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The Failed Mental Health Services Act (MHSA) Stakeholder Process led to a feeding frenzy whereby worthy and unworthy social services programs were liberally funded, while programs that help people with serious mental illness were denied funding.

 
Introduction
The following is an excerpt on the Failed Stakeholder Process from Mental Illness Policy Org report: “MHSA: A 10-Year, $10 Billion Bait and Switch” that documented numerous problems with the Mental Health Services Act that prevent funds from reaching the most seriously ill. The excerpt includes an overview, examples from Sacramento, Fresno and Butte Counties; and a detailed analysis of Los Angeles County, Also read how the failed process played out inSan Diego (which is the same everywhere)

Background
MHSA legislation codifies a stakeholder process to provide input to county Mental Health Services Act (MHSA) plans

Problems: In every county we looked into, we found the stakeholder process was fatally flawed and in most counties the process led by the county behavioral health director. The stakeholder groups were primarily composed of representatives and clients of social service and mental ‘health’ programs that do not serve people with serious mental illness and wanted funding for their own favored programs. Stakeholder input was allowed to trump the legislative language and voter intent to spend the funds on those with serious mental illness.

  1. Professionals with experience treating and caring for the most seriously mentally ill were not part of the stakeholder process. i.e, police, sheriffs, corrections, district attorneys, inpatient doctors, inpatient nurses, doctors at homeless shelters, and others who treat the seriously ill individuals who are shunned by mental ‘health’ providers.
  2. Stakeholders were allowed to prioritize programs that lacked evidence of efficacy or were known to be ineffective.
  3. A billion dollar feeding frenzy erupted as programs tried to get MHSA funds for their own programs.
  4. County behavioral health directors blindly accepted stakeholder input, even when inconsistent with the legislation.

Results:

  1. Social Service programs that don’t serve seriously mentally ill were prioritized for funding.
  2. Programs received funding in spite of lack of evidence they work or known evidence they don’t.

Case Study: Sacramento County

Sacramento County allowed stakeholder input to trump helping people with serious mental illness. At a Sacramento County Mental Health Board Meeting in May 2013 attendants were told about PEI 'Strengthening Families Project'. Within this program are Quality Child Care Collaborative, HEARTS for Kids, Bullying Prevention Education and Training, Early Violence Intervention Begins With Education and Independent Living Program 2.0. Someone noted these were social services programs and ineligible for MHSA funding. They were told, “when the public hearing were held on these programs, the community wanted them”

Case Study: Fresno County

Fresno County allowed stakeholder input to trump helping people with serious mental illness: The director of behavioral health services in Fresno County said “(H)e would like more of the Mental Health Services Act money to treat people with severe mental illness. With county budgets tight, he said, the priorities should be 'crisis first, treatment and then early intervention, prevention. Evans said the county plan isn't perfect, but it is a compromise between what the community wants and what the staff sees as gaps in the system 'It's all a compromise,' she said. (Fresno Bee, January 6, 2013) " />Programs that serve people with serious mental illness went unfunded.

Case Study: Butte County

Butte County allowed stakeholder input to trump helping people with serious mental illness. Butte County’s failed stakeholder process led to the funding Hmong Gardens. Butte did a study of the need for housing for people of Hmong ancestry. Eight people participated. We do not know if any had serious mental illness or if any housing was ever built. But this ‘study’ found that two important services for this housing that is not limited to people with mental illness are “gardens” and a “community room”. The researchers aggregated the two to conclude that if they built housing, 58% wanted “community room and garden” and therefore a garden was a service that prevents mental illness from becoming severe and disabling and was included in the PEI Plan (See discussion of Butte under county misspending chapter).

Detailed Case Study: Los Angeles County

Los Angeles County Used a Failed Stakeholder Process to Distribute MHSA Funds that Left Programs for Seriously Mentally Ill Seriously Underfunded While Programs that Did Not Serve Mentally Ill were Liberally Funded

LA County stakeholders were primarily those who provide social services to people without serious mental illness  LA conducted an extensive, expensive stakeholder input process that included social service and ‘mental health’ groups who were vying for MHSA funding for their social service programs.  The stakeholder process included a

  • A 100 member “Stakeholder Delegate Group”  representing various special interests seeking funding.

  • A 29 member Ad hoc “Plan to Plan Advisory Group” that included representatives of those seeking funding;

  • A 28 member Ad hoc “Guidelines Advisory Group” largely comprised of those seeking funding;

  • A 25 member ad hoc “PEI Plan Development Advisory Group”, largely comprised of those seeking funding; and

  • A 150 member  Service Area PEI Ad Hoc Steering Committee many representing programs seeking funding.

LA County excluded stakeholders with the most expertise in serious mental illness.

  • There was no input from persons with mental illness who are in inpatient units

  • There was no input from mentally ill patients who live in jails or prisons. About 30% of LA County prisoners have serious mental illness. LA County Jail is the largest psychiatric facility in the state. There are 3 times as many Californians with mental illness in jails than hospitals.

  • We are unaware of any attempts to seek input persons with mental illness who live in shelters or are homeless.

We believe the failure to solicit and prioritize input from the most seriously ill and those who know most about the population the legislation states “deserve priority attention” led to a plan that made eligible individuals ineligible and diverted the funds to other.
 
LA County Behavioral Health Department misinterpreted the legislation and failed to reject stakeholder recommendations that were outside the law.

The Home Page for the Los Angeles County Prevention and Early Intervention (PEI) Plan states

The Los Angeles County Prevention and Early Intervention (PEI) Plan focuses on prevention and early intervention services, education, support, and outreach to help inform and identify individuals and their families who may be affected by some level of mental health issue” (emphasis added).

That is incorrect. PEI funding is limited to those with mental “illness” or “serious mental illness” not “some level of mental health issue. This misinformation is repeated in the 2009-2010 Plan. This is not just nomenclature; there is a significant difference between those “who may be affected by some level of mental health issue” (i.e., can be made happier), and those who have serious mental illnesses like schizophrenia and treatment resistant bipolar disorder. The funds are legislatively required to help the later, not the former.
 
LA County Mental Health Department Plan relied on guidance from the California Department of Mental Health and MHSOAC that was contrary to statute, rather than relying on the statute itself

LA County justifies the part of their plan that uses funds to ‘encourage a state of well being’ and target a population group ‘not identified on the basis of risk’, by quoting direction from the Oversight Commission:

Prevention in mental health involves reducing risk factors or stressors, building protective factors and skills, and increasing support. Prevention promotes positive cognitive, social and emotional development and encourages a state of well-being that allows the individual to function well in the face of changing and sometimes challenging circumstances. Universal Prevention targets the general public or a whole population group that has not been identified on the basis of individual risks.  

MHSA is to help people with serious mental illness, not improve ‘well being’ or ‘target the general population’.

The LA County Plan justifies withdrawing services from people with serious mental illness by quoting direction from the Oversight Commission stating:

Early Intervention is directed toward individuals and families for whom a short duration (usually less than one year), relatively low-intensity intervention is appropriate to measurably improve a mental health problem or concern very early in its manifestation, thereby avoiding the need for more extensive mental health treatment or services, or to prevent a mental health problem from getting worse.

The LA plan, seems to suggest that PEI funds must be withdrawn once a person is identified. This direction from the former California Dept. of Mental Health and Oversight Commission is not true. To prevent “mental illness from becoming severe and disabling” often requires on-going treatment. By limiting PEI funding to short term, low intensity programs, they have essentially excluded those who face lifelong disability.

LA County Behavioral Health Department fails to report data by diagnosis or require a diagnosis so it can not know if it’s programs are serving people “with mental illness” or “serious mental illness” as required by law.
 
In order to know if a program is targeting those with mental illness or preventing mental illness from becoming severe and disabling, officials would have to collect data on the
1 diagnosis of people being served,
2. diagnosis of the mental illness the program is ‘preventing’
3. Diagnosis of the mental illness that they reduced duration of

This information is not collected or provided by the county.

Los Angeles’ failed stakeholder process led to a failed spending plan.

The failed stakeholder process led to failed spending. For example, while serious mental illnesses are most likely to strike in late teens early twenties, LA allocated 60% of funds to Transition Age Youth. Less than 3% of individuals in LA County PEI were the most seriously ill individuals with psychotic disorders. Rather than focusing on the most seriously ill, LA focus is “clients at higher levels of recovery.” We could not find a single program that was designed specifically to help people with psychotic disorders or help the homeless who are at risk of becoming psychotic because they can’t get medicine.

Incarceration of children went up. This is surprising because one of the programs, “Incredible Youth” ($200K) is supposed to decrease incarceration.  On page 80, authorities blamed a “coding error”.

$2,393,926 of funding for “at risk” families is likely wasted. (Page 120 column six of LA County PEI Plan) They are social service programs that purport to help people ‘at risk’ of mental illness. There are no known factors that put people at risk of “serious” mental illness (other than having a parent with it, which is a genetic issue). There are issues, like losing a family member or job that do put people at risk of being sad, being depressed, but not of the most serious mental illnesses like schizophrenia and bipolar disorder that MHSA was intended to prioritize. (Page 30. Also see page 88 for stats on how well this group “who are at higher levels of recovery” are doing.)

$2,899,231 of Trauma Recovery spending are likely wasted (Page 120 column 7 of LA County Plan)

. Trauma is not a mental illness. Almost everyone experiences trauma of some degree of severity (losing a loved one, having an accident, witnessing something horrible). PTSD is a mental illness. Severe traumatic events (being held prisoner, war, etc.) might cause trauma disorder. But these services are likely going to people who experienced the rights of passage we all experience: knowing someone who died, failing a grade in school, breaking up with a boy/girlfriend, not paying rent, etc. For example, “Incredible Years” is a crime prevention initiative aimed at aggressive youth.

Many of the other programs Los Angeles is spending on are social service programs masquerading as mental illness programs: Reflective Parenting, Strengthening Families, Positive Parenting, Brief Strategic Family Therapy, Loving Intervention for Family Enrichment Program, Multidimensional Family Therapy Program and Promoting Alternative Thinking Strategies.
 
CONCLUSION
Flawed process led to massive mission creep. A stakeholder driven “gold rush” that excluded experts who work with the seriously mentally ill resulted in funding programs not directly related to the purpose of PEI or MHSA.

See full “Bait and Switch Report” at http://mentalillnesspolicy.org/states/california/mhsa/mhsa_prop63_bait&switchsummary.html for more information

            


The information on Mental Illness Policy Org. is not legal advice or medical advice. Do not rely on it. Discuss with your lawyer or medical doctor. Mental Illness Policy Org was founded in February 2011 and recently received 501(c)(3) status. In order to maintain independence MIPO does not accept any donations from companies in the health care industry or government. That makes us dependent on the generosity of people who care about these issues. If you can support our work, please send a donation to Mental Illness Policy Org., 50 East 129 St., Suite PH7, New York, NY 10035. Thank you. For more information, http://mentalillnesspolicy.org.