabled people with chronic mental illness to receive services
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outside of hospitals. Supplemental Security Income and Social Security Disability
Income, developed under the Johnson administration of the 1960’s, were the main
source of financial support for people with severe mental illness who were living in
the community. It should be mentioned that people with severe mental illness were
required to apply for this service and not all of the indigent people were fortunate
enough to become educated on the service or actually receive assistance in completing
the complicated paperwork (Bell, 1989).
In 1963 the Community Mental Health Centers Act was passed which
emphasized the need for mental health care in a community setting and sought to
provide therapy, prevention, crisis intervention and other indirect services including
outreach to schools, police, and civic groups to all people in need despite their ability
to pay (Sharfstein, 1978). These programs contained some aspects of a Social
Rehabilitation model in that they recognized the impact that environment and social
stressors have on mental health and wellness (Dickey & Sederer, 2001). These
programs were initially funded by the federal government and it was assumed that
after an initial 51 month period of funding, that the Community Mental Health Centers
would find alternative funding sources and become self sufficient (Sharfstein, 1978).
Most Community Mental Health Centers (CMHC’s) were unable to secure alternative
sources of funding and federal support was extended 8 years. The CMHC’s continued
to have problems securing funding outside of the federal government. During the
Nixon-Ford administration the CMHC’s were almost phased out because it was
determined by these administrations that the programs were “successful
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demonstrations” and should be funded entirely with state, local and private resources
(Sharfstein, 1978). This could have been the end of the programs if Congress did not
pass Public Law 94-63.
Public Law 94-63 recognized that community mental health care was not only
the most humane form of care for a majority of mentally ill individuals but also had a
significant impact on improving mental health care by decreasing the number of
overlapping resources and increasing the efficiency of available mental health
resources (Andrulis & Mazade3, 1983). While the support of Congress did help
maintain the existence of the CMHC it also placed new demands on CMHC’s. Under
this new law CMHC’s were required to increase the services they provided to include
mental health care to children, elderly, people with drug and alcohol abuse problems,
as well as services for people leaving hospitals that required services such as follow up
care and transitional living arrangements (Andrulis & Mazade, 1973). Congress also
imposed additional requirements including: meeting cultural sensitivity goals,
establishing quality assurance programs, using at least 2% of the budget for program
evaluation, complying with provisions of the law within one year and transitioning to
providing additional services within two years (Andrulis & Mazade, 1973).
Community Mental Health Centers were also required to increase their ability to
document the actual services provided to mental health consumers. It has become
clear that Public Law 94-63 was a blessing in that it secured needed funding for
CMHC’s but also a curse as CMHC’s were required to provide significantly more
services and document those services. The Community Mental Health Centers were
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required to achieve this goal within a relatively short time frame of 2 years. Public
Law 94-63 did not dictate what type of treatment approaches should be used in
delivering these services. Community Mental Health Centers used psychotherapy and
medications as primary forms of treatment (Grob, n.d.).
The Carter administration offered new hope to CMHC’s. President Carter
signed an executive order that created the Commission on Mental Health that was
charged with reviewing the national mental health needs and making subsequent
recommendations (Andrulis & Mazade, 1983). The Commission on Mental Health
recognized some of the budgetary problems CMHC’s were facing and acknowledged
the discrepancy between what Medicare would cover for psychiatric care versus
physical health care (Andrulis & Mazade, 1983). The commission recommended
expanding existing mental health coverage with a new national health insurance
package. The findings of the Commission on Mental Health led to the passing of the
Mental Health Systems Act in 1980. Ideally this legislation would have aided in
developing a national system that would support Community Mental Health Centers in
providing services. Unfortunately, the Mental Health Systems Act was not enacted
long enough to significantly impact the CMHC’s.
When Ronald Reagan was elected later that year he quickly reversed this
policy. The Omnibus Budget Reconciliation was signed into law in 1981. This act
repealed most of the provisions within the Mental Health Systems Act, converted
federal funding for CMHC’s into a single block grant for states and essentially placed
the responsibility for funding mental health programs solely on the states without
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providing any federal assistance.(Ebben, Bliss & Perlman, 1991). Unfortunately, this
legislation passed at a time when states were experiencing economic problems that
increased financial burdens. The block grants specifically stated that states would
assume the responsibility of funding CMHC’s for the fiscal year of 1982 and
essentially turned the control of the CMHC program development over to the States
(Andrulis & Mazade, 1983).
Community Mental Health Centers that reached their eight year limit for
financial support from the federal government began to implement changes. Many of
the changes limited the amount of services that were provided to the public. Services
that were considered non revenue producing began to get cut back or eliminated.
Some of these services included interventions that theoretically made CMHC’s more
effective than their state hospital counter parts. These interventions included
consultation, psychotherapy, education, and other preventative services (Andrulis &
Mazade, 1983). Some CMHC’s were forced to increase the fees patients paid for
services. Generally speaking, mental health service providers increased their reliance
on billing to federal Medicaid where the financial contribution provided by the federal
government was matched by state governments (Frank & Glied, 2006). By doing this
States were able to significantly decrease their direct spending on mental health
services.
In 1991, California Legislature approved measures that shifted financial
responsibilities from the state to the counties (Legislative Analyst’s Office, 2003).
This has come to be known as realignment. Financial responsibility for social service
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programs, mental health programs, and health programs were transferred to counties
under realignment (Legislative Analyst’s Office, 2003). Realignment programs were
funded through vehicle license renewal fees and a half-cent increase in state sales tax
(Legislative Analyst’s Office, 2003).
In 1999 Assembly Bill 34 was passed by state Legislature in California. This
bill provided ten million dollars for pilot programs to develop and offer services to
homeless individuals residing in Stanilaus, Los Angeles and Sacramento Counties.
The pilot programs that were developed as a result of Assembly Bill 34 were
successful in reducing the amount of days that participants spent on the street, in jail
or in psychiatric hospitals (California Counsel of Community Mental Health Agencies
[CCCMHA], 2006). The success of these initial pilot programs led to the passing of
Assembly Bill 2034 which expanded funding for existing programs and provided
funding for creating new programs that could provide services for probationers,
parolees, and homeless persons living with mental illness. Assembly Bill 2034
provided the opportunities for counties to fund an array of programs and services
which included community outreach, supportive housing, housing assistance,
vocational training, substance abuse treatment, mental health care and physical health
care (CCCMHA, 2006). These programs recognized that maintaining stable housing
was an important part of recovery and offered case management services along with
many other services that would aid persons with chronic mental illness and drug or
alcohol addiction in maintaining stable housing (Burt & Anderson, 2005). Many of
the programs that provided services under AB 2034 provided these services with
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treatment models that are congruent with the Wellness and Recovery Model which
will be discussed in the next section.
Medical Model of Treatment
While there were many changes in the way that mental health services were
funded, the overall treatment model remained, generally speaking, the same.
Obviously new technologies and breakthroughs influenced changes in specific
treatments but they were still structured around the medical model. While a move
towards Community Mental Health Centers was initially influenced by the need to
increase the availability of humane care and treatment for people with mental health
disorders, the medical model and approach to mental health treatment was never really
challenged. A medical model for treatment has specific ramifications in regards to
mental health treatment.
The medical model is a way of explaining mental health disorders. In general
it is focused on identifying a problem in biological terms or pathology by doing an
assessment and then basing the treatment on this assessment (Freeth, 2007). The
medical model clearly requires an expert, the person or doctor identifying the problem
then prescribing a treatment of medication and sometimes psychotherapy, and the
consumer. This dynamic can create a power imbalance between the consumer and the
professional. The experience of the individual is defined by the professional without
taking other potentially relevant factors into consideration such as environmental
influences that might be influencing the problem. It also does not allow for the
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consumer to have the power to define the problem and solution in his or her own
terms.
Social Rehabilitation Model of Treatment
Some aspects of the Social Rehabilitation model were used in Community
Mental Health Centers. The Social Rehabilitation Model recognizes the impact of the
environment on an individual’s wellness and seeks to increase the consumer’s ability
to deal with their environment and decrease the impact that chronic mental illness has
on functioning (Dickey & Sederer, 2001). This approach focused on client strengths
and increased collaboration between the professional and consumer, however, it did
not necessarily foster an environment where the consumer was given the opportunity
to lead treatment or define wellness in his/her own terms.
While Community Mental Health Centers made huge strides in increasing the
amount of humane treatment available for people in need it did not significantly
change the relationship between the consumer and professional. Community Mental
Health Centers did not fully embrace the Social Rehabilitation Model (Andrulis &
Mazade, 1983). People in need were essentially still told what to do. As the
psychopharmacology field made new advancements consumers were given
medications that could treat their symptoms. Some consumers were also provided
with other interventions including different types of therapies to supplement treatment.
Community Mental Health Centers incorporated aspects of the Social Rehabilitation
Model, the treatment provided was still centered around an expert helping a consumer
eliminate symptoms.
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Wellness and Recovery Model of Treatment
While there were programs that focused on increasing the mental health
consumer’s level of independence and self determination, no formal funding was
provided for these types of programs until California voters passed Proposition 63 or
the Mental Health Services Act in November of 2004. This act prescribes a treatment
approach that has come to be known as the “Wellness and Recovery Model.”
The Mental Health Services Act (MHSA), also referred to as the millionaires
tax, provided funds for mental health services by placing a one percent tax on
individuals in California with a taxable net income of over 1 million dollars (Feldman,
2009). These funds were to be used for specific purposes and programs. The act
provided funds for five different program areas: Community Services and Supports,
Workforce Education and Training, Prevention and Early Intervention, Capitol
Improvements and Technology and Innovations. The Mental Health Services Act
(MHSA) required that these funds be in added to existing funds provided by the State
Department of Mental Health. This was to ensure that funding for mental health
programs actually increased and that the extra funds would not be used to supplement
existing financial obligations or treatment models. Specifically, the act states that
funds raised from this tax be placed in the Mental Health Services Fund of the State
Treasury and that, “Nothing in the establishment of this fund, nor any provisions of
the act establishing it or the programs funded shall be construed to modify the
obligation of the health care service plans and disability insurance policies to provide
coverage for mental health services…” (Feldman, 2009 p. 809). The act also stated
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that the funding will only cover portions of costs that cannot be covered with other
existing mental health funds such as those provided by public and private insurance,
and other public state and federal funds.
The act included a very specific purpose, intent and type of treatment. Funds
would be allocated to identify serious mental illness among children, adults and
seniors as a condition that deserves priority attention. Reducing long term adverse
impacts of serious mental illnesses on individuals, families and state and local budgets
resulting from untreated mental illness was the intent of the act. Expanding the
number and types of innovative, successful programs available for children, adults and
seniors along with programs that develop cultural competency to reach underserved
populations was the intent of MHSA. To provide state and local funds to all children
and adults who qualify for services under this proposition and specifically provide
services that are not already covered by federally funded programs was another goal of
MHSA. Finally the act stated that funds would be expended in the most cost effective
manner.
An aspect of the MHSA that gives it the potential to truly impact the way
mental health services are provided to people with chronic mental illness is the
inclusion of the requirement that services provided under this funding be consistent
with the Wellness and Recovery Model. Each of the five program areas are required
to maintain the Wellness and Recovery model as the primary treatment approach.
The Wellness and Recovery Model shares some aspects with the Community
Mental Health Service Centers of the 1970’s but takes the concept one step further in
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that it denotes specific values that must be present when providing mental health
services by using the Wellness and Recovery Model. The Mental Health Services Act
states that concepts that are viewed as key to recovery for individuals living with a
mental illness are promoted in these services. These concepts are, hope, personal
empowerment, respect, social connections, self responsibility and self determination.
