This project will analyze the changes in mental health care brought about by the California Mental Health Services Act (MHSA), focusing on the mechanisms by which change is achieved and the impact on client outcomes. The MHSA significantly increases support for mental health care in California via an additional 1% tax on personal income above $1 million, currently generating $700 million in additional yearly revenue for public mental health care. Mandating that counties use MHSA funds only for programs and interventions based on a philosophy of "recovery," the MHSA has the potential to radically transform the mental health care system in California. In collaboration with Los Angeles County Department of Mental Health (LAC DMH), we propose to assess the impact of MHSA on service provision and client outcomes in Los Angeles, the country's most populous county. Our overarching goal is to understand both what effects the MHSA has on clients and why the observed effects occurred. We have gathered a multidisciplinary team of psychiatrists, mental health services researchers, an experienced public mental health administrator, an historian, a sociologist, and an anthropologist. Our specific aims are: 1) at the county level, to assess how LAC DMH develops and implements MHSA clinical policy over time; 2) at the clinic level, to assess how clinics implement LAC DMH's interpretation of the MHSA, and how this implementation transforms clinical culture, structure, and providers' understandings of illness and treatment; and 3) at the client level, to assess the impact of local clinical transformations on clients' objective outcomes and subjective treatment experiences. We employ a longitudinal design to assess change in the first three years of MHSA implementation in two clinics receiving MHSA funding and two not receiving funding. Methods include client (n=480-640) and provider (n=377) self-administered surveys; qualitative interviews of LAC DMH administrators (n=28), providers (n=50), and clients (n=50); audio-taped clinical interactions (n=20 dyads); ethnographic observation; document analysis; and analysis of the LAC DMH database. LAY SUMMARY: The California Mental Health Services Act (MHSA) represents an effort to radically transform the public mental health care system by putting the concept of "recovery" at the forefront of treatment for the severely mentally ill (SMI). The purpose of this project is to study the impact of the MHSA on SMI clients and their treatment over the course of three years. By studying the MHSA, we hope to provide a comprehensive and instructive example of what happens when a new policy, potentially affecting thousands of patients, is imposed upon a public mental healthcare system with the goal of improved care. [unreadable] [unreadable] [unreadable]