AAMFT California Newsletter, Winter 2014
ACA Implementation in California: Opportunities and Challenges for Mental Health Providers
Olivia Loewy, PhD
AAMFT-CA Executive Director
Evolving Systems of Care
The implementation of Healthcare Reform is underway in California. Mental Health/Substance Abuse services are included in the Affordable Care Act as Essential Health Benefits. Funding has increased. Systems of coordinated, integrated care are conceptually beautiful and holistic. Yet there are glitches and disconnects that need attention and adjustment in order for the extended coverage and new systems to proceed effectively.
All of the topics addressed below will be presented comprehensively during our Futures Forum program on March 1 in San Francisco. State leaders who are influencing and shaping the change will be there to answer your questions and respond to your comments. You will find a link to registration at the end of this article.
- Increased Funding
In January 2014, the California state budget reflected the first surplus in 14 years. The legislature has planned to allocate $200 million for counties to develop community services designed to reduce recidivism for the increased reentering prison population. Senator Darrell Steinberg is seeking to dedicate $50 million of that for Mentally Ill Offender Crime Reduction Grants. In addition, the recovering economy has yielded increased Mental Health Services Act and state realignment revenues. There will also be significant federal funding coming into California to serve the MediCal expansion population. More funds and expanded services translate into an increasing need for qualified clinicians. Employers and insurance plans will need more providers.
- Coordinated Care: Integrated Delivery Systems
The emerging new systems of care have been shaped by comprehensive research and inspired by the Center for Medicare/Medicaid Services (CMS) Triple Aim: Better health; Better care experiences; Lower cost. Fundamental tenets of service delivery have surfaced:
- Care is integrated.
- Care is accountable.
- Services are consumer-driven.
Integrated care honors the complexity and inter-relatedness of all of our functioning systems, whether personal, relational, biological, societal, or other. The concept is widely recognized and acknowledged.
California is approaching the transformation carefully in the form of Cal MediConnect: a pilot project involving eight counties that are developing fully integrated systems of care for their Medicare/MediCal insured population (Dual Eligibles). These systems of care will be monitored, scrutinized and studied to provide the guidance needed to proceed on an inclusive statewide basis. In these emerging models, MFTs are included as providers, despite our inability to bill for Medicare services.
- The Incarcerated and Reentering Population
In 2005, Los Angeles Sheriff Lee Baca said: “I run the biggest mental hospital in the country”. In 2010, it was noted that there were more at least three times more seriously mentally ill persons in jail than in hospitals (Treatment Advocacy Center and National Sheriffs’ Association Report, 2010). In 2011, the U.S. Supreme Court ordered the state of California to reduce the prison population by roughly 25% within 2 years. AB 109 shifted responsibility from the state to the counties for lower level offenders and paroles. Goals included:
- Developing effective county programs
- Transforming offender behavior
- Incapacitating those whose crimes merit it.
- Ultimately reducing recidivism.
The state funds allocated for community programs for this population are generous and bring increased employment opportunities for MFTs.
Although accepted, research-based concepts and goals are in place and funds are potentially abundant, the state is faced with important implementation challenges. Adequate compensation for providers is a major concern and finance reform is a top priority for stakeholders at the state level.
Additionally, the potential to increase access to services and provide better care in a more cost-effective way is impaired by time-consuming documentation and paperwork requirements that harm productivity. New means and methods for contracting, communicating and connecting need to be created and established.
Funds and goals that seek to reduce recidivism and provide treatment for mentally ill offenders in their own communities are established, however the complex and multidimensional issues that need to be addressed with this population are challenging and many clinicians are not trained to do the work.
Everything is new and evolving. As we run into barriers or dead ends in the process of transformation, we have opportunities to invent and implement solutions to the subsequent problems.
Learn All About It:
Do you want to know more about the future of Healthcare Reform in California from the state leaders who are influencing and shaping the change? AAMFT-CA is active in Healthcare Reform state level policy and planning meetings. We view everything from the perspective of an MFT “lens” and tune into what will be critical to know and address in our efforts to advance the profession in California. Based on what we are learning, we have created a one-day Futures Forum featuring experts in the state presenting on those topics that address the crucial issues related to emerging systems of care and compensation.
The program includes:
- HEALTHCARE REFORM: 2014
RUSTY SELIX, co-author of the Mental Health Services Act and Executive Director of the California Council of Community Mental Health Agencies.
