Problems with MHSA Expenditures in Orange County

This contains an article from Orange County Register exposing waste in Orange County MHSA spending and our raw notes on misspending within the current 2013 Orange County MHSA Plan .It is clear that if OC wanted to implement Laura’s Law, it could easily be funded by eliminating waste and using existing MHSA funds as is done in Nevada County.

Did Feeding Frenzy Divert Orange County Mental Health Funds

by Teri Sforza

Orange County Register 8/26/13

When California voters agreed to tax the rich to fund programs for people with serious mental health issues, the selling point was that the money would be focused like a laser on the most tragic and intractable cases. Nearly a decade – and $10 billion – later, critics say that’s not quite the way it has happened. One recent study of the billions flowing into Proposition 63 says it spurred a “feeding frenzy” among social service providers whose programs are only peripherally related to mental health. Among those programs: Yoga, horseback riding, wilderness hikes and, from right here in Orange County, an amusement park-like gondola ride through the brain.
“There is a substantial need to educate the general population about mental illness and its relationship to the brain,” says the County of Orange’s plan to spend $2.2 million on an interactive exhibit that might be at home at a kids’ museum or county fair. “Preliminary research shows that there are no permanent hands-on exhibitions about the brain and mental illness existing to the scale and scope being proposed for this project.”
Visitors will board gondolas “for an exciting immersive journey through the brain,” O.C.’s plan boasts. “Using an onboard computer, the visitor will select an illness which they want to learn more about. Then, they will fly through a large scale model of the brain while the on board computer integrated with the model of the brain educates guests about the illness they selected. Along the journey guests will learn that mental illness is treatable.”
Nicole Stanfield, a county spokeswoman, said the gondola ride project still needs approval and will increase the community’s understanding about mental illness and mental health. “The accompanying resource center will expose visitors to services that they may not have been aware of. This increase in awareness and understanding will lead to increased linkage and access of consumers and family members to the mental health services they may need or seek,” she said in a written statement.
Orange County has received about $700 million in Prop. 63 money since the initiative was passed in 2004, including $104 million this year. Many millions will go to programs that have little to do with helping those diagnosed with severe mental illness. Consider

  • $1.7 million is slated for a “Positive Behavioral Intervention Supports” program, which “offers a school-wide systems approach for preventing problem behaviors including, but not limited to, truancy, pervasive violence, acting out in class, negative behaviors due to limited cognitive development, and emotional stress … for children K – 12th grade.”
  • $1.3 million will go to the “Violence Prevention Education” program, which targets gang prevention, bullying, conflict resolution, hate crimes and teen dating violence “to reduce violence and its impact in the schools, local neighborhoods and families.”
  • $1 million will pay for the “Connect the Tots/School Readiness Expansion Program,” which helps “underserved families” with young children “who are exhibiting behavioral problems, putting them at increased risk of developing mental illness and experiencing school failure.”
  • Millions more will be spent in Orange County to help kids in the juvenile justice system or recently out of it, to provide job assistance and other help to the parents of emotionally disturbed children, to engage the homeless and those at risk of homelessness.

All may well be virtuous social service programs. But how much actually impacts people with a bona fide mental health diagnosis? No one knows. Despite collecting detailed data about the age, language and ethnicity of clients, the state does not compile details about diagnosis.
Proponents of Prop. 63 say that the programs critics poke fun at are in the tiny minority – from the 5 percent of funding set aside for innovation. And while it’s true that Prop. 63 funds were originally meant to be icing on the state’s mental health cake, if you will, cuts in funding over the years have meant they wind up in the batter itself. The majority of Prop. 63 money – 75 percent – still targets those with the most severe problems, proponents say.


Two reports critical of Prop. 63 have been pumped out over the last week – one by an activist group on mental health issues based in New York, and one by the California state auditor. The first called the entire exercise a $10-billion bait-and-switch. The second said there was no assurance that California’s billions have been spent as voters intended. “The enactment of Proposition 63 set off a new California Gold Rush,” said Mental Illness Policy Org’s scathing review. “Social service programs that worked to help students get better grades, adults find better jobs, women avoid prostitution, teens avoid crime, gays gain comfort with their sexual orientation and parents be better parents masqueraded as mental illness programs to make themselves eligible for funding. In spite of there being no known way to prevent serious mental illnesses like schizophrenia and bipolar disorder, yoga, horseback riding, wilderness adventure tours, gardens, native and African American cultural centers, line-dancing, drumming and art shows were declared evidenced-based prevention activities and showered with money.”
The group, based in New York, is a big proponent of Laura’s Law, which would allow courts to order severely mentally ill people into treatment, even against their will. Virtually none of the billions raised by Prop. 63 has been spent on efforts like that for the most severely ill – the kind who rant on street corners about being the Messiah, and who do not know they are ill, said D.J. Jaffe, the organization’s executive director. “Of the $10 billion raised since 2004, $2 billion was diverted to social service programs that do not serve people with mental illness; $2.5 billion was spent without any oversight; $23 million went to organizations associated with oversight commissioners; regulators prevented funds from helping the mentally ill; politicians enacted ‘clarifying’ amendments that diverted funds elsewhere; and the most seriously mentally ill continue to be offloaded to jails, shelters, prisons and morgues,” said a summary by Jaffe. It is undeniable that some people with serious mental illness are being helped, but “unmitigated mission creep has left many of the most seriously mentally ill seriously underserved,” his report said. “There is an unregulated feeding frenzy going on.”
California State Auditor Elaine Howle did not go so far as to say money was misspent. But she couldn’t say that it wasn’t misspent. “Because of the minimal oversight Mental Health and the Accountability Commission provided in the past, the State has little current assurance that the funds directed to counties—almost $7.4 billion from fiscal years 2006–07 through 2011–12—have been used effectively and appropriately,” the auditor’s report said. “(W)e also expected that Mental Health would have taken steps to ensure counties received the guidance necessary to effectively evaluate and report on the performance of their MHSA programs, particularly given the MHSA’s focus on accountability. However, Mental Health did not provide explicit direction to the counties on how to evaluate their programs effectively, including directions for setting reasonable goals, establishing specific objectives, and gathering the data necessary to meaningfully measure program performance,” the auditor said. None of the three entities charged with evaluating program effectiveness had undertaken serious efforts to do so — and it took more than eight years after Prop. 63 passed for the Accountability Commission to adopt a framework for evaluation.
The auditor drilled down on this so-called Accountabilty Commission, saying its approach to funding its evaluation efforts “also appears skewed.” Its expenditures have grown significantly, to nearly $7 million last year – yet are disproportionate to the amount spent on evaluation, which was only about $1.3 million, the auditor said. “We are even more concerned that in its implementation plan for fiscal year 2012–13, the Accountability Commission states that without an augmentation to its funding and staffing, it will only be able to complete roughly half of the evaluation activities called for in the plan,” the auditor wrote. “(E)valuation of MHSA programs is a primary purpose of the Accountability Commission, and its belief that it needs additional specific funds to support its evaluation efforts causes us to question whether the commission is properly prioritizing its resources.”


