Good intentions, when tried before, don’t have better results
There’s a particular kind of optimism that shows up every few years in the mental health world. It arrives with new funding streams, polished language, and the promise that this time—finally—we’ve figured it out.
Enter the latest wave: large-scale funding initiatives by the state of California, aimed at addressing moderate to severe mental health needs, backed in part by taxes and major corporations. On paper, it sounds like a long-overdue correction. More money. More structure. More accountability. What could go wrong?
The Problem With High-Fidelity Mental Health Models
Well… quite a bit, actually.
Let’s start with the rollout. The plan leans heavily on training professionals in highly structured, high-fidelity models. These are approaches that come with manuals, protocols, checklists—sometimes entire ecosystems of compliance. In theory, this ensures quality, but these models require an extraordinary level of oversight and staffing to implement well. And the delivering agencies will measure ‘well’ because they need statistics to look good in order to keep selling their products.They will blame the counties lack of employees or lack of fidelity to fulfill the requirements or compliance issues within the communities they serve.
HOW DOES BURNOUT impact the system?
And counties being trained? They’re already stretched thin, staff-wise and in their budgets and in their strategic capacity to to hold teams together under this level of pressure and overhaul. The cultures in the agencies are struggling to find their “north star”. Since every few years there is a new wave, people are often trying to lay low until it passes. Understandably because the expectations and targets frequently move.
Agencies tasked with carrying out these changes are saying not enough supervisors and not enough time. And definitely not enough bandwidth for the kind of meticulous fidelity these models demand. And certainly not stamina to endure one more forced training.
So what happens next is predictable. The mandated trainings roll out, agencies shrink and the work is contracted out to other organizations. The work within the counties includes redefining roles and rules. Training and more training are invested in and still the people doing the work struggle to not get deterred by burnout or the benefits for the clients they serve.Out of necessity, corners get cut, not out of negligence, but survival. The model becomes more of a suggestion than a structure or fidelity is maintained and very few people get services with these new measures. Documentation increases, while meaningful engagement quietly decreases for the majority. What used to work for the patients, is no longer able to be done because the new protocol does not allow it: another connection lost between practitioner and patient requesting help. This disempowers everyone in the system for real time decisions and creative engagement.
But even if we solved the staffing issue (and that’s a big “if”), there’s a deeper problem we keep sidestepping.
Mental Health Systems Remain Organized Around Diagnosis Rather Than Function
We’re pouring resources into systems that are still fundamentally organized around diagnosis rather than function. Around categories instead of the context and less “out of the box” thinking. It’s a bit like upgrading the software without questioning the operating system.
An example includes when a young adult is referred for care and is mandated to treatment and has their basic needs provided for by an adult and is living in their parent’s home and the county does not allocate resources for meeting with the adults they depend on. Or this is done as a last measure, rather than when initially building an alliance; we lose an opportunity for change,
Or an example when a couple are both separately referred for counseling due to CPS or drug court and there is no attempt to see how they are working together or against each other in their treatment. The systemic interventions are a second thought as they are divided as if their worlds don’t co-exist and impact one another.
The structural processes for engaging different parts of the system, for bringing in important people in the live of the identified patients or managing funding for housing more long term with accountability attached to it or accountability around funding and SS benefits is acknowledged as a shortcoming, but no- one is touching it in a meaningful or sustainable way.
In our work with the county over the past 4 years we consistently saw these flaws inconsistent communication and funding management. We saw the hesitancy to involve interested family members and we saw the lack of accountability for consistent communication between providers . We saw departments fumble for accountability. Staff unaware that they could ask for more participants from the system . While many of the new models are aimed at higher engagement and systemic activation they overcomplicate it and put in so many “middle men”that the application will be nearly impossible.
Why Client Motivation Matters More Than Protocols
Many of these models, for all their sophistication, are not particularly nimble when it comes to working with real human ambivalence. They don’t always account for motivation—the fact that people don’t change because a protocol says it’s time. They change when something in their world shifts enough to make doing something different needed. That is usually when someone will ask for help – or to avoid going to prison in some cases– and when they come in, they find professionals who are mandated to fill forms, apply protocols and are therefore not able to listen to what is important to them. One could say, the patient will often encounter a deaf person because that person needs to focus on the meta-request from the system.
The Importance of Flexible, Client-Centered Care
Listening and adapting to a patient’s requests at the time they come in and with an understanding of what led them to reach out at that moment is important,following this motivation even if negative at first because it wasn’t the identified patient’s idea , requires flexibility. Creativity. A willingness to work within the client’s “circle”—their relationships, their constraints, their worldview—not just apply a model, a protocol to it.
Instead, we often see the opposite. Interventions that live around people rather than with them. Systems that expect participation without fully understanding who wants what change to occur and how to engage them. Plans that look excellent in a proposal and far less convincing in the living room of the person trying to implement them
The Role of Corporate and Political Priorities
Yes, there’s another layer worth naming.Large corporations funding these initiatives are not neutral actors. Their involvement often aligns with broader social pressures—homelessness being one of the most visible. Cleaner streets, more stable workforces, fewer public crises. These are understandable goals, but they shape the urgency and direction of solutions in ways that don’t always center the lived complexity of the people being served.
To be clear, the issue isn’t that funding exists. It’s that funding alone—especially when funneled into overly complex, top-down systems—doesn’t resolve the underlying fractures. So where does that leave us?Somewhere between pessimism and skepticism.
Mental health reform is necessary.
Yes, resources matter. Yes, investment is necessary. But without addressing workforce realities, simplifying implementation, shifting away from purely diagnostic frameworks, and engaging more directly with the systems people actually live in, we’re likely to see a familiar outcome. A lot of reporting and a lot of tired professionals .
This will also mean a lot of professionals without a job at the County level because, when the latest training fails ‘because it was applied by staff who did not adhere to what they were trained in’, patients will be funneled to Managed Care facilities, for profit. The County will now be faced with more complex patients, who need more care with even less resources. And far less change than we’d hoped for. The state will move towards conservatorship and more inpatient facilities will emerge ( something we had done away with because of ethics in the past). This is a good example of schizmogenesis, a system vacillating between extremes for over correction which ultimately keeps a system stuck, but that’s a topic for another article.
What California Mental Health Reform Needs Next
If we really want something different, we may need to teach clinicians how to think, we need to incentivise change by looking at how we pay people who get social services and who delegates that funding and we need social workforce and justice systems that are more practical. Less rigid, more responsive. Less about perfect models—and more about workable ones.
Because in the end, change doesn’t happen in policy documents.
It happens in messy, imperfect, human systems. And those don’t respond well to being managed from a distance.