- COORDINATED CARE: INTEGRATED DELIVERY SYSTEMS
GALE BATAILLE, Project Director for the California Institute for Mental Health (CiMH) Quality Improvement Collaboratives.
- WORKING WITH THE INCARCERATED AND REENTERING POPULATION
MONIQUE LeSARRE, Director of Child Youth and Family Westside Community Services
- SCHOOL ACCREDITATION CONSIDERATIONS
BENJAMIN CALDWELL, Associate Professor, Alliant International University, and chair of the AAMFT-California Division Legislative and Advocacy Committee.
For More Information about the Forum:
To REGISTER: https://www.formstack.com/forms/?1617541-xWaEfBPmyJ
AAMFT-CA is the MFT association in California that is focused on providing the information and resources you need to ensure your professional stability in the future. For more information, do not hesitate to contact Olivia Loewy: email@example.com.
Olivia Loewy, PhD is Executive Director of AAMFT-CA. She can be reached at firstname.lastname@example.org
Image source: Courtesy of Olivia Loewy, PhD
LEGISLATIVE & ADVOCACY UPDATE
AAMFT-California Division 2014 Advocacy Priorities
Benjamin E. Caldwell, PsyD
AAMFT-CA Legislative and Advocacy Chair
The AAMFT-CA Legislative and Advocacy Committee has set four priorities for 2014, which were approved by the Board at the November 2013 meeting. We have already begun taking action on each of them:
- Resolving the BBS backlog of licensure applications.The current processing backlog for applications for MFT license exam eligibility is approximately eight months. Our lobbyist testified at a Senate budget committee hearing on the issue of returning state funds to boards and bureaus to reduce the backlog. In addition, we are coordinating with CAMFT and other associations on letters to the Governor and the Legislature emphasizing the importance of approving new positions at the BBS. We are cautiously optimistic that our individual and combined efforts can produce movement on this, and were pleased that the Governor’s budget appears to include additional money for BBS hiring. However, the positions are not yet guaranteed.
- Inclusion of MFTs in health care reform wherever possible.We have been on conference calls with several associations and outside experts to learn more about how other states and counties are leveraging federal monies today to include MFTs within federally-funded systems of care through various contracts and waivers. We hope to use the information gained to provide guidance as we work collaboratively to secure MFT inclusion in the evolving systems of care.
- Publicizing our advocacy successes.In the past few years, we have successfully pushed for changes that others have not, including SB1172 (the ban on reparative therapy for minors), removing discrimination in child abuse reporting, and more. We are eager to tell the stories of our successes to members, nonmembers, and policymakers.
- Addressing the economic difficulty in becoming an MFT.The educational process for becoming an MFT has gotten longer and more expensive, and the average time one spends in internship is now more than four years. The BBS processing delays extend this time an additional eight months. Ultimately, many drop out of the licensing process, or choose other fields in the first place. We know this is a difficult and complex issue, and designating it as a committee priority for 2014 will allow us to dedicate some substantial time to detailed exploration of the problem. We are looking at potential immediate and long-term solutions.Updated February 2014
Benjamin E. Caldwell, PsyD, is an Associate Professor for the COAMFTE-accredited graduate programs at Alliant International University in Los Angeles, and chairs the AAMFT-CA Legislative and Advocacy Committee. He can be reached at email@example.com
Image source: Courtesy of Ben Caldwell, PhD
AAMFT-CA DIVISION: LEADERSHIP PLANNING FOR 2014
Naveen Jonathan, Ph.D.
AAMFT-CA Division President
The AAMFT-California Division Leaders, met in San Diego, CA, January 24-26, 2014 for the annual Division Leadership Retreat. The first part of the weekend was designated as the Board Retreat. Newly elected Board Members and those continuing their time in office, met for an orientation meeting on Friday afternoon. Board Members were asked to share their vision and hopes for their time on the Division Board this year. As President I shared my vision for the Division.
In my term of office, I plan on engaging the members of our division in a very active manner. My plans include a monthly President’s Letter that will be sent to the membership, informing them of the activity of the Board and also sharing ways that members can become actively involved in the work of the division. As President, I also commit to making a visit to each District at least once this year to meet with members. I also will be inviting members to write letters to the Board concerning various issues that they would like the Board to be aware of and consider. Another part of my vision focuses on working with the board to develop ways to showcase the amazing work that we do as AAMFT-California Division, with educators, community mental health agencies, advocacy initiatives, being a premier educational source to our members, and having an active voice in the changing mental health landscape in California.
On the level of the Board with its process, my focus includes focusing on ways that we can build structure and efficiency with the development of board committees that have an Organizing Document that outlines policies and procedures for the committee. A further component of this focus also, includes developing a culture of mentorship for Board Officer Positions and also Committee Chairs for continuity of the excellent work that these committees do. Members of the Division will also be invited to be a part of these committees to provide an important voice to the work that each committee will be involved in. Finally my vision includes continuing to strengthen our relationships with AAMFT as well as other mental health organizations in the state.
The Board met for their first meeting of the year on Saturday morning. The Board focused much of their discussions on a restructuring plan for the Networking Districts in the Division. Under the direction of Division Restructure Taskforce Chair, Angela Kahn, the Board engaged in a discussion and set plans for informing the District leaders later in the weekend about these plans. AAMFT-California Division has made the move as done in other AAMFT Divisions around the nation, to charter our Districts. Through this process of chartering, Districts will be much more autonomous than before. Each District that is chartered will have their own Charter, Bylaws, 501(C)6 Status and elected officers. The Board has set 2014 as a year of changes as we assist Districts in moving toward this restructuring. The Board has committed financial resources to assisting Districts to move towards this process. Each Board Member has also adopted a District to help with this transition.
The California Division board is very confident that moving in this direction, Districts will be able to create vibrant and dynamic activity that reflects the work of the California Division and AAMFT. District leaders from all over the state, joined us Saturday afternoon and Sunday of the retreat and were informed of all of these decisions and the specific steps that would need to be taken in order to begin this restructure process. District Leaders also shared their best practices with the group so that attendees could learn about different ideas to implement in their Districts.
The Division Leaders Retreat was an incredible event. Special thanks to Olivia Loewy for the great job she did of organizing the event, to Angela Kahn who led in the District Restructure Taskforce discussions and training of District Leaders, the Board of Directors of AAMFT-California Division for their work and for all District Leaders for your participation and work! Watch for more information in upcoming enews editions and President Messages on these initiatives that were set in place at the Division Leaders Retreat. For comments, suggestions or more information, please do not hesitate to write to me at firstname.lastname@example.org.
PREPARING MFTS FOR CLINICAL TREATMENT OF AFRICAN AMERICAN COMMUNITIES
Norma Scarborough, DMFT, LMFT
Assistant Professor, Alliant International University
Black History Month has been designated as a time to review and celebrate the accomplishments of African Americans in the United States. In the mental health profession there has also been improvement of clinical treatment to this population. The improvements may be attributed to the way educators have begun to make students aware of cultural differences, multiculturalism, feminism, and internationalism. This focus on educating clinicians has made it more likely that the African American population will receive culturally relevant and more effective treatment and MFTs have been one of the leaders in multicultural training for new clinicians.
Some of the progress that has been made in the clinical treatment of Black families is the recognition that there is diversity within the group and that behavior does not occur outside of the context of experience. The more historical and contemporary information clinicians have about the African American population, the more effective clinicians can be in delivering mental health services to them. For instance, a clinician who is familiar with the convergence of educational factors, economic factors, and legal factors that create a perfect storm and contribute to some of the contemporary issues the Black population faces, will have a more empathic way to enter into the family system. It cannot be ignored that the African American population has made some progress in all of these areas, but even with these gains the stress of living in a society that still views African Americans as their own biggest problem can be overwhelming (W.E.B. Du Bois, p.8). Boyd-Franklin (2003) did an excellent job of outlining some of the problems facing the Black community that are not of its making and those issues are beyond the scope of this paper.
Some of the problems in the community can be said to begin with education. The high school graduation rate for Black males is currently at 52% (blackboysreport.org 2012) and while that is a low rate, the impact on the community is that less African American males will be available to marry and support families, contributing to an increase in single-parent households (Boyd-Franklin, 2003; Alexander, 2012). It is commonly known that the employment status was complicated after September 11th also known as 9/11 and that event began a decline in employment opportunities for everyone. The unemployment rates in African American communities were even higher and have been twice as high as the majority culture for more than 50 years (pewresearchcenter, 2013). The systemic picture that emerges would be that poor education leads to low employment and/or no employment, which could lead to legal problems and involvement in the justice system, which leads to stress in families. Other larger systems may also become involved in a Black family’s life, if drug/alcohol use or domestic violence becomes a part of the family’s experience. Child Protective Services could become involved and remove the family’s children, which often leads to these families being referred to counseling. These families may also be referred by Probation and the Juvenile Justice System, which will further impede the ability of families to progress.
