For most of our nation’s history, involuntary psychiatric commitment operated with sweeping and often unchecked power: State hospitals confined people for years or even lifetimes based on such broad claims as mental illness and “moral defect,” often with little legal recourse.
Public outrage over abuses in overcrowded asylums — dramatized most famously in the book One Flew Over the Cuckoo’s Nest — helped propel the patient’s rights movement in the 1960s and 1970s toward successful deinstitutionalization. A series of court rulings limited the state’s power to confine people against their will.
Now that balance is shifting again.
Last summer, President Donald Trump signed Executive Order 14321, which purports to address homelessness by greatly expanding involuntary psychiatric commitments and encouraging police to arrest people experiencing homelessness.
The order — its constitutional validity remains in question — undermines decades of court precedent and removes judicial constraints to hold people in institutions. It could resurrect the old ways as a national standard without debate or congressional action.
If enforced, this order would worsen the problems we have while creating new ones.
A sprawling facility recently built outside Salt Lake City already shows the trappings of a prison camp for people experiencing homelessness. This spring, the administration started legal guardianships for hundreds of veterans — some of whom are homeless — that could drive more of them into institutional care.
And in a historic shift, federal officials are slashing millions of dollars in homeless grants across the country, including in Philadelphia and its suburbs, forcing a broad swath of nonprofits to curtail their efforts to house unhoused people. The Philadelphia Furniture Bank, which gave free furniture and mattresses to more than 22,000 people facing homelessness, became the latest casualty, announcing it would close on June 30.
Past presidents couldn’t make these changes — even if they wanted to — because our system empowers the states to set laws for involuntary commitments. Trump’s order would undermine that by ending consent decrees that aim to ensure stays are safe, ethical, and clinically appropriate.
His order also seeks to incentivize confinement by directing federal agencies to green-light grants to towns and states that get people off the street and into institutions. And those receiving federal homeless services would have to undergo mental health care as a condition for those benefits.
If enforced, this order would worsen the problems we have while creating new ones.
We know a lot more about mental illness than in 1962 when Ken Kesey published Cuckoo’s Nest. At the same time, homelessness is growing in the U.S. An estimated 700,000 people live unhoused every night.
Involuntary psychiatric treatment is sometimes necessary, but open-ended and inappropriate commitment harms patients and creates a moral indignity that can have a lifelong negative impact. And even when it is appropriate, our system tailors commitment lengths to people’s health needs, as the U.S. Supreme Court has affirmed several times. Most states limit the first court-ordered commitment to six months or less. Removing those limits would subvert the Supreme Court’s authority and abandon patients to the whims of unchecked administrators.
Another problem: The order violates the Constitution by impinging on the state’s authority to direct health and safety, including civil commitments.
Those with disabilities should be concerned about this, too. They have the right to live independently in their homes, with access to state-funded services. But this order would threaten that.
Importantly, the order could also force clinicians to break their fiduciary responsibility to serve their patients’ best interests first by pressuring them to inappropriately confine homeless individuals who might not be seriously mentally ill.
History shows many examples of the political misuse of psychiatric power. Soviet communists invented the diagnosis “sluggish schizophrenia” to justify the imprisonment of political dissenters. Vladimir Putin continues to use psychiatric excuses to shackle his critics. More recently, U.S. police used the contested diagnosis “excited delirium” to justify giving controlled substances to calm down people resisting arrest. The diagnosis has since been discredited.
Our system is far from perfect. Too many seriously mentally ill people end up unhoused, imprisoned, or cycling in between. But the executive order risks turning clinicians into Soviet-style apparatchiks, who violate their ethics to make the system run.
Federal policy should encourage the advocates who run safe consumption sites and syringe distribution efforts to keep people alive until they get help, because these efforts have been proven to work. But the president would levy civil or criminal charges against these caregivers.
The executive order also dismisses efforts like Housing First, which give housing without requiring treatment or sobriety. These programs help make people more likely to improve their mental health and stay in housing.
By contrast, arresting and confining people is associated with more death, illness, and misery.
It may be politically appealing in some quarters to sweep up, institutionalize, and resettle unhoused people who are barely surviving with mental illness. But this approach was recognized long ago as inhumane and impractical.
The time is now to build a real mental health care system to support the most vulnerable in our society. Instead of issuing retrograde executive orders, the Trump administration should invest real money to advance evidence-based interventions and policies.
Dominic Sisti is a senior fellow at the Leonard Davis Institute of Health Economics and associate professor in the department of medical ethics and health policy at the University of Pennsylvania. He directs the Scattergood Program for the Applied Ethics of Behavioral Health Care at Penn.