Systems of public healthcare are changing, nationally as well as statewide. Finally we are “reattaching the head to the body” after years of research findings have indicated that clinically responding to the needs of the Whole Person, in an integrated approach to care, is treatment – as well as cost-effective.
Subsequent implications for change are far-reaching and stem from deep within our structures of care. Our target populations have expanded as state policy leaders and lawmakers prioritize mental health care in the form of increased funding and new community programs. Our perceptions related to the provision of care are challenged, along with traditional practices for educationally preparing clinical providers. California, with its unprecedented funding stream provided through the 2004 passage of Proposition 63, has long been ahead of the Public Behavioral Healthcare transformation curve.
Setting the Foundation for Integrated Care
Proposition 63 was the landmark voter initiative, written by a brilliant advocate, Rusty Selix, in partnership with then-Assemblymember (now Sacramento Mayor) Darrell Steinberg. In 2004, Rusty Selix was the Executive Director of the California Council of Community Behavioral Health Agencies (formerly CCCMHA) and I was a member of his Board of Directors. Rusty and Darrell worked closely with our Board to develop a strategy for getting the initiative on the ballot and successfully passed. I remember the thrill of seeing that Proposition 63 had passed, after staying up almost all night on November 9, 2004, to watch the election returns.
Prop 63 became the Mental Health Services Act in January 2005 and a transformation of the public mental health system in California began. The passage of the Affordable Care Act in 2010 further advanced our state’s transformation, most significantly by including Mental Health and Substance Use Disorder services within the law’s Essential Health Benefits. In my thinking, this inclusion established the foundation upon which systems of integrated care could be built. The potential funds were now in place to support the Whole Person approach to care endorsed by research. I was already a Santa Barbara resident in 2004, impressed with the conscientious services provided by our community mental health agencies.
Integrated Care Implemented by Community-Based Organizations
Sanctuary Centers has long been a leading force, offering a unique continuum of care, which is now supported by continually expanding community access to integrated care. Sanctuary is turning concept into practice. Through the work of a forward-thinking management team, the agency has been solidly positioned to reach out and accommodate those “at risk” populations in the community such as: homeless; justice-involved; reentering; substance addicted; veterans. Those in the community who may be unwanted or unseen are invited in, assessed, and, if appropriate, encouraged to become involved with the service programs. This could not be provided without clinical staff who have been prepared and trained to deliver recovery-oriented community care.
Recovery-orientation digs deep into the roots of psychotherapy as it simultaneously propels us into the future of community-based treatment. Sanctuary’s innovative services approach requires on-the-job ongoing training, careful oversight, and continuous, clear communication among all involved. It demands a process of delicately balancing adherence to documentation and billing requirements with a strength-based, client-oriented approach to treatment. Clinicians must: listen as they direct; evaluate as they proceed; function independently as they request input or guidance.
Grad school programs do not generally teach these kinds of practices and skills, which have often evolved in the years since faculty themselves were educated or provided direct services. It is no wonder that, in a 2017 survey (Loewy, 2019), community behavioral health employers cared as much about “who you are” as about “what you know” when asked what they look for in interviewing potential clinicians. Employers want to hire individuals who are, first and foremost, flexible, collaborative; relationship oriented.
Orientations and models of psychotherapy continue to emerge, some proving to be especially effective with mental illness and/or addictions, but these treatments can no longer operate in a silo when systems of Whole Person care are implemented. Within a context of integrated care, updated competencies acknowledge the importance of expertise in distinct disciplines alongside cultural humility, collaboration and teamwork, interpersonal communication. Agency training and supervision can teach skills, offer experience and provide knowledge, but a respectful, flexible attitude and ability to build relationships within the culture of a particular work setting differentiates those who excel. Sanctuary Centers seems to have created the cooperative and supportive working culture that allows staff to confidently respond to the needs of the expanded community.
Looking Forward
Sanctuary is not alone. Counties throughout the state, as well as organizations in Santa Barbara, can boast of innovative programs and community centers of excellence. For now, California public behavioral healthcare is in the midst of a Golden Age, and community service providers are collaborating to wrap care around the Whole Person. But we don’t want this Golden Age to somehow shrink to become only “one brief shining moment”. No matter how intuitively correct Whole Person/Whole Community care may seem, outcome studies of treatment and cost-effectiveness must be conscientiously conducted to protect its status. For the new systems of care to become structurally solid and continue to grow, we need to secure its support.
If you are interested in learning more about evolving structures of community care, recovery orientation, the workforce provider shortage and changing clinical competencies, please see Working in the California Community Behavioral Health System: A Navigational Tool, a recently published book by Olivia Loewy and Associates.
About the Author
Olivia Loewy, Ph.D., LMFT
Olivia Loewy, Ph.D., LMFT, was the Clinical Director of Verdugo Mental Health in Glendale, CA. before becoming the Executive Director of the American Association for Marriage and Family Therapy, California Division. Currently, through Olivia Loewy and Associates, she is developing resources, educational materials and training courses designed to support the needs of the public behavioral health workforce.