For many clinicians, especially MFT trainees and interns, the most likely way they will see African American clients is through one of these systems, i.e. education, social services, or legal. Clinicians treating Black clients may want to be aware of some of the social issues their clients face so that they can allow space for their clients to give a voice to those issues. Postmodern therapies like Narrative, Solution Focused, or Collaborative Language that are based on social construction thought and because of their non-blaming, non-shaming, strength based approaches are often the best match for working with this client population. When clients are not self-referred, they are often described as “resistant” and difficult to treat (Boyd-Franklin, 2003 p.23). A more productive reframe could be that African American clients are self-protective due to their encounters with therapists and other well-meaning professionals. Allowing space to hear their narrative about past experiences, without judgment and/or disbelief promotes the clinician’s ability to build relationship.
All MFTs are aware that relationships are primary and our relationship with our clients is the basis for effective treatment. Therapeutic relationships with Black clients can be enhanced by a clinician who is accepting and open to different worldviews.
Author: Joan Shaver, LMFT.
Publisher: Santa Monica, CA: Wonder Realm Press
Reviewer: Nadia Brewart, Ph.D. DrNadia@PositivePsychologyWay.com
Shaver’s evocative title captures a “truth”: There is a certain mystique to integrating the mundane (lipstick/external world) with the esoteric (soul/internal sense of being) to touch the sublime (self-love/cardinal virtues/ “inner presence”). Shaver’s experientially-based book invites female readers on a journey to uncover, elucidate and move into a space of presence which she calls the “mysterious” or “inner feminine.” The mysterious feminine, Shaver declares, “…is a wonderful, warm, loving, all-embracing humane energy that resides within each one of us as well as all around us” (p.xiii).
To enter this space, Shaver offers a format in each chapter, which provides readers tools for reflection, transcendence/expansion of the boundaries of the rational mind, and experience to settle into a place of intuitive knowing through ongoing practice. To this end, she effectively utilizes various voices (beauty advisor/intimate friend/facilitator-guide), poignant quotations (from celebrities to artists, to philosophers, to ordinary folk with wisdom), metaphors (mostly beauty-oriented), experiences (autobiographical/imaginative), writing activities (stream of consciousness/cognitively-focused); and, while not specifically identified as such, mindfulness-based concepts/approaches (non-judgmental awareness, centering with the breath, mini body scans, mindful eating, mindful activities), and “homework” for further integration, knowledge and guidance along the journey.
The journey itself is three-fold. In part one, “Book One: Be Bold,” readers assess their current state of openness and their blocks. In addition to the approaches noted above, through a self-assessment questionnaire, readers are able to identify their “blind spots” and recurrent patterns, which thwart the process of connecting to one’s inner, authentic core. In this early stage, Shaver encourages readers to freely express their challenges, making room for new possibilities.
New possibilities are cultivated in “Book Two: Be Beautiful,” which embeds two phases. In the first phase, the veneers (defense mechanisms, unconscious blocks) of the core self are identified and addressed, feelings are experienced and embraced. Building upon phase one, phase two continues to lead readers to their inner core, experiencing feelings, identifying and confronting the “saboteurs” of the heart. With gentleness, vulnerability and receptivity, a natural beauty emerges.
This natural beauty, a pulchritudinous soul, is where Shaver finds the “mysterious/inner feminine.” In the final stages of the journey, “Book Three: Be True To Yourself,” readers encounter the flexibility, strength and wholeness of shifting between what Shaver describes as “masculine and feminine presence.” Here, there is attunement to cognitive and emotional states, rootedness and integration of various facets of self; thus, responses to self and others are grounded-as opposed to reactive. It is this place of the authentic core that beauty emanates, where the well-loved feelings cannot be sullied or compromised by life’s difficulties.
Therapists desiring to move their clients to this place can utilize activities from Shaver’s work. Her book can also be offered in a women’s group format, which Shaver herself conducts. As there is much process work, therapists and readers might reap the most benefits from approaching the work slowly, perhaps no more than a chapter a week. And, clients must be receptive to writing/journaling activities as this tool is heavily focused. Social constructivists and/or postmodern theorists/therapists for whom the language and gendering of experience and selves are culturally and historically situated, may still utilize the activities, while deconstructing-as Shaver does herself in some areas-the implications of gendered notions of the feminine.