In November 2004, California voters passed Proposition 63, a ballot initiative that authorized a 1 percent tax on annual adjusted gross income over $1 million to support county-operated mental health systems.

The tax will result in an estimated $1.8 billion in revenues over the first three years.

The initiative provides more flexibility than Medicaid in terms of the kinds of services it can fund and the populations it can cover.

In the symposium "Recovery System Transformation in California" at the APA Institute for Psychiatric Services in October in San Diego, veteran mental health advocates and practitioners described implementation challenges posed by the new law and lessons learned from its passage.

Richard Van Horn, president and chief executive officer of the National Mental Health Association of Greater Los Angeles, described a half-century of federal and state legislative mental health initiatives.

Adequate funding for mental health, according to Van Horn, always has been a tough sell. "In good times," he said, "funding stays even. In bad times, you lose."

Presenting a "clear vision" of what the money generated by Proposition 63 could accomplish was key to gaining public support, he believes.

Advocates pushed several themes to secure its passage.

They emphasized the idea that the new money would encourage recovery and resilience for those who used the mental health system, rather than just temporarily ameliorating their symptoms.

Advocates were able to present data showing positive results of state legislation passed in 1999 (AB 34) to provide mental health services to people who were homeless or at risk of homelessness. According to their evaluations, the number of days of psychiatric hospitalization, incarceration, and spent" homeless" decreased by more than 50 percent for the population served.

Voters reported sympathy with the idea that the new legislation represented an effort to redress "35 years of broken promises," according to focus groups. The phrase referred to the state's failure to provide adequate community-based mental health care to people who had been released from public psychiatric hospitals beginning more than three decades ago.

Focus groups also revealed that voters were particularly supportive of services that would help children and generally were unsympathetic toward services directed to people with substance abuse disorders.

Mark Ragins, M.D., medical director of The Village Integrated Service Agency (The Village), in Long Beach, Calif., stated that transformation of the mental health system to promote recovery would require significant changes in attitude and behavior by the staff in many agencies.

The Village pioneered the use of collaborative case-management teams that encourage those who use its services to set their own goals and developed strategies to permit those teams greater responsibility for allocation of fiscal resources that affect a client's care.

The Substance Abuse and Mental Health Services Administration selected The Village as an exemplary practice model.

Ragins urged the audience to find ways of rekindling the passion that brought them and their colleagues into the mental health profession.

Staff involved in mental health care benefit from stories of recovery. They spend a great deal of time with people who are in crisis or "doing poorly" and need to be reminded of successes and to learn of the research that documents the possibility of recovery.

A major challenge for staff will be working with those people for whom the current system has been particularly unproductive. Ragins believes that recovery programs have succeeded with "people with dual diagnosis, homeless people, jail diversion people, `noncompliant' people, and people lacking `insight.' "

Overcoming the obstacles to engaging and treating members of those" hard-to-reach" groups successfully, however, often requires an attitudinal change by staff and specific skills training.

Wayne Munchel, The Village's director of training and consultation, argued that an organization must create a "culture of recovery" that reflects core principles of the recovery movement: hope, healing, and community engagement. Implementation of the third principle—that community engagement is critical—will require that leaders move their agencies beyond the traditional mental health system to more active involvement with other agencies and individuals.

All the panel members cited the critical importance of being able to demonstrate to the general public the value of the increased funding and new legislative flexibility deriving from Proposition 63. Martha Long, The Village's director, said, "We've all worried `what if we got Proposition 63 and nothing changed?' " ▪