Other concepts that were stated in the act included promoting consumer operated
services as a way to promote recovery, to reflect cultural, racial and ethnic diversity of
mental health consumers, and to plan for each consumer’s individual needs. The
combination of promoting personal empowerment, treating consumers as individuals
and emphasizing self determination show a clear shift away from the traditional values
commonly associated with the medical model.
The California Department of Mental Health issued a vision statement to help
guide the implementation of the Mental Health Services Act in 2005. The Department
of Mental Health (2005), stated that it has dedicated resources to developing a
culturally competent system that promotes wellness and recovery for adults and older
adults with mental illness while providing resources that provide outreach for children
with emotional disturbances and their families. The vision statement also includes
making access to services a priority along with reducing out-of-home and institutional
care (California Department of Mental Health [DMH], 2005). Another stated priority
of the mission statement is reducing stigma placed on individuals with mental illness
and severe emotional disturbance (DMH, 2005).
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The Department of Mental Health’s mission statement includes making
changes in consumer and family involvement in treatment, transforming programs and
services, addressing age specific needs, developing community partnerships,
developing culturally competent programs and a commitment to assuring outcome
accountability.
Changes in family and consumer involvement include the development of
programs where an individualized treatment plan is established by the client actively
participating in developing his or her goals based on the individual’s strengths, needs,
race, culture, concerns and motivations (DMH, 2005).
Some of the changes in programs and services include developing different
types of services for children, elderly and transitional age youth along with the
development of services that integrate treatment for mental illness and substance abuse
(DMH, 2005). The development and expansion of value-driven evidenced based
services is also recommended in the mission statement.
The Department of Mental Health (2005), states that focusing on age specific
needs while developing new programs be a priority. These needs include increasing
collaboration between existing systems such as juvenile justice, child welfare, the
education system and primary health care. For transitional age youth it is suggested
that more programs be developed that help the individual move toward independence
while managing mental health symptoms and aid them in transitioning to adult
centered programs when necessary. Collaboration among local physical health
resources, housing, employment, and law enforcement, are to be achieved by
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implementing specific strategies in order to enhance the adult consumer’s ability to
achieve adequate health care, independent living and self sufficiency. The needs of
the elderly mental health consumer are addressed by implementing programs that will
increase their access to services and ultimately allow them to reside in their
community of choice.
Development of community partnerships refers to increasing the number of
agencies, schools, employers and community based organizations that participate in
creating various opportunities for individuals with mental illnesses. When the mission
statement mentions increasing cultural competency it is referring to the expansion of
service availability to diverse cultures and making sure that those services are able to
meet the specific needs of the culture they are reaching out to.
Outcome accountability is one of the most important aspects of the MHSA.
The California Department of Mental Health (2005), states in its mission statement
that they are committed to evaluating the effectiveness of programs by using standard
performance indicators, data measurement and reporting strategies. The
implementation and development of changes in all of the areas mentioned will help
transform a significant portion of the mental health services and treatment approaches
to be congruent with the Wellness and Recovery Model.
The Mental Health Services Act and the California Department of Mental
Health have done an excellent job representing the key principles of the Wellness and
Recovery model in the legislation and in the mission statement. Research has been
done in the 1990’s that suggested that an individual’s wellbeing does not necessarily
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deteriorate over time among individuals living with mental illness (Anthony, 2000).
Harding, Zubin and Strauss’s research suggested that the deterioration of the
individuals wellness might have less to do with the mental disorder and more to do
with environmental and social factors that interact with the person and the disorder (as
cited in Anthony, 2000, p. 160). This research finding and other findings contributed
to the philosophies that would drive the Wellness and Recovery model. The Wellness
and Recovery model differs significantly from medical models that are currently used
in mental health treatment.
The Wellness and Recovery model is based on several key assumptions. One
important assumption is that recovery can occur without professional intervention and
that the role of the professional is to help facilitate recovery with the consumer
(Anthony, 2000). This concept is very important aspect of recovery model as it
illustrates the consumer’s level of involvement in recovery. The consumer does not
simply do what he or she is told but works with the professional and other members in
his or her support system to work towards recovery. This Wellness and Recovery
model stresses the importance of the consumer having people who believe and support
the person in recovery (Anthony, 2000). The recovery approach is not concerned with
whether mental illness is a biologically caused, it purports that recovery can occur
even if symptoms reoccur (Anthony, 2000). In the Wellness and Recovery model the
focus is not on eliminating all symptoms but aiding the consumers in using their own
personal strengths to identify ways that will make the presence of symptoms less
debilitating and occur for briefer periods of time. Because of the individual nature of
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each person and their own personal strengths, the Wellness and Recovery model
emphasizes that there are many different paths to recovery and that the ultimate result
may be different for each person (Anthony, 2000). Consumer choice is prioritized
when utilizing the recovery model. The presence of choice helps consumers develop
and utilize self determination which is essential to the recovery process (Anthony,
2000). The recovery model also recognizes that eliminating the symptoms does not
necessarily cure a person who has been living with a severe mental illness; recovery
will also address other consequences of living with a mental illness such as poverty,
segregation and social stigma (Anthony, 2000). An agency or treatment facility that
upholds these assumptions of recovery will look very distinct to the discriminating
observer.
