One flew back to the cuckoo’s nest: Forced institutionalization will not fix America’s homelessness and mental health crises

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An important but painful chapter in American history — one for which Donald Trump has expressed nostalgia — is the story of “homes for the insane.” Patients were placed in these institutions involuntarily in order to isolate them from society. Such psychiatric facilities are known to the broader public thanks largely to the book and film One Flew Over the Cuckoo’s Nest. In real life, as in the “fictional version,” harsh methods including the use of lobotomy were prevalent, and conditions in general were frequently horrific. Some people ended up being “hospitalized” by chance, and then found themselves unable to get out for years. However, thanks to civil rights advocates, journalists, and activists, in the 1950s a movement for deinstitutionalization began in the United States, and most facilities where people with mental illnesses were forcibly confined were gradