“There was a righteousness in the ‘60s, with Democrats and Republicans saying, ‘We have to move away from these locked institutions,’” Newsom said this year before he signed a pair of mental health bills. “We were supposed to replicate that with community-based care and there was no accountability, there was no obligation either way.”

The governor stresses that the bulk of the new services will be voluntary — and will provide shelter to thousands of people ailing on the streets. His bond proposal, combined with three other programs he’s rolled out recently, is expected to fund almost 46,000 outpatient treatment slots.

Today, California has only a vague idea of how many people it can treat in outpatient settings — just that it’s not enough. That number could include slots in group therapy, detox, counseling or a host of other methods that don’t require a license and are hard to count. That’s part of the need for changes, officials say, to finally get a census of where the state is on treatment.

It’s going to require a massive workforce to provide all the treatment the state is promising. Newsom’s proposal includes around $7 billion to beef up the workforce, which will rely on new medical education slots to supply practitioners, as well as people who have been trained as counselors after receiving substance abuse treatment themselves.

“I know critics will say you don’t have the workforce so you can’t change the laws,” said state Sen. Susan Talamantes Eggman (D-Stockton), who wrote one of the laws that will appear on the March ballot. “For mental health care, we seem to think everything has to be existing in its perfect environment before we can make any kind of changes.”

The fact that California is building new treatment facilities and training more staff on this scale is a feat unlike what other states are doing, California Health and Human Services Secretary Mark Ghaly said in an interview. The idea is to strengthen the entire spectrum of care, including with prevention and early interventions.

“But it doesn’t obviate the need for some folks whose conditions become so severe, potentially so violent, so difficult to manage, that they do need some level of involuntary care,” Ghaly said. “The California vision for this is, is that [involuntary treatment] is only used when absolutely necessary.”

Still, the bond measure allows some of the money for residential treatment to be used to build secure psychiatric facilities. California has also made it easier to put people into conservatorships, an arrangement that allows judges to appoint someone to make legal and health decisions for people they deem “gravely disabled” and unable to care for their health and safety. Compelled care, for some, will mean involuntary holds in a psychiatric facility ranging from 24 hours to evaluate a person to 180 days in extreme cases to treat them. Court-ordered treatment plans may include medication, therapy or a housing placement.

Some mental health advocates fear Newsom is overcorrecting.

“We’re looking at all of this, and it’s going in the wrong direction,” said Clare Cortright, policy director for Cal Voices, a coalition of groups that represents community mental health organizations. These groups and others have organized into Californians Against Proposition 1, to oppose the changes on the March ballot. With no professional organization or high-dollar backers, the opposition’s main asset is outrage from people in the mental health system who fear they’ll be funneled into involuntary treatment.

The idea of forcing people into treatment had long been politically untenable for progressive Democrats, who saw it as a civil rights infringement. Until recently, few state lawmakers were willing to call for more conservatorships or court-mandated services outside the justice system — and California’s recent laws reflect a painstaking attempt at balancing such measures with civil rights concerns.

But Democratic mayors of cities in the grips of housing and addiction problems have started loosening or changing laws around civil commitments, in which people living on the street who are unable to care for themselves are given court-ordered treatment plans. Some argue governments need a way to reach people who can’t or won’t seek help on their own.


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