An agency that works within the Wellness and Recovery model will still focus
on traditional treatment goals such as alleviating symptoms, but it is how these goals
are reached that make a recovery oriented facility unique. In a recovery oriented
facility consumers will be encouraged to define what wellness means for them and
then supported in reaching those goals. A consumer who can live a fulfilling life
while experiencing a manageable amount of symptoms will be supported in his or her
efforts. The complete reduction of symptoms is not necessary as long as the consumer
is allowed to express his/her usefulness and contribution to society in a way that he or
she finds meaningful. Clients will be supported in achieving this by being referred to
services that they identify as essential, participating in developing skills that allow
them to function at the consumer’s intended level, and engaging the consumer in
25
fulfilling and satisfying activities (Anthony, 2000). It is very important that
professionals working in such a facility not only believe in the consumer’s potential
but also help foster hope and belief in the consumer’s own mind. Professionals in a
Recovery oriented facility might be required to advocate for consumer rights and
inform consumers of opportunities for them to advocate for the rights of people with
mental illness by organizing community educational events. Basic support in
acquiring food, shelter and clothing is provided for consumers in certain recovery
facilities along with the opportunity for the consumer to gain knowledge on all aspects
of a healthy lifestyle.
America has undergone many changes in the treatment of its citizens living
with mental illness. Responsibilities in providing services have shifted between local
communities, the states, and the federal government. In California, mental health
treatment for people living with a mental illness has changed from locking them up in
State hospitals to providing them with opportunities to grow and thrive in society.
The Mental Health Services Act and the development of the Wellness and Recovery
model seemingly offers hope in developing a new era for mental health treatment.
26
Chapter 3
METHODS
Introduction
This project is an exploratory descriptive case study that will utilize qualitative
data. Its purpose is two fold; 1) to examine how the Wellness and Recovery model is
being implemented by mental health providers and 2) to identify any influencing
factors or barriers to the implementation of treatment models congruent with criteria
outlined in the Mental Health Services Act (MHSA). The study will describe the
types of treatment philosophies that were utilized by the selected organizations and the
types of services that were offered to consumers prior to and after the implementation
of the MHSA. Such a description allows the researcher to better understand any
identified barriers or influencing factors involved in implementing MHSA and its
corresponding treatment approaches to persons with chronic mental illnesss.
Population and Sampling
The subjects of this research are two county and two private non-profit mental
health service providers. Each provider/subject is treated as one case. Subjects for
this study were selected using purposive sampling. The subjects had to be a mental
health service provider that participated in MHSA. The subjects were also chosen on
the basis of convenience and their willingness to be interviewed by this researcher.
Several counties declined to participate due to current economic and political
situations in which county human services found themselves.
27
Research Design
This exploratory case study incorporates standard case study methods (Baker,
1999). For this research, a case is an organization which currently provides mental
health services in whole or in part under the MHSA. The data collected is from both
secondary and primary sources.
Data Collection, Procedures & Instruments
This exploratory case study involves the use of both primary and secondary
data sources. The secondary data, planning documents, funding streams, steering
committee minutes/plans, and historical documents, are all public information. The
secondary data will provide an historical context which in turn will allow the
researcher to better understand and assess the primary data. The primary data comes
from interviews of directors/managers from each case. The interviews were directed
towards ascertaining the influencing factors and barriers involved in implementing the
services and treatment approaches designated by the MHSA. Interviews will also
provide the researcher opportunities to explore organizational service transformation
which is one of the expectations of the MHSA. Interviews were recorded with a
digital tape recorder when permission to use the device was granted by the
director/manager of the mental health program. The interviews were transcribed by
this researcher.
All of the interviews were conducted using an open ended interview guide (see
appendix A).
28
Data Analysis
The researcher transcribed data gathered during interviews and combined it
with secondary data gathered prior to completing the interview. The data were
analyzed using a standard content analysis (Baker, 1999). The researcher first
analyzed the data according to two categories. The first category is influencing factors
to transitioning to a Psychosocial Rehabilitation model. The second category is
barriers to implementing a Psychosocial Rehabilitation model. All of the transcribed
interviews were analyzed and any influencing factors that were identified were
highlighted by the researcher so that common themes could be identified. The second
category, barriers to transitioning, were highlighted in transcribed interviews by the
researcher in order to allow the researcher to identify common themes in barriers to
transitioning to the Psychosocial Rehabilitation model.
This researcher also analyzed data for themes concerning how, if any,
organizational transformation occurred and whether organizational cultural change
was a common theme among agencies that began participating in MHSA.
Protection of Human Subjects
The Protocol for the Protection of Human Subjects was submitted to the
Division of Social Work and approved as a no risk study (approval number 09-10069). Informed consent was obtained by all participants involved in this study. The
names of the cases and interviewees are not used in the research. Participants in this
study were not asked to disclose any personal information about themselves or any
information about the agency that would not otherwise be public knowledge.
29
Chapter 4
FINDINGS
Introduction
Primary and secondary data that were gathered by the researcher will be
described in this section. Secondary data will be presented for each case. These
secondary data include the demographic information for each case as well as treatment
approaches and types of services offered for adults living with chronic mental illness.
Case # 1 and 2 are the two county mental health providers that participated in this
study. Case 3 and 4 are the private non profit mental health providers that participated
in this study. It should be mentioned that cases 3 and 4 were located in the same
county. Primary data will be presented after secondary data has been discussed and
presented for each case.
Case #1
Secondary data gathered on Case #1 revealed the following information. The
county has a population of approximately 650,000 residents (California Mental Health
Directors Association [CMHDA], 2008). This county is made up of a diverse
population of individuals with approximately 41% Caucasian, 35% Hispanic or
Latino, 14% Asian American/Pacific Islander, 7% African American, 2% of the
population reporting their race as “other” and 1% reporting as Native American. It
was estimated in 2007 that 15% of the population in this county lived below the
poverty level. Approximately 5000 residents in this county were reported homeless in
2005.
