Involuntary Treatment Policies: A Growing Debate

In July 2025, an executive order from President Donald Trump, focused on "crime and disorder on America's streets," significantly elevated the national discussion around involuntary treatment as a response to visible homelessness and drug use.

Following this, in September 2025, Utah officials unveiled plans for a sprawling 16-acre facility near Salt Lake City. This center is designed to house up to 1,300 individuals experiencing homelessness who are removed from public spaces. They would be presented with a stark choice: reside in the facility's abstinence-based shelter or face jail time. Crucially, the facility also allocates 300 to 400 beds specifically for the involuntary treatment of adults diagnosed with psychiatric and substance use disorders. While supporters hail it as a humane alternative, critics have drawn parallels to a prison.

Since the executive order, proposals to expand involuntary treatment for adults with substance use disorder have emerged in states including New Jersey, Washington, and New York.

Expert Perspective on Substance Use Treatment

A licensed clinical psychologist, substance-use treatment professional, and researcher from the University of Washington, with three decades of focus on effective substance use treatment (including for people experiencing homelessness), began studying involuntary treatment in 2018 with the implementation of "Ricky's Law" in Washington state.

The research indicates that while involuntary treatment for adults with substance use disorders may be necessary in extreme cases, it does not consistently outperform voluntary care and raises significant concerns regarding patient safety.

Defining Involuntary Treatment

Individuals struggling with substance use disorder often encounter various forms of pressure to seek treatment. This pressure can be informal, such as pleas from family members, or formal, like court-mandated treatment. Involuntary treatment, officially known as "involuntary civil commitment" in the U.S., stands as the most restrictive form of formal coercion.

Civil commitment grants a court, frequently based on a health care professional's evaluation, the authority to order the involuntary deprivation of liberty. This typically involves confinement in a locked treatment facility. Unlike court-mandated treatment, which implies a degree of consent, involuntary treatment is administered entirely without consent and against a person's will. The duration of such treatment is legally determined by court order and state law.

Such treatment is usually considered when an individual poses an imminent risk of serious physical harm to themselves or others, or in cases of grave disability where an adult cannot care for themselves without assistance.

Historical Context and Expansion

Involuntary treatment has historically been reserved for extreme circumstances. This caution stems from widespread institutional abuses in state psychiatric hospitals during the 19th and early 20th centuries, where patients were often confined for extended periods and stripped of their civil rights. Reforms in the 1960s subsequently reduced the application of civil commitment law and strengthened patient legal protections.

However, recent decades have witnessed a renewed interest in involuntary treatment, particularly for substance use disorder. As of early 2026, 37 states and the District of Columbia have laws permitting involuntary treatment for substance use disorder. Most of these jurisdictions have either added new or expanded existing civil commitment statutes within the last decade. These statutes vary widely in their criteria, duration, and utilization.

Efficacy and Risks of Involuntary Treatment

Despite the significant expansion of these laws, there is no clear scientific evidence demonstrating the effectiveness of involuntary treatment for substance use disorder.

Systematic Reviews

Three systematic reviews (2005, 2016, 2023) have summarized research on coercive substance use treatment in adults. When these reviews are limited to studies of true involuntary treatment (civil commitment), the literature indicates no measurable benefit and, in some cases, clear harm.

Common Harms

The most commonly cited harms associated with involuntary treatment include:

• A higher risk of relapse.
• Increased likelihood of rearrest.
• A greater risk of death following release from treatment.

One international study specifically indicated that the risk of death increases two- to nearly four-fold in the weeks post-release, primarily due to overdose.

Program Evaluations

Currently, there is no consistent and transparent program evaluation and reporting framework for involuntary substance use treatment in the U.S. Massachusetts and Washington are among the few states that have published outcome evaluations of their programs.

• Massachusetts Data: Adults with a history of involuntary treatment under Massachusetts Section 35 law experienced a 40% higher risk of death from overdose compared to those without such a history.
• Washington Data: Washington's program has published only one evaluation in eight years. This evaluation showed mixed short-term results, including modest reductions in emergency department use and homelessness, but revealed lower rates of follow-up treatment and no change in arrests or employment. Crucially, no analysis of subsequent substance use outcomes or post-release mortality was conducted.

More data and frequent reporting are urgently needed to determine the true effectiveness and safety of involuntary treatment. Documenting patients' subjective experiences, similar to studies for psychiatric disorders, may also help improve delivery.

Financial Costs

Voluntary inpatient substance use treatment is already significantly more expensive than lower-intensity, lower-barrier treatment and service settings. Involuntary treatment adds further substantial costs due to secured, statutorily designated placement, formal court proceedings, and ongoing legal oversight.

• Massachusetts: Involuntary treatment under Massachusetts Section 35 law is estimated to cost US$76,819 per male patient annually.
• Washington: The average 11-day stay costs $7,298. Washington's program yielded a low benefit-to-cost ratio, with the program losing approximately 81 cents for every dollar spent within the first year after treatment.

Existing U.S. evaluations have not indicated that involuntary treatment reduces publicly funded service costs enough to offset its expense.

Alternative Solutions

Evidence consistently supports lower-barrier and voluntary approaches as more effective, less costly, and less risky than involuntary treatment. These proven alternatives include:

• Housing Options: For individuals with substance use disorder who also experience homelessness, this includes affordable and supportive housing, ranging from abstinence-based recovery housing to low-barrier permanent supportive housing paired with services like Housing First. Research consistently demonstrates Housing First's effectiveness in increasing housing stability and reducing publicly funded service use.
• Harm Reduction Programs: These encompass street-based engagement, syringe service programs, and providing naloxone kits for overdose reversal. Such programs prevent overdose, reduce blood-borne illness transmission, and connect individuals to voluntary services and treatment.
• Effective Treatments: Behavioral treatments and medications like buprenorphine, methadone, naloxone, and naltrexone are considered gold standards in substance use treatment and overdose prevention. They are proven to reduce craving and overdose risk.
• Justice System Diversion: Programs that divert individuals convicted of low-level drug use and possession crimes from jail have shown to be highly effective. Case managers in these programs assist participants in finding housing and vocational services, leading to improved stability, reduced recidivism, and alleviated strain on the legal system.

Given the lack of scientific evidence supporting involuntary treatment, its expansion beyond acute, life-threatening crises is considered unwarranted. Investment in and delivery of lower-barrier, voluntary services are seen as more effective in saving lives, reducing harm, and fostering sustainable recovery.