The Pendulum Swings from Deinstitutionalization to Expanded Civil Commitment

Expanding Authority for Involuntary Evaluation

In 2022, following a string of violent crimes perpetrated by individuals with mental health disorders, New York City’s Mayor Eric Adams directed city agencies to more fully utilize existing authority under Article 9 of the state’s Mental Hygiene Law.^31,32 This directive empowered law enforcement and outreach workers to remove persons who appear to be mentally ill from the street for a psychiatric evaluation when they display an inability to meet basic living needs, even in the absence of recent dangerous acts.^32,33 Under this guidance, the New York Police Department, Emergency Medical Services, and Department of Health and Mental Hygiene outreach teams were authorized to initiate such removals using the “likely to result in serious harm” (Ref. 33, § 9.01 (c)) standard already present in Article 9.^32,–,34

Mayor Adams described this provision as a part of the city’s “moral obligation” to those New Yorkers “suffering from mental illness.”³¹ At least some bioethicists voiced agreement, opining that it is morally dangerous to place so much value on individual autonomy while having so little support for people in need.³¹ Advocates argued that the approach will prevent avoidable suffering and incarceration, whereas critics warned it risked expanding coercive state power without addressing the underlying shortage of mental health resources. Critics have also raised concerns about continued reliance on law enforcement to conduct psychiatric transports given the risks of stigma, escalation, and retraumatization, particularly in communities of color.^32,35

In 2025, New York State enacted amendments to the state’s mental hygiene law commitment standards, clarifying that a “substantial risk of harm” may include being gravely disabled (i.e., being unable to meet basic needs of food, shelter, or medical care).³⁶ In announcing these changes, New York’s Governor Kathy Hochul cited recent violent incidents on the subways believed to have been perpetrated by individuals experiencing untreated mental illness.^36,37 Governor Hochul has paired the amendments with new investments in psychiatric beds, supportive housing, and crisis services, although critics maintain that these steps fall short of the system’s broader capacity needs.³⁷

Historical Context and Emerging Critiques

These shifts reflect New York’s longstanding role as a national bellwether in mental health policy, with the pendulum periodically swinging toward broader intervention in response to perceived crises, resulting in pioneering, and often polarizing, civil commitment reforms that draw both emulation and critique.³⁸ The state’s Kendra’s Law, passed in 1999, created one of the nation’s longest-standing involuntary commitment frameworks, allowing courts to mandate outpatient psychiatric care for individuals with histories of treatment nonadherence and repeated hospitalizations or violent incidents.³⁹

Critics of the Mental Hygiene Law clarifications and implementation changes have argued that, although the legal tools for intervention have long existed, the root of the crisis rests with insufficient investment in housing, outpatient care, and care coordination, rather than within statutory gaps.^40,–,42 At the time these changes took effect, the IOC waiting list already exceeded 800 people.⁴² The New York Civil Liberties Union (NYCLU) expressed “grave concerns” about the changes, cautioning that these practices could undermine procedural safeguards and lead to excessively broad or coercive enforcement.⁴³ Other critics warn that they risk transforming New York into “the coercion capital of the country.”⁴⁴ Further opposition has been voiced regarding operational implementation, with clinicians stating that the broadened application may result in a revolving door of involuntary detentions, overburdened hospitals, and inflated court dockets without sufficiently increasing access to long-term outpatient resources.^45,46

Although policymakers such as Mayor Adams and Governor Hochul have defended these reforms as necessary and, in Hochul’s case, paired them with new investments in inpatient beds, housing, and crisis services, critics have cautioned that expanded commitment authority may still outpace the capacity of the voluntary system.^45,46 Advocacy groups, including the NYCLU, have argued that statutory and operational changes without commensurate development of community infrastructure risk displacing rather than stabilizing individuals, leading to repeated short-term detentions rather than sustained recovery.⁴³ These concerns underscore that legal innovation can broaden the ability to intervene, but without robust housing, outpatient care, and crisis supports, reforms may inadvertently reinforce cycles of coercive encounters and fragmented care.

Historical Context and Policy Foundations

California has historically served as a national trendsetter in civil commitment legislation. At its peak in the mid-20th century, California’s state hospitals housed more than 30,000 individuals, often in overcrowded and underfunded conditions.⁴⁷ The state’s 1967 Lanterman-Petris-Short (LPS) Act⁴⁸ ensured due process for individuals subject to involuntary treatment and led the national trend toward deinstitutionalization, a pendulum that in recent years has begun to swing back toward expanded civil commitment.⁴⁷

By 1975, five California jails reported an increase of over 300 percent of people with chronic mental illness in their populations over the prior decade. They cited the lack of available community treatment and the increasingly punitive criminal laws, often traced to President Nixon’s war on drugs, on incarceration for drug-related crimes and petty theft that disproportionately affected those with chronic mental illness.⁴⁹ Subsequent legislation, including the creation of IOC under Laura’s Law in 2002, sought to address these gaps by enabling court-ordered outpatient care for individuals with repeated hospitalizations and law enforcement encounters.^24,50 Few counties implemented IOC, however, and community treatment resources remained inadequate.⁵¹

Recent Legislative and Structural Reforms

By 2020, California faced escalating, visible, and overlapping crises of homelessness and substance use disorders, prompting state leaders to seek more assertive interventions. Governor Gavin Newsom emphasized the need to reform involuntary treatment laws to better address individuals with severe mental illnesses and substance use disorders who were unable to care for themselves, often cycling through emergency rooms and jails.^49,52

The same year, the California State Auditor published an audit of the LPS Act, focusing on Los Angeles, San Francisco, and Shasta Counties.⁵¹ The independent report concluded that system capacity constraints, not statutory gaps, drive poor access to care and found no evidence supporting expansion of the LPS Act commitment criteria. The report held that the state and local governments lacked adequate treatment capacity. On average, individuals committed under the LPS Act waited 345 days for a state hospital bed and those on the waitlist did not receive adequate care in the community. The report also found that many California counties lacked access to community hospitals’ data and only one-third had adopted IOC. As a result, only nine percent of patients with five or more short-term involuntary holds were appropriately registered in full-service partnerships (intensive, recovery-oriented outpatient programs funded through California’s Mental Health Services Act) or IOC.⁵¹

In 2020, California Assembly Bill (AB) 1976⁵³ required all counties to participate in IOC and California Senate Bill (SB) 507⁵⁴ amended the IOC legislation and removed the requirement for patients to be substantially deteriorating to qualify for the program. The bill also introduced a capacity affidavit for psychotropic medications to address concerns about treatment nonadherence. In 2022, California SB 1338 established the Community Assistance, Recovery, and Empowerment Court program, known as the CARE Act.⁵⁵ This legislation allows petitions to be filed not only by family or household members, first responders, treating clinicians or hospital directors, county officials, and authorized tribal officials but also by the respondents themselves. This reflects a departure from traditional civil commitment frameworks, which generally do not permit self-petition. The CARE model prioritizes voluntary treatment engagement while including judicial oversight through a court-ordered CARE agreement or plan. Respondents who are eligible for the CARE Act include adults with a schizophrenia-spectrum or other psychotic disorder who are not clinically stabilized in voluntary care and are likely to benefit from a least-restrictive CARE plan that coordinates treatment, housing, and social services to prevent hospitalization, homelessness, incarceration, and conservatorship.

The California Department of Health Care Services (DHCS) released its fiscal year 2022 report in 2024 on IOC’s effectiveness in reducing program participants’ homelessness, hospitalizations, and involvement with local law enforcement across 27 counties.²³ Where implemented, IOC participants experienced a 52 percent decrease in hospitalizations, a 41 percent decrease in law enforcement contacts, and a 16 percent decrease in homelessness. They also experienced a 61 percent decrease in violent behavior, a 60 percent decrease in victimizations, and a 31 percent decrease in substance use. Forty percent secured employment or education, with some counties also finding that social functioning improved by 82 percent.²³

Although the 2020 LPS Act audit did not identify a need to expand involuntary civil commitment criteria,⁵¹ California Senate Bill 43, enacted in 2023, provided for an expansion.⁵⁶ Before SB 43, LPS Act eligibility required danger to self, danger to others, or being gravely disabled (i.e., unable to provide for one’s own food, clothing, or shelter) because of a mental disorder. The amendment adds severe SUD, including chronic alcoholism, as defined in the latest edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM)^56,57 and broadens “gravely disabled” to include an inability to provide for one’s personal safety or necessary medical care because of a mental disorder or severe SUD; it also authorizes conservatorship under these new criteria.⁵⁶ In 2024, California SB 1238 expanded the definition of LPS “designated facility” for civil commitments under the LPS Act to include psychiatric, general acute care, and chemical dependency hospitals or facilities for the treatment of severe SUD.⁵⁸

Implementation Challenges and Critiques

California’s recent reforms represent an effort to modernize its civil commitment framework in response to mounting political and public pressure driven by the state’s homelessness and substance use disorder crises. Some legislative changes, however, particularly the expansion of civil commitment criteria to include individuals with SUD under SB 43 and the CARE Act, have drawn sharp criticism.^59,–,63 Counties, including Los Angeles, delayed implementation of SB 43, citing fears of litigation, lack of infrastructure, and concerns about disproportionate impacts on marginalized communities.⁵⁹ Civil liberties groups, psychiatrists, and county leaders have raised concerns about the availability of appropriate treatment resources, the practical and legal feasibility of implementation, and the potential for these laws to further entrench structural inequities by disproportionately targeting unhoused and minority individuals without adequate procedural safeguards.^60,–,63

These concerns highlight a disconnect between California’s legislative responses and the existent realities of its mental health infrastructure. Although the reforms aim to address the gaps that were not fully realized under the initial LPS Act framework, their success will depend on continuous investment in voluntary, community-based care, procedural safeguards, and stable funding mechanisms.

Historical Context

Changes in Minnesota’s civil commitment framework exemplify a system grappling with the growing strain of competency restoration demands and limited inpatient resources. Like other states, Minnesota experienced a dramatic decline in long-term state hospital capacity beginning in the 1950s, with overall bed space decreasing by 75 to 90 percent.^64,65 From 2013 to 2023, Minnesota saw a sharp increase in referrals for individuals found incompetent to stand trial (IST), straining state hospital resources, driving up wait times for competency restoration services, and exposing longstanding gaps in the state’s behavioral health system.^66,–,68 As dwindling civil capacity was stressed by expansion of civil commitment referrals from the criminal court, some individuals cycled between jail, hospitalization, and the community, sometimes without ever regaining full competency or without sustained access to treatment.⁶⁶ These pressures were intensified by features of the Minnesota criminal code that presumed sufficient inpatient resources to support competency attainment exclusively through civil commitment referrals.

System Strain and Legislative Change

Public concern reached a peak following a high-profile local investigative series, “The Gap,” published by local news station KARE 11.^69,70 The series spotlighted several violent crimes involving defendants previously deemed IST, framing the failures of Minnesota’s mental health system as a public safety crisis. The media coverage, although drawing attention to the state’s treatment capacity challenges, often highlighted outlier cases, some of which may reflect failures of the criminal justice and community mental health systems rather than the competency restoration process. Nevertheless, the stories galvanized bipartisan legislative action. In 2022, the Minnesota legislature passed sweeping reforms aimed at overhauling the state’s approach to competency restoration and civil commitment.⁷¹ These changes reflect a shift in the pendulum from a primarily treatment-centered model toward one with greater legal oversight and control.

Prior to the 2022 reforms, the state relied exclusively on civil commitment for competency restoration.^66,67 Statutes mandated the dismissal of low-level charges upon such findings, and for high-level charges, the state relied on indeterminate civil commitment for long-term hospitalization and supervision of individuals found incompetent to stand trial, nonrestorable, and dangerous (IST and NR&D).⁷² This form of indeterminate commitment parallels Minnesota’s not guilty by reason of insanity or not criminally responsible (NGRI or NCR) commitment framework. Until 2022, civil commitment was the only pathway for providing competency attainment services, yet even those committed were not guaranteed treatment specifically aimed at competency attainment. As a result, the criminal justice system served as a significant source of referrals for civil commitment but had little to no authority to mandate behavioral health treatment or to ensure supervised treatment of IST cases toward a final disposition. Individuals found IST that met civil commitment criteria could be hospitalized, but they were not required to remain until restored or charges resolved; those who did not meet civil commitment criteria often received no treatment or aftercare, particularly in under-resourced communities.⁶⁶

Among the most consequential 2022 reforms was the shift allowing criminal courts to retain jurisdiction over IST cases rather than deferring entirely to a civil commitment and state-hospitalization model. The intent of this change was to avoid unnecessary delays and premature release from custody without the criminal court’s awareness or input, in addition to promoting efficient use of state hospital resources. Under this new scheme, the criminal court is required to use validated risk assessments and input from forensic examiners to determine the least-restrictive level of supervision for competency attainment services, specifically considering the impact of substance use on competency and need for court-ordered medications.^71,73 The statute also created a centralized state agency responsible for overseeing competency restoration, designed to streamline coordination between courts, hospitals, jails, and outpatient providers and certify entities providing competency attainment education. The legislation further introduced forensic navigators charged with supporting individuals through the treatment process and assisting courts with aftercare planning.

Implementation and Stakeholder Concerns

Although the new law formalized these innovations, its implementation is still in the early stages, and its long-term impact remains uncertain. Supporters hope the changes will improve both public safety and access to individualized care; potential criticisms are that the model may entrench court involvement at the expense of clinical autonomy and could shift rather than resolve the state’s resource shortfalls.^69,70

Minnesota’s evolving framework underscores the inherent tension between the medical model of evidence-based treatment and the political nature of making policy. Sullivan argues that such dynamics are unsurprising: when dramatic events dominate the media, policymakers tend to respond to what they feel, not necessarily to long-term system data.⁷⁴ As forensic psychiatrists engaged in shaping commitment laws, we must navigate a landscape where public fear, values, and media narratives hold significant sway. Ultimately, civil commitment laws reflect not only clinical evidence but also the cultural, legal, and moral priorities of the communities they serve.