30
Case #1 primarily used the Social Rehabilitation Model, beginning around
1995, before implementing MHSA treatment models. The Social Rehabilitation
model changed some of the language that was used in the mental health industry and
allowed for different opportunities to provide interventions to consumers. One
example of additional opportunities presented to service providers under the Social
Rehabilitation model was that mental health service providers could bill Medi-Cal for
interventions provided over the phone. While using the Social Rehabilitation model,
the county provided outpatient case management services, socialization opportunities,
vocational training, crisis intervention, inpatient psychiatric facility interventions,
therapy and medication support. The county’s mental health services were primarily
funded through Medi-Cal billing and Re-alignment funds prior to implementation of
MHSA.
The services provided by this case changed significantly after implementing
MHSA. While this case always strove for culturally competent services, their ability
to offer services and provide culturally based outreach services improved significantly.
Outpatient mental health services were contracted out to existing non-profit
organizations in the community which were culturally competent with their respective
populations. These organizations provided social services for the African American
population, Latino/Hispanic population, Native American population, Middle Eastern
population, Lesbian and Gay populations, and Asian populations. These existing
organizations had built a rapport with these communities but had not provided mental
health services to their respective populations. With the advent of MHSA this case
31
reached out to these organizations and trained them to deliver Wellness and Recovery
based mental health services.
This case’s crisis center went through significant changes as well, after
implementing MHSA. The crisis center provided a mental health crisis line that
people in the community could call for support. The types of calls that the psychiatric
technician or mental health specialist would receive would vary significantly. Some
calls would be concerned family members seeking advice. Others would be suicidal
individuals. The clinician responsible for answering these calls also had to keep an
eye on the inpatient unit, work with local law enforcement bringing in potential
clients, and potential consumers waiting for assessment and possible admittance to the
psychiatric hospital facility. After implementing MHSA this county was able to hire
and train 14 outreach workers. Outreach workers were self identified mental health
consumers. The outreach workers helped staff a telephone service that less intensive
calls could be forwarded to. Outreach workers could provide support and advice for
members of the community that were not feeling suicidal. This allowed the
psychiatric technician more time to work with individuals in the facility and allowed
more time to spend on calls received from suicidal individuals.
The crisis facility was also able to alter its existing triage system in a way that
made it more welcoming and supportive to mental health consumers. Prior to MHSA,
a person seeking mental health services would talk to the clerk staffing the crisis unit.
The clerk would gather various demographic information, register the person and then
refer the person to a technician for an evaluation. The new system involves a team
32
composed of a mental health clinician, a psych technician and an outreach worker who
complete the assessment and provide support. After the need of the person seeking
services has been established, they are then referred to the clerk for registration. The
new system allows for a more personable experience for the consumer seeking
support.
Vocational training for consumers has changed significantly since
implementation of MHSA. Consumers are now trained and working as recovery
coaches in the outpatient mental health programs. Prior to MHSA, consumers were
not provided the opportunity to work directly with the case management team in
providing psychosocial rehabilitation services.
Case # 2
Secondary data gathered on case #2 revealed the following information. This
case/county has an estimated population of 317,000 residents (CMHDA, 2008). It is
estimated that 6% of the population live below the poverty line in this case. Of the
317,000 residents, 82 % reported that they were Caucasian, 10% Hispanic or Latino,
4% Asian American/ Pacific Islander, 2% African American, 1% Native American
and 2% reporting their race as other.
Case # 2 reported that they were on the path to implementing recovery oriented
services for some time and have been using the Social Rehabilitation model since the
mid nineties. This case stated that consumer input was sought to help determine how
services were delivered prior to implementing MHSA. This case provided case
management services, inpatient treatment, occupational training programs, therapy,
33
medication management, as well as alcohol and drug treatment services. This case
had programs for youth and adults prior to implementing MHSA.
After receiving MHSA funds, this case began implementing various training
programs to help the staff transition to a Wellness and Recovery model. While the
case did provide services under the Rehabilitation model prior to MHSA, since MHSA
it has invested significant time in training staff members in order to increase their
ability to utilize the Wellness and Recovery model within the agency. This county has
sent many of its mental health employees to Immersion training. The training helps
explain how to implement harm reduction, motivational interviewing, strengths based
approaches and many other aspects of the Wellness and Recovery model into their
existing system of care. This county also provided training by Mark Ragins, a doctor
from the Village who has a long history of working with the Wellness and Recovery
model, for employees. This training covered similar aspects of Immersion training
that were already mentioned while also focusing on how to work with consumers and
provide consumer led services. These trainings have helped the case management
services staff transition from the medical model case management services that were
focused on medication compliance, reduction of symptoms, and case manager as
parental figure that knows what is best. Services are now oriented towards helping
consumers identify what wellness is for them and looking at increasing quality of life
for consumers instead of focusing on symptoms and medication compliance.
Training for consumers within the mental health program also changed after
implementing MHSA. Prior to MHSA consumers seeking employment with the
34
county were trained for clerical type positions or other positions that did not allow
them the opportunity to work with consumers in the capacity of a provider of services.
The county has begun implementing training for consumers who are interested in
being service providers. The training prepares them to work as mental health
professionals alongside the existing case managers and psychiatrists. Consumers are
currently working as mental health professionals within the existing case management
program.
This county was also able to open a consumer run Welcome Center that
provides free services for people in the community. The Welcome Center provides
consumer run groups, resource referrals, and various other services. This center helps
to increase the resources available for mental health consumers in the community by
providing experienced staff to provide support in a “drop in” environment.
Case 3 and Case 4
Case 3 and 4 are both private nonprofit service providers. These cases are both
providing services in the same county. The county that they are serving has
approximately 1.4 million residents. It is estimated that over 10,000 people are
homeless in this county. The population is made up of 48% Caucasian, 21%
Hispanic/Latino, 15% Asian/Pacific Islander, 11% African American, 2% Native
American with 3% reporting race as other.
Case # 3 uses multiple funding streams for their programs. These funding
streams included Housing and Urban Development (HUD) funds, Department of
35
Human Assistance (DHA), Housing Opportunities for Persons with Aids (HOPWA),
Retirement Housing Foundation (RHF) as well as Realignment funds.
Case # 3 started providing services in 1981. This agency is affiliated with the
California Association of Rehab Agencies (CASRA). The agency’s programs have
largely been driven by the needs of the populations they are serving. Initially, the
agency started by providing services for people who became homeless after
deinstitutionalization from psychiatric facilities that happened during the 1980’s. The
program evolved to provide housing opportunities for persons living with chronic
mental illness, people living with co occurring disorders (mental illness and drug or
alcohol addiction) and other underserved populations that do not necessarily have
mental health service needs. The program provided staff support 24 hours a day seven
days a week. The program also developed community living skills training programs,
independent living skills training, psychosocial educational groups, case management
services all of which were driven by the needs of the consumers they served. This is
only a brief summary of the agency and the services that they provided prior to
MHSA.
Case number three did not experience significant changes in treatment models
after receiving MHSA funds. This provider had already been “consumer driven” and
was already using various treatment approaches that were congruent with MHSA.
These treatment approaches included strengths based models, motivational
interviewing, solution focused interviewing and had placed a very high value on
collaborating with consumers in order to help them increase their quality of life.
36
This case was able to implement a Full Service Partnership program for
consumers that were already enrolled in some of their housing programs. This agency
was able to provide consumers with psychiatric services, case management services
and housing support. The additional MHSA funds facilitated increased
communication between and among the various divisions of the organization and
ultimately benefited the consumer. Prior to implementing MHSA many consumers
received psychiatric services from an outside agency.
Unfortunately this case faced some negative consequences after MHSA
funding was accepted. The consequences were explained as being influenced by a
decreased budget rather than a direct result of MHSA, but this explanation is
questionable. Because MHSA funds come through counties, the County Department
of Mental Health are able to dictate, who, how and where people are receiving
services. In this particular case, the determination of who, has primarily been based
on the use of a standardized tool to assess the service need. This assessment is used to
qualify or disqualify individuals for certain programs within this agency. As a
consequence of this county practice Case #3 has had to shift consumers from program
to program within the agency. This has negatively impacted the services that the
agency has been able to provide consumers because services have become based on an
assessment score rather than based on consumer choice and need. It appears in this
case that budget has once again driven program and services.
Case 4 also has a rich history with the county that it serves. This agency
started out as a free medical clinic in 1969. Consumer need drove the agency to begin
37
offering drug treatment and residential drug detoxification facilities. The agency
offered a medical detoxification facility for consumers that needed to be medically
monitored while going through drug or alcohol withdrawal and a residential facility
for people that did not require medical supervision while withdrawing from alcohol or
drugs. The facility offers outpatient follow up care which utilizes Motivational
Interviewing and Cognitive Behavioral Therapy interventions for individuals living
with addiction.
Over time this agency has expanded its entire array of services, including
mental health services. The expansion was a result of expanded funding opportunities
throughout the years (since 1969), client needs, and societal changes. In addition to
the original services it now provides a crisis line, suicide prevention line, Early
Prevention and Screening Diagnosis and Treament (EPSDT), and individual therapy.
These programs were adopted based on consumer and community need.
The agency eventually changed its free clinic license to a community health
center license. It qualified as a provider in a medically underserved area and they
eventually became a Federally Qualified Health Center. As a Federally Qualified
Health Center the agency can bill medi-cal and medicare at a much higher rate. The
agency reports that the federal funding streams it has obtained overtime have been a
stable source of support for the agency. The agency currently accepts MHSA funds
for its suicide prevention line and has expanded this line to include a “warm line”,
informational brochures for the community, and increase the agency’s ability to
provide linguistically appropriate services.
38
Influencing Factors of MHSA
Each of the cases that participated in this study reported that they were using
client driven and Social Rehabilitation models before MHSA funds were received.
Though these models are not specifically Wellness and Recovery they are one step
away from the MHSA required approach. All of the cases except for one of the
private non profit agencies (Case 4) implemented MHSA to help leverage some of the
losses they were receiving from diminishing realignment funds. One private non
profit organization (case 3) was told by the county Division of Mental Health that the
only way they could stay open would be to become a Full Service Partnership program
which would qualify them for MHSA funds. Case 4 stated that the MHSA funds were
offered to their suicide prevention hotline program. The funds were used to expand
the existing program.
One positive aspect of the decrease in realignment funds was that it enhanced
the need for programs to receive MHSA funds and transition to a Wellness and
Recovery treatment approach. Employees understood that they were going to have to
change some of the treatment approaches in order to meet MHSA standards because
that was the only option that would allow the program to continue. Employees
understood that MHSA money would allow them to keep operating so they were less
resistant to some of the changes that came along with receiving MHSA funds. It was
viewed as the only option to maintain services.
While this researcher expected to find various other influencing factors, it
appears that the prospect of more money for services and/or money to stay open was
39
the main influencing factor for implementing MHSA. This reality seems to
underscore the commonly held belief that economics drives programs.
Barriers to Change
Each program faced specific challenges and barriers while implementing
MHSA. Some of these barriers were congruent across agencies and some of them
were specific to certain agencies and were directly related to the decisions they made
while implementing MHSA.
Some of the challenges that county mental health programs faced while
implementing MHSA were presented when incorporating consumers onto the mental
health treatment teams as staff members. For counties that are staffed, primarily with
highly educated clinicians, incorporating consumers in a professional role was initially
challenging because boundaries had to be set up regarding the dual role they now had.
In some cases, consumers had to work alongside the psychiatrist who treated them, so
they had to be encouraged to separate their professional role from their role as a
consumer. Encouraging the new employees to only speak with psychiatrists on a
professional level rather than for personal support or treatment while at work was
something that needed to be addressed during the initial stages of implementing
MHSA.
Implementing MHSA treatment approaches was a challenge, generally, for the
county mental health providers. MHSA required the role of the case manager to shift
from the traditional expert role to one of facilitator. Wellness and Recovery treatment
models emphasized consumer autonomy and the consumers view of wellness. Some
40
employees who have been working in mental health for over 20 years did not
understand what their new role was and felt threatened by what they were asked to do.
Some employees felt that they were being told everything they had done in the past
was wrong and not helpful. The perception of Recovery and what recovery meant was
not fully understood in the initial stages of implementation. One county reported that
this was especially challenging for some of the staff members with higher levels of
education, (masters degrees and Ph.D’s). Both county cases reported that these staff
were educated to be the “experts” and applying their education in a way that was
congruent with Recovery was initially challenging.
Misperception about MHSA programs and about the Wellness and Recovery
model affected certain consumer populations as well. Implementation of MHSA
happened around the same time counties were faced with large budget cuts and some
programs were downsized or removed entirely. Because the closures and openings
happened around the same time, some consumers felt MHSA did not support crisis
units or medication programs. Many consumers interpreted the closure of old
programs and subsequent referral to a new program as being a result of MHSA’s
implementation. These consumers reported that hospitalizations and medications have
been an important part of their recovery. Some consumers have been transferred to
programs that do not initially feel “right” to them.
One of the cases faced challenges when incorporating cultural based
organizations into the mental health case management field. Many of these existing
organizations had never provided mental health services. Training the employees at
41
some of the culturally based organizations to meet Medi-Cal billing standards and the
requirements set by the Department of Mental health has been a challenging process.
The services that are provided have shifted dramatically and so has the type of work
that employees are required to do. Some of the culturally based organizations have
wanted to keep their staff and the work they do independent from county supervision,
yet contracting with the county (through MHSA) to provide mental health case
management in partnership with the county does not allow them to do that.
The private non profit service provider faced challenges specific to its
program. This case utilized multiple funding streams in order to run the various
programs that it offered. Some of the funding streams were not congruent with some
of the criteria that were presented after implementing MHSA. For example, one
program received funds from a Housing Redevelopment Agency. This required the
organization to comply with landlord tenant law. The county division of mental health
was asking this organization to base acceptance into this program on the consumer’s
assessment level rather than traditional criteria for housing. Doing this violated
landlord tenant laws. This case has been required to work with the county and explain
the influence that multiple funding streams has on their programs and their ability to
meet the division of mental health’s expectations. Incorporating MHSA funds into
this program has been a very complex process that has resulted in the organization
having to shift clients between programs, submit more paperwork to the county and
has ultimately decreased there ability to be consumer driven. The organization is
reporting that it has become increasingly difficult to refer consumers to programs that
42
they are interested in because of some of the new criteria that the consumer has to
meet to be eligible for that program (based on funding criteria).
Organizational Change
Incorporating consumers as members of the mental health treatment teams has
caused significant organizational change. As consumers are participating in team
meetings they have had the ability to bring up concerns that might have otherwise
gone unnoticed. The language within organizations has changed as well. Cases
reported that there is more awareness of what is being said and how it is being said.
This level of awareness has increased the overall level of sensitivity within the
organization. Consumers working on treatment teams have also aided in breaking
down barriers between staff and consumers. One case described the change as the “us
and them” mentality being diminished.
The general philosophy regarding the role of the case manager changed after
implementation of MHSA. While many programs were Recovery oriented it was not
necessarily a requirement that their services be Recovery focused. Treatment
approaches have changed in that the definition of wellness is now defined more by the
consumer than by the case manager or more accurately the reduction of symptoms.
All of the agencies participating in MHSA are working towards developing treatment
goals that are based on the consumers stated need. One case has even altered some of
the required paperwork to make more evident the Recovery aspect of services.
The county service providers faced challenges specific to their programs when
implementing MHSA as did the non profit service providers. Many organizational
43
changes and changes in treatment approaches posed specific challenges for the county
mental health programs. Non profit service providers faced challenges in meshing
MHSA funding with existing funding sources. The influencing factors in
implementing MHSA were similar in all agencies; MHSA funds allowed the agencies
to continue to provide services when re alignment funds began shrinking.
44
Chapter 5
CONCLUSIONS
Introduction
This case study illustrated some of the relevant aspects that are involved when
mental health service providers transition to using new treatment approaches. The
relevant aspects include the influence funding has in determining the types of
treatment approaches used by mental health service providers, changes to treatment
approaches, the Wellness and Recovery model’s impact on organizational culture, and
barriers to transitioning to a Wellness and Recovery model. After collecting and
reviewing primary data from the cases it seems that mental health service providers
faced challenges while implementing the Wellness and Recovery model as opposed to
barriers.
Funding and Services
This study appeared to illustrate that funding continues to play a significant
role in determining how services are provided and what types of treatment approaches
are used by mental health providers. The agencies that participated in this study
identified additional funding as the most significant factor in transitioning to a
Wellness and Recovery model. It is important to mention that this study took place
after/during an economic downturn which resulted in a decrease in the amount of
funds available for mental health service providers. The main influencing factor for
mental health service providers in implementing MHSA was the prospect of more
money for services and/or money to stay open. This case study illustrated that funding
45
plays a very significant role in determining which treatment approaches are used by
mental health service providers: in some cases providers were able to improve services
while others experienced a decrease in access to the range of services already in
existence.
This study helped to illustrate the general trend surrounding the influence of
legislation on how and where mental health services are provided in the United States.
The mental health services that are offered are largely influenced by the available
funding streams. Funding sources play a significant role in determining where services
are delivered and the types of treatment models that are used by mental health service
providers. Legislation and funding impact the types of treatment approaches that are
used by mental health service providers on a large scale. The Mental Health Services
Act is an example of legislation and funding that has influenced such a mass
transformation in the mental health industry. Unfortunately this study did not address
the influence that non profit service providers, and the treatment approaches they were
using, had on the creation of MHSA. Many non profit service providers were using
the Wellness and Recovery client driven approach before MHSA was passed.