One of Prop. 63’s main champions has been Sen. Darrell Steinberg, D-Sacramento, who said he has seen it do life-changing work.
But he knows it’s not perfect. Steinberg asked for this audit last year, and agrees that the state must run a tighter ship. “In recent years I have pushed legislation to improve oversight of the life-changing programs delivered by Proposition 63,” Steinberg said in a prepared statement. “The State Auditor’s fair and welcome review echoes the concerns that I have expressed about historic gaps in oversight….We know these programs work and the State Auditor found no evidence that Proposition 63 funds are being misused, or that prevention and early intervention programs are ineffective. We also know Proposition 63 has delivered treatment that has reduced hospitalizations, incarcerations, and has put Californians on the road to mental wellness. “But if we are to build consensus for mental healthcare funding, the state must demonstrate the effectiveness of existing programs in an objective and consistent way. It’s not good enough just to do the work. We must tell the story to help break the stigma surrounding mental illness and encourage those suffering in silence to seek help.”
Steinberg spokesman Rhys Williams is less sympathetic to the points raised by Jaffe and the Mental Illness Policy Org’s report.
Three-quarters of Prop. 63 spending is on the type of hard-core, whatever-it-takes interventions for severely ill people that critics like Jaffe want, Williams said. Complaints grow out of the other 25 percent, which seeks to keep things from getting so severe in the first place. “Prop. 63 was taken to the electorate as a watershed moment in mental healthcare where, yes, three-quarters of funding would be dedicated to the severely mentally ill, but the old ‘crisis first’ model was both very costly and the least effective treatment,” said Williams in an email. “Mental illness, like physical ailments (e.g. cancer), is more effectively treated at early stages or better yet, promoting mental wellness to prevent from mental illness from developing at all. Hence the one-fifth focus on prevention/early intervention and five percent on ‘culturally competent’ and innovative services to increase access to care among minority communities where mental health carries severe stigma.”
About 84 percent of people who receive appropriate, timely treatment during their first bout of psychosis go on to make a full recovery, he said.
Most of the criticism centers on the 5 percent set aside for innovation programs, Williams said. Orange County has its gondola; San Francisco had classes in yoga, line dancing, drumming and Soul Chi, (soulful movement), as well as massage therapy, meditation and acupuncture; Butte County had “therapeutic wilderness experience interventions” for teenagers; Fresno had community gardens for Hmong refugees. “On paper, gardening wouldn’t seem to be a very good way of treating mental health, until you dig behind the scenes,” Williams said. “Practitioners in mental health will tell you it’s very hard to access California’s minority communities, some of which don’t even have a word for mental health. They don’t walk into mental health clinics on the street. And often immigrants are coming from places where life wasn’t very good — the Hmong, from a nation savaged by war, which we know can raise mental health issues.”
Meanwhile, changes are being made in how Prop. 63 money is overseen and how progress is measured. Steinberg has also introduced a bill that would explicitly allow money to be used to implement the controversial Laura’s Law – ordering patients into treatment even against their will — that Jaffe’s group is seeking.
The issue has been a big one in Orange County, in the wake of the death of schizophrenic Kelly Thomas at the hands of Fullerton police. More on that soon.

Waste plagues Orange County Mental Health Services Act Plan

Funds would be better spent to help people with mental illness by implementing Laura’s Law

Mental Illness Policy Org was asked to take a quick look at the 2013-14 Orange County Mental Health Services Act (MHSA) plan and provide comments. The Orange County Register (8/13) found Orange County plans to spend $2.2 million in Mental Health Services Act funds on “an amusement park-like gondola ride through the brain” (above) Our own report on the Mental Health Services Act (California’s 10 year, $10 billion bait and switch) previously noted Orange County spent MHSA Funds for

    • Wellness Centers specifically for those “who have achieved a high level of recovery,” Groups to improve “personalized socialization,” relationship building, and exploring educational opportunities.
    • Teen Screen, an ineffective teen suicide program.  See Marin County for a discussion of Teen Screen.
    • High end annual report with no data on where the money went.  This is interesting because the link you sent me to their 2013 data, does a good job at providing data on how many were served and costs. I was glad to see it.

Below are our raw notes on the examination of the 2013 Orange County Mental Health Services Act (MHSA) plan. These are raw notes, so please use carefully and double check. We crredit OC for more fully disclosing how many dollars are going where and how many are being served. However, OC does not reveal which non-profits get the grants so it is difficult to do a deeper dive on what the programs funded really do. Like with the rest of the state, it is easy to find massive misspending within the Prevention and Early Intervention Component (starting on page 84 of the plan) where all the social service programs that are masquerading as mental health programs to get MHSA funding are hiding.

Our main concern with the Orange County MHSA Plan is

  • Are MHSA funds targeting people with serious mental illness as required by the law.
  • Are the important outcomes (reduced homelessness, incarceration, hospitalization, suicide) being measured in the target population.

It is not enough for a program to be ‘evidence based”, it has to be used on the right people and be evidence based to reduce a meaningful (ex. Incarceration) vs. meaningless (ex. satisfaction) outcome.

Page 93 (and 98)
It looks like $899K was spent on ‘wellness’ for 34 people ($26K each!). That money could have provided services to 40 or more people in Laura’s Law.  It also looks like $1.3 million was spent on ‘socialization’ for 425 seniors ($3K each). Again, socialization for the elderly may be a worthy social service program, but it is not a mental illness program. MHSA has a clause preventing MHSA funds from being used to ‘supplant’ other funds. In other words, MHSA funds were designed to create incremental services, not merely relieve budget deficits. Our guess (only that) is that this program was previously funded with non-MHSA funds and all they did was switch it to the MHSA line.
They also identify post-partum wellness. We don’t know if this is a program to address moms with post partum depression, or merely a generic postpartum program masquerading as a mental health program to make it eligible for MHSA funds.

Page 100 (continued on 107)
$1,103,172 was spent on violence prevention. Violence is not a mental illness. This represents diverting MHSA funds intended to help people with mental illness to other social service programs the taxpayers did not vote to fund.

Page 116
Stop the Cycle is a crime reduction program, not a mental illness program and therefore ineligible for funding. It is $525K that is more appropriately spent on Laura’s Law. Laura’s Law is proven to reduce violence and incarceration among people with serious mental illness. This program is not.

Page 117
This is a $546,213 program to help teens cope with being teens and does not have a nexus to serious mental illness. It is designed to help reduce bullying, get better grades, avoid drugs and other issues that are not at their core mental illness issues. No outcome indictors show it is helping reduce the duration of untreated serious mental illness or prevent mental illness from becoming severe and disabling as required by the PEI component of legislation

Page 120
This suicide reduction program apparently does not work. According to the Orange County Register:  According to a reporter at the Orange County Register reported suicide in California is up and the MHSA suicide prevention program is not working:

“Jenny Qian, a manager in county behavioral services, says thanks to an injection of money from Proposition 63, Orange County has beefed up its suicide programs in the past two years and continues to roll out more programs. Qian tells me by calling what she describes as a local hotline number, 1-877-727-4747, people will find all the local help they need.” “I called that number and asked for help for someone needing a counselor in the Mission Viejo area. I was informed the person who needs help should call. I pressed and was told they can’t help with local counselors because the service is nationwide.”

Page 15
Orange County extensively funds ‘peer support’. It says “ The original Innovations Plan contained 10 projects centered on a common theme of using peers to provide services. “ And in fact, peer support is at the core of many of the initiatives throughout the plan. But there is no research that says peer support is better than professional support or parent support, at reducing meaningful outcomes like reducing incarceration, hospitalization, suicide etc. Yet massive funding is going to this. Perhaps the best study on this is the recently released, highly respected Cochrane Report. Authors’ conclusions:

Involving consumer-providers in mental health teams results in psychosocial, mental health symptom and service use outcomes for clients that were no better or worse than those achieved by professionals employed in similar roles, particularly for case management services.

This is consistent with the study in December 2012 Psychiatric Services

Conclusions: This study adds to the evidence suggesting no short-term incremental benefit (or harm) from peer services beyond usual care. (Psychiatric Services 63:1243–1246, 2012; doi: 10.1176/

Page 19-20
Charts define CSS clients by age, language, and ethnicity but there is no info including on the diagnoses of those being served. That is a fatal flaw. MHSA was legislatively created by voters to “define serious mental illness as a condition deserving priority attention”. The legislation separates all mental illness (20% of pop) from serious mental illness (about 8-9%) and says the funds are for the later (mainly schizophrenia and bipolar disorder) not the former. There is no data that shows Orange County funds are reaching people with serious mental illness.  We know FSPs, PACT, etc. exclude those so sick they don’t know they are sick (i.e. they only serve voluntary patients).

Page 21-22
Page 21 shows Orange County served 475 children. But page 22 seems to only show 31 or 32 (less than 10%) were hospitalized in the year prior to enrollment in FSPs. That suggests to us that most of the children being served are not the most seriously ill. In fact, the chart on page 22 seems to suggest that the funds are being used to improve grades, rather than treat serious mental illness.

Page 37
The success story featured does not seem to have relationship to mental illness. MHSA is for people with serious mental illness. There are many other important social services that need funding, but MHSA funds are only available for mental illness.

Chart on page 39
It shows 10% were rehospitalized, but does not compare it to how people without the service did or how these specific patients did in the year prior. So we have no way of knowing if anything was successful. It’s a measurement, but not a useful one.

Page 31, 38, 41, 56 (and elsewhere)
“Linkage” measures and “resilience’ measures are good, but if the people ended up homeless, psychotic, hospitalized, incarcerated or killed themselves, then “number of linkages’ or ‘resilience’ measure is a meaningless number.

