Is Compulsory Treatment An Answer For Homelessness?
President Trump recently proposed a shift in approaching homelessness toward compulsory treatment. Explaining his rationale, "Our once-great cities have become unlivable, unsanitary nightmares. For those who are severely mentally ill and deeply disturbed, we will bring them to mental institutions, where they belong, with the goal of reintegrating them back into society once they are well enough to manage." The President has included substance use disorder in his definition of mental illness. Is it the case that compulsory treatment is an effective approach?
In “Patients with substance use disorders need care, not coercion” at Harvard Public Health the authors state bluntly, “Forced treatment doesn't work. It's time for health leaders to invest in better alternatives.”
We tend to think of compulsory treatment as something new and a policy of last resort. It is neither. The authors note that their home state of Massachusetts involuntarily commits more than 6,000 individuals each year for substance use disorders under a statute allowing family members, medical providers, and law enforcement to forcibly detain individuals for up to 90 days when they pose “a clear and convincing risk of harm” to themselves or others. They report that such laws exist in 38 states. A last resort implies that other things have been tried. No reasonable person could suggest that we have taken the necessary steps to treat homelessness or substance use disorder.
The authors point to implementation issues as a great part of the failure. Compulsory treatment often co-mingles patients with criminals thus traumatizing them from the start and introducing a behavioral health issue as criminal. In America today the disease model is the prevalent basis for treatment and requires the patient being treated not as a criminal or moral failure but as a human being with a medical issue albeit sometimes with socially problematic consequences.
Further, they note that hospitals that are often the point of entry for involuntary treatment are not equipped to address substance use disorder treatment that is best addressed immediately. Rather than administering proven, effective medical assistance such as suboxone and introducing some form of behavioral health therapy, hospitals per force isolate the patient relatively unattended awaiting transfer. Attention to withdrawal symptoms now forced on the patient are lacking and can result in severe medical issues and even death.
Another study published in the International Journal of Drug Policy, “THE EFFECTIVENESS OF COMPULSORY DRUG TREATMENT: A SYSTEMATIC REVIEW” reviewed several studies on the effectiveness of compulsory drug treatment. These authors also note that compulsory treatment is not new or ever rare. The reviewed studies showing that as of 2009, 69% of a sample of 104 countries had criminal laws allowing compulsory drug treatment.
The authors conclude, “There is limited scientific literature evaluating compulsory drug treatment. Evidence does not, on the whole, suggest improved outcomes related to compulsory treatment approaches, with some studies suggesting potential harms. Given the potential for human rights abuses within compulsory treatment settings, non-compulsory treatment modalities should be prioritized.”
Why doesn’t involuntary treatment work? The most likely issue is personal motivation. The most successful approach to date, twelve step approaches, historically targeted only the most severe cases in that they were the most highly motivated to make change and accept the requirements for doing so. Today that motivation is achieved in many cases without going so far down the famed Jellinek Curve, but persistent motivation is still the bedrock condition. Involuntary treatment will not likely spur that motivation and may create further resistance. That resistance may include further stigmatization that people with a substance use issue and homelessness experience. Today there are approaches to creating motivation, but involuntary confinement is not one of them.
There are execution issues as also noted in both studies cited. The initial engagement may be in a hospital or carceral setting that is not conducive to successful treatment. The length of stay in typical treatment approaches is often inadequate to the task. Related, individuals who have been identified typically have many and often severe underlying issues that require intense and long term attention that is most often not addressed.
Both studies cited also raised concerns about the ethics of involuntary commitment. Certainly, there are people in America who are unable to effectively navigate in society with the skill sets they have been able to develop. Oftentimes severe physical and intellectual issues require additional support. That is not, in the main, what we are talking about here. In many States deploying involuntary detention strategies can only occur for short periods of time without a judicial proceeding. Again, that is not what we are talking about here. Drawing the line between supportive compulsory treatment, where that is a legitimate concern for an individual, and less well motivated intentions is not an easy task. Callous disregard for that fine line is certainly unethical. Too often we are left to conclude that what we are seeing is yet another attempt to corral the homeless and get them out of sight. Sadly, that happens all too often in our experience.
Given that the evidence for improved outcomes from compulsory treatment for substance use disorder is at best weak, and the ethical issues involved, we can only conclude that current proposals are not effective at reducing homelessness or active substance abuse and that they should not be pursued.
Gene Gilchrist
October 2025