Treatment Approaches and Organizational Culture
MHSA had a significant impact on treatment approaches used by county
mental health service providers. In order to participate in MHSA, organizations had to
transition to the Wellness and Recovery model. In some cases this required
organizations to alter their existing definition of wellness and provide training for staff
members so that services could be provided competently in a client driven atmosphere.
46
Mental health service providers placed a new priority on seeking out consumer input
and adjusting existing programs to better fit consumer needs after implementing
MHSA.
The cultural change that happened within county mental health service
providers was largely influenced by consumers. As consumers were trained to be
mental health service providers and brought in to work alongside existing staff
members their influence grew within the agencies. In some cases this was the first
time that consumers were actually able to sit at staff meetings in a professional role
and voice their opinions on changes that were being made within the organization.
Working alongside existing staff members helped consumers explain some of the
specific challenges and feelings about receiving mental health services that might have
otherwise gone unnoticed. The mental health service provider’s role in training
consumers and incorporating them into the professional work environment had a
significant impact on the overall changes that were made after implementing MHSA.
The non-profit organizations that participated in this study did not experience
organizational cultural change in the same way that county service providers did. One
non profit organization (Case 3) had a long history of providing services in a client
driven environment. The agency is well known for its client driven and client centered
approaches. The organizations history of being client driven led the county division of
mental health to encourage this agency to participate in MHSA in order to leverage
losses from other funding sources; to the county it seemed like it would be a good fit.
Unfortunately the implementation of MHSA had a negative impact on the
47
organization’s ability to meet the needs of their consumers. This organization
transitioned its services to become a full service provider. Some of the regulations
that went along with being a full service provider inhibited their ability to provide
consumers with the services that they requested. Prior to receiving MHSA funds the
organization was free to refer consumers to programs that the consumer felt would
best meet their needs. After implementing MHSA, the organization was forced to
base referrals on the consumer’s need assessment score. The organization did not
directly fault MHSA for this unfortunate shift and eluded to the idea that shortages in
funding result in increased outside influence over how the organization provides
services.
Challenges to Transitioning
Specific challenges were faced by mental health service providers while
incorporating consumers onto treatment teams. These challenges were focused around
finding the strengths of individual consumers and using those strengths in a way that
enhanced services. These challenges would be expected when training any population
of individuals but MHSA did not necessarily prepare service providers to face these
challenges beyond providing funding for training. Other challenges faced were
specific to existing staff and their acceptance of the Wellness and Recovery model.
It seemed that mental health service providers reported significant challenges
in getting some of the seasoned staff members to embrace the Wellness and Recovery
model. Many of these staff members were trained and had been utilizing a treatment
approach that was more congruent with the medical model. These staff members did
48
not fully understand or accept the new role they were expected to play while providing
services under the Wellness and Recovery model. It seemed that education level
played a significant role in acceptance of the Wellness and Recovery philosophy.
Some directors reported that staff members with masters degrees and Ph.D’s were
more likely to challenge the Wellness and Recovery model because it was not
congruent with their education and it challenged their educational achievements. One
participant suggested that a full transition would to the Wellness and Recovery model
would not be made until a significant number of existing staff members retired.
These findings illustrate the impact that cultural beliefs, whether developed in
an educational environment or work environment, have on treatment approaches.
People who have been exposed to certain belief systems for a significant time period
have an investment in keeping treatment approaches the same and appear to be less
willing to transition to a significantly different philosophy. If MHSA becomes widely
implemented it could end up influencing educational institutions to incorporate some
of the ideals and treatment approaches into existing educational programs.
Practical Implications
These cases illustrate some of the challenges to altering existing treatment
models and how these challenges were addressed. The cases presented in this study
have illustrated the types of challenges that service providers are likely to face while
transitioning to MHSA and how these challenges were met. Mental health service
providers that are considering transitioning to MHSA could use the examples
presented in this study as a general guide to help smooth the transition process.
49
Implications for the Profession
Providing services that enable mental health professionals to individualize
services while providing the consumer the opportunity to lead treatment, is an
important aspect of recovery. The findings in this study illustrate that funding
significantly impacts the mental health provider’s ability to provide services in this
way. Consequently, mental health service providers need to anticipate how different
funding streams will impact services offered to consumers and they will need to
become innovative and think outside the box in order to utilize a recovery approach
when working with those with severe and persistent mental illness.
Recommendations
Some of the results of this research were largely influenced by extraneous
variables. The extraneous variable that most impacted this research is the economic
environment in which this research took place. As mentioned, many mental health
service providers were faced with significant budget cuts when this research was
conducted. These budget cuts had a significant impact on why mental health service
providers implemented MHSA. While many of the treatment approaches defined in
MHSA are evidenced based, it would be interesting to gather data on why agencies
would choose to implement this model during times when they were not required to do
so in order to leverage losses from other funding streams. This researcher would
expect to see very different factors influencing the transition to MHSA under different
circumstances economic conditions.
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APPENDICES
51
APPENDIX A
Interview Guide
It appears, from reviewing the historical documents, that your organization has
changed some or all of its services and treatment approaches since the enactment of
the MHSA. Would you mind elaborating on these changes?
Why did the organization move to a Wellness and Recovery model or a combination
of a Wellness and Recovery with other treatment models?
If different treatment approaches are being used after the passing of MHSA, please
talk about the factors involved in transitioning to a Wellness and Recovery model.
Can you describe how the transition occurred (or is occurring) and what were or are
some of the barriers and stimuli?
Has the organizational culture changed? If so, in what ways?
How was the transition made from the old treatment approaches to new treatment
approaches? What were some of the barriers to this transition?
52
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