By Dawn Brunkalla, Accessibility Educator, Global Disability Caucus

The other day, I heard someone ask, "Didn't the United States close its institutions for people with mental illness and disabilities?" 

In short, the answer is no. 

Beginning in the 1950s, the United States focused efforts on deinstitutionalization, which brought services for people with mental health conditions and other disabilities away from large institutions into community-based support. Fast forward 75 years, and we are taking steps backward toward institutionalization.

It is difficult to educate and understand about an issue so personal with such tremendous consequences for individuals and families. It is difficult to advocate for policies around institutionalization that support and honor disabled individuals.  Many times the policy decisions that hurt our rights are hidden in seemingly unrelated bills. There are hundreds of bills in the states that would touch on this issue, but they are scattered through different levels of state and federal governments. One of the most important actions you can take is to vote. Vote IN elected officials who support the independence and dignity of disabled individuals; vote OUT those who don’t.   

Local hospitals opened outpatient centers and short-term inpatient treatment programs. Services became available within our neighborhoods, and independent living centers were developed. 

Those actions were built on  a tremendous amount of civil rights history, advocacy, and legal battles. It was not simple, and it was not easy to change society's view of treatment and support for mental health and other disabilities. The call to action was there, and over time the movement toward community-based services became accepted as best practice. 

So, to answer the question, yes, many state-run and privately operated institutions were closed. However, these institutions still exist. With major shifts in U.S. policies and potential Medicaid cuts, it is important to examine current ideological trends carefully. We need to have these conversations. We cannot afford to turn a blind eye to the changing political landscape fueling these backward steps. 

Vigilance matters: dehumanizing language, segregation, and policies that treat certain lives as less valuable can have grave consequences if left unchecked. In Nazi Germany, adults and children with disabilities and mental illnesses were the first groups targeted for systematic state-sponsored killing under the Nazi Aktion T4 program. 

Civil Commitment 

One hundred years ago in the United States, it was relatively easy to have a person placed in an institution, or, to use the outdated term, an "asylum." Women had few legal rights and could be institutionalized without consent for reasons that today would not be considered a mental disorder. This included religious beliefs, epilepsy, or simply behaving in ways that were not understood or accepted by their families or husbands. Rates of institutionalization were especially high among immigrant women. 

Today, there are strict legal criteria for taking away a person's freedom. The modern term is civil commitment. It is not a criminal proceeding, but a civil process grounded in strong due process protections. 

Civil commitment is a court-ordered, involuntary psychiatric treatment process used when a person meets strict legal criteria, typically when they pose a danger to themselves or others, or when they are gravely disabled and unable to care for their basic needs. 

Some people require intensive care and treatment. There are individuals who do pose a danger to themselves or others and who cannot take care of their most basic needs. We cannot overlook the need to support vulnerable people while also keeping our communities safe. Civil commitment remains a part of our healthcare system. Because of the vulnerability of those subject to civil commitment, states have developed laws that work with constitutional safeguards, including the due process protections guaranteed by the Fourteenth Amendment to the United States Constitution. These protections help ensure that any deprivation of personal liberty is subject to judicial review and procedural safeguards. 

State initiatives to watch 

California has expanded CARE Courts, supported broader use of conservatorships, and increased the use of court-ordered treatment for some individuals with severe mental illness. 

CARE Court is a California program created in 2022 that allows family members, clinicians, first responders, and others to petition a court to connect a person with mental illness to treatment and services. While supporters view the program as a way to help individuals access care, critics argue that it expands court involvement in mental health treatment and may erode civil liberties and self-determination. Many believe that resources would be better spent expanding voluntary community-based services, affordable housing, crisis supports, and other interventions that allow individuals to receive assistance without court involvement. 

New York is a closely watched state in the debate over civil commitment and involuntary treatment. Historically, New York generally required a finding that a person posed a danger to themselves or others before involuntary hospitalization could occur. 

In 2025, New York amended its law to clarify that a person may meet the standard for involuntary hospitalization if, because of mental illness, they are unable or unwilling to provide for essential needs such as food, clothing, shelter, medical care, or personal safety. At the same time, the state has expanded inpatient psychiatric capacity, including the addition of 100 forensic psychiatric beds in New York City. 

As a result, an individual may now be hospitalized involuntarily even if they have not recently engaged in violence, threatened self-harm, or committed a criminal act, if their mental illness substantially impairs their ability to obtain basic necessities or maintain their personal safety. Some are concerned that the changes expand government authority to deprive individuals of their liberty based on subjective judgments about their ability to care for themselves. For many advocates, that shift raises important concerns about due process, self-determination, supported decision-making, and constitutional protections. 

Institutions exist and are unlikely to disappear altogether. The debate, in my view, is about the role they should play within a system that has, for decades, increasingly emphasized community integration, self-determination, and services delivered in the least restrictive setting possible. 

I do not believe that creating larger congregate settings is the answer. To me, that would represent a step backward toward the days of the asylum  "out of sight, out of mind" approach that separated people and limited their personal choice. 

Instead, we should focus on strengthening community-based services, addressing workforce shortages, supporting families, and ensuring that people have access to the individualized supports they need to live meaningful lives in their communities. Institutions may continue to serve a limited role for some individuals with highly specialized needs, but they should not become the primary solution to gaps in our service system. An  institutional setting should be the last resort. 

We must work together to make sure that our due process safeguards remain. We cannot allow preconceived ideas, stereotypes, fear, or discrimination to override our obligation to see the person as an individual and respect their constitutional rights. We must keep a watchful eye. Protecting both individual rights and access to appropriate care is an essential part of democracy. 

On July 24, 2025, President Donald Trump issued Executive Order 14321, "Ending Crime and Disorder on America's Streets." Among its provisions is a call for increased use of involuntary commitment for individuals with mental illness and substance use disorders. The order assumes a connection between homelessness, mental illness, addiction, and crime. 

The Executive Order sets a tone. Several states have recently enacted policies that make involuntary commitment easier or expand institutional and court-ordered treatment options. These developments should raise concerns about due process, self-determination, and whether the nation is moving away from community-based services and toward more restrictive forms of care.