Page 44
Great. They are targeting PACT at “individuals have to have been psychiatrically hospitalized multiple times in the last year for being considered dangerous to people in the community and/or themselves, or because they were unable to avail themselves of basic food, clothing or shelter due to their mental illness. In addition, treatment at a lower level of care must have failed to keep the person stable. “ But only 147 were served. This is the group FSPs and the bulk of MHSA services should be focused on: The most seriously ill. And the cost is about $6,000 per patients. Our concern with both PACT and FSPs is that there is no data on the diagnoses of those being served. It’s a great program IF it is serving SMI

Page 46
These are the FSPs. It is unknown if the patients in  FSPs have serious mental illness because there is no data on the diagnoses of those being served.  They cost twice as much as PACT $14,176 per patient. Neither FSPs nor PACT serve individuals who are too sick to recognize they are ill. This is called anosognosia and affects a large percentage of those with schizophrenia and bipolar. Ex. John Hinckley (schizophrenia) who figured out best way to get a date with Jodi Foster was to shoot Reagan and Martin Sheen (winning!- nope: bipolar). The definition of who they are serving in the brochure is very good, but we wonder if it is true. FSPs are supposed to do “whatever it takes”. But the one thing they won’t do is help those who are so ill they can’t volunteer.

Page 50
Seems like a great program. We would LOVE to know if there was follow up on those they decided didn’t need hospitalization. Did they become homeless, commit suicide, end up incarcerated? What happened to them. In fact, what happened to those 5150d after their observation period was over? Did they get supports?

Page 51
Again, it seems like a great program, but what happened to those discharged? On page 52 bottom, it says 94% went to lower level of care. And then what? Did they wind up in jail, suicide, homeless? Without tracking what happened to people being served in all the Orange County programs, it is not useful to know that X were served at $y cost. We want to know what happened to the patients. I see that part of this program is to create a Wellness Recovery Action Plan (WRAP) We have extensive info on that not being evidenced based program.

Page 55
It claims “The Supported Employment Program served 353 program participants, which included 266 new enrollments. During FY 11/12, the program placed 107 program participants in competitive employment jobs and 6 participants in a paid traineeship.” That is an incredibly high number if they are saying those were non-subsidized jobs. We are always wary of employment programs.  Why? They tend to focus on the higher functioning, not the most seriously ill. As much as we wish it wasn’t true, after 30 years of advocacy, we know fewer than 10 people with schizophrenia in non subsidized employment outside mental health and arts fields. This program claims 107 of 353. I find it hard to believe they are serving the seriously ill. I think the jobs are government jobs or ‘peer support’.

Page 58
We are supportive of drop in centers, but suspicious of ‘wellness centers’. They use a peer-to-peer model for which there is no research showing it works better at reducing incarceration, homelessness, violence, etc. than other support. The Cochrane report recently confirmed this. They measure outcomes as being more people attend. I am not sure that indicates anything.

Page 62.
This is expensive program ($3,000 per client) and we really don’t know what it is or isn’t doing. And the outcomes are the real outcomes for most peer programs. I.e. they are not showing any decreases in meaningful measures like hospitalization or incarceration, just “consumer and staff satisfaction scores. “ My guess is that is true for all the other programs.

Page 63
Peer mentoring is not evidence based to help people with serious mental illness. I can send you data if you want.

Page 71
Outrageously expensive (more than $10K per client) and all they get is mentoring. For this amount of money, OC could put 40 people in Laura’s Law.

Page 84
Also note that OC fills it’s Prevention obligation by kicking in MHSA funds to CalMHSA, a JPA that pools county funds. Page 10 of our MHSA “Bait and Switch” report details how those funds are misspent (especially on suicide and PR campaigns.)

Page 86
Orange County misunderstands PEI programs. OC defines PEI as

“ 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.”

That is wrong. PEI is to “reduce the duration of untreated mental illness” or “prevent mental illness from becoming severe and disabling”. That may mean ongoing high intensity services, not short term low intensity ones. Further, MHSA funds are not to “improve a mental health problem” (Like feeling sad ‘cuz mom died). They are for serious mental illness. Because Orange County misunderstands  the use of the funds, they spend them inappropriately. On the same page they indicate they are focusing on school based services. But while many mental health issues occur in school age, ‘serious mental illness’ does not usually manifest itself until teens or twenties.

Page 87
Outreach and engagement. The most likely people to develop serious mental illness are those with parents or other first degree relatives who have serious mental illness. This was highlighted this month in a new meta study this month that found children of those with serious mental illness have a 1/3 chance of being seriously mentally ill. But none of the Orange County outreach efforts are focused on the high risk population. They are focused on all other. We know serious mental illness manifests itself in teens and twenties, but OC focuses efforts on those in schools. They are not the high risk population for SMI.

Page 88
Bottom says “MHSA requires that 51% of PEI funding be used to fund programs for individuals 0-25 years of age” That is not true. It was misdirection given by the Mental Health Services Oversight Commission to counties that has no force or bases in law. It is one of the reasons we called Prop 63 a “bait and switch” They go on to say that “Community Stakeholders wanted to devote 75% of the funding to cover the 0-25 year age group. “  It is very hard to dice this. The reality is that the bulk of serious mental illnesses begin in late teens/early twenties. So without seeing how they divide up the money within  the 0-25 year old group, it is hard to see if it is reaching those most likely to show initial signs of SMI.

Page 88-92
These pages show how the money was spent by ethnicity, age, etc. but do not contain any info on what mental illness was being served or what mental illness they were preventing.

Orange County falsely claims “Prevention Services were designed to reduce the likelihood that a mental health event or condition may occur.“ The purpose of Prevention is to reduce duration of untreated serious mental illness (i.e. provide treatment) or “prevent mental illness from becoming severe and disabling”.

Page 96
This is a social service program masquerading as a mental health program to access MHSA funding. Family stress does not cause mental illness. Reducing stress in families where someone has a mental illness can improve outcomes for that person, but there is no indication that that is what this program is doing.

Page 97
We don’t know enough about the program. They admit there is no evaluation of outcomes. This appears to be a worthy program to help vets in schools, but does not appear to have any nexus to mental illness and therefore shouldn’t be funded with MHSA funds.

Page 98
See page 93 above. This program appears to have no nexus to untreated mental illness. It seems to be a worthy social service program masquerading in order to get MHSA funds.

Page 100
Connect the Tots apparently evaluates kids before they are old enough to enter school. We are not aware of this being effective or even if you can identify someone with mental illness at that age. It sounds questionable. It is clearly expensive as 157 tots were served at a cost of $549,958 ($3500 per tot). Like many programs, our guess is the improvement rates quoted were by those who administer the program and are not independent.

Page 110
The narrative for this program seems to suggest that it is for homeless, because homelessness puts people at risk of mental illness. That is not correct. Mentally ill become homeless because of the illness. We have to look at the numbers more closely, but it seems like they evaluated over 80K people (or performed 80K evaluations), ‘engaged’ (whatever that means) 28K, but only “served” 2519 and only gave case management to 27. Again, we’d have to look at the stats and understand the program better, but If you do 80K people (or even 28K) homeless, We would expect 1/3 (10K) to have serious mental illness. So we don’t understand at this point why only 2519 or 27 are being managed (assuming we understand correctly). They report high satisfaction rates, but we assume that is among the infinitesimal number who are being helped. The program seems to be racking up number of ‘touches’ with very few people having any meaningful change in their life as a result.

Page 111
Youth as Parents seems to be to help teen parents that uses the phrase “behavioral health problem’ in passing to make it seem related to serious mental illness.  It has long been known that parents do not cause mental illness. It costs more than $5K per parent and seems to be a worthy social service program masquerading as a mental health program. They seem to admit it was not serving people likely to develop serious mental illness “(T)he depression severity level was generally low for the pre-test scores”. Normally, this would mean the program should not go on as it is not a serious mental illness program. However in this case, OC just decided to use a different measurement. “This measurement tool has been discontinued “

Page 115
“Program serves families that have a common parental history of serious substance abuse and/or mental illness; children living with family members who have developmental or physical illnesses/disabilities; children living in families that are impacted by divorce, domestic violence, trauma, unemployment, homelessness, etc.; and children of families of active duty military/ returning veterans. “ Note that of these factors, it is only parental history of mental illness that makes one prone to mental illness. All the other groups targeted are not high risk groups. We do not know what percentage of people served in this program have a parent with mental illness and what percentage are in the other groups. The measure of ‘success’ is whether the parents believe they have better parenting skills. Since parents don’t cause mental illness it is hard to see a connection that would make this eligible for MHSA funds.

Page 119
Nothing indicates they are mental illness programs

Page 124
Bullying conference. Bullying is not a mental illness.