The Limits of Coercion: What Research Reveals About Involuntary Substance Use Treatment

As President Trump’s July 2025 executive order focusing on “ending crime and disorder on America’s streets” gains traction, a renewed emphasis on involuntary treatment for individuals experiencing homelessness and substance use disorder is taking shape across the United States. From plans for a large-scale facility in Utah – offering a choice between abstinence-based shelter and incarceration – to similar proposals in states like Recent Jersey, Washington, and New York, the idea of compelled treatment is gaining momentum. But decades of research paint a complex picture, suggesting that while involuntary intervention may be necessary in extreme circumstances, it consistently underperforms voluntary care and carries significant risks.

I’ve spent three decades as a licensed clinical psychologist and substance use treatment professional, and my research has consistently focused on what truly works in the field. Beginning in 2018, with the implementation of Washington State’s “Ricky’s Law,” I began a deep dive into the existing body of evidence surrounding involuntary treatment. What emerged was a clear pattern: while sometimes necessary, it’s rarely the most effective path, and often carries unintended consequences.

Defining Involuntary Treatment: Beyond Simple Coercion

It’s crucial to distinguish between the various forms of pressure individuals with substance use disorder may face when considering treatment. Informal coercion – pleas from family, or providers linking services to housing – and formal coercion like court-mandated treatment, still involve some degree of consent, however limited. Involuntary treatment, or “involuntary civil commitment,” is fundamentally different. It authorizes a court to deprive someone of their liberty, confining them to a locked facility, often against their will, with the length of stay determined by legal order.

This level of intervention is typically reserved for situations where an individual poses an imminent threat to themselves or others – expressing suicidal or homicidal intent with a concrete plan – or demonstrates “grave disability,” meaning they are unable to care for themselves. This cautious approach stems from a historical awareness of the abuses that occurred in earlier eras of institutionalization.

A History Marked by Abuse and Renewed Concern

The use of involuntary commitment isn’t new. Throughout the 19th and early 20th centuries, state psychiatric hospitals were plagued by abuses, with patients confined for years, stripped of their rights, and subjected to inhumane conditions. Reforms in the 1960s significantly narrowed the criteria for civil commitment and strengthened legal protections. However, in recent decades, there’s been a resurgence of interest in involuntary treatment specifically for substance use disorder. As of early 2026, 37 states and the District of Columbia have laws allowing it, with many expanding these statutes in the last decade. NPR reports that this shift reflects a desire for more assertive interventions.

The Evidence: Heightened Risks and Limited Benefit

Despite this growing trend, robust scientific evidence supporting the effectiveness of involuntary treatment for substance use disorder remains elusive. Three systematic reviews – comprehensive analyses of peer-reviewed research – conducted in 2005, 2016, and 2023, consistently demonstrate a lack of measurable benefit and, in some cases, clear harm. A critical distinction is that many studies labeled as “involuntary treatment” actually involve mandated but voluntary care, not true civil commitment. When focusing solely on studies of genuine involuntary treatment, the literature reveals a concerning pattern: higher rates of relapse, rearrest, and even death following release from treatment.

One international research study found that the risk of death increases two to nearly fourfold in the weeks after release, primarily due to overdose. This underscores a critical point: forcibly removing someone from their environment and disrupting established patterns of substance use can be profoundly destabilizing.

Currently, there’s a significant lack of consistent and transparent program evaluation in the U.S. Massachusetts and Washington appear to be the only states to have published outcome evaluations of their involuntary treatment programs. Data from Massachusetts showed a 40% higher risk of overdose death for individuals with a history of involuntary treatment compared to those without. Washington’s program, after eight years of operation, has produced only one evaluation, showing modest short-term reductions in emergency department use and homelessness, but no change in arrests or employment, and no analysis of long-term substance use outcomes or mortality. CNN’s coverage highlights the ongoing debate surrounding these programs.

The Financial Costs of Coercion

Beyond the ethical and safety concerns, involuntary treatment carries a substantial financial burden. Voluntary inpatient treatment is already significantly more expensive than lower-intensity options. Adding the costs of secured facilities, court proceedings, and ongoing legal oversight further escalates expenses. In Massachusetts, involuntary treatment under Section 35 law costs an estimated $76,819 per male patient annually. An 11-day stay in Washington averages $7,298, with a low benefit-to-cost ratio – losing approximately 81 cents for every dollar spent within the first year. Evaluations to date haven’t demonstrated that involuntary treatment reduces publicly funded service costs enough to justify its expense.

What Works: Prioritizing Voluntary, Lower-Barrier Approaches

The evidence consistently points towards lower-barrier and voluntary approaches as more effective, less costly, and less risky. For individuals experiencing both substance use disorder and homelessness, this includes a range of affordable and supportive housing options, such as Housing First, which prioritizes housing without preconditions. Research demonstrates that Housing First increases housing stability and reduces reliance on publicly funded services. Harm-reduction programs – including street-based outreach, syringe service programs, and naloxone distribution – are also crucial for preventing overdose, reducing the spread of blood-borne illnesses, and connecting individuals to voluntary treatment.

Effective behavioral therapies and medications like buprenorphine, methadone, naloxone, and naltrexone represent the gold standard in substance use treatment and overdose prevention. Justice system diversion programs, which offer treatment and support instead of incarceration for low-level drug offenses, have also proven effective in reducing recidivism. The White House’s executive order, while emphasizing enforcement, doesn’t fully address the need for expanded access to these evidence-based services.

Given the lack of compelling evidence supporting involuntary treatment, expanding it beyond acute, life-threatening crises appears unwarranted. It’s not a substitute for investing in and delivering lower-barrier, voluntary services that have been proven to save lives, reduce harm, and foster sustainable recovery.

Looking Ahead: The Need for Data and a Shift in Focus

More frequent and comprehensive program evaluations are urgently needed to determine the true effectiveness and safety of involuntary treatment. Documenting patients’ subjective experiences, as is done in psychiatric settings, could also help improve its delivery. A shift in focus towards evidence-based, voluntary approaches is essential to address the complex challenges of substance use disorder and homelessness effectively and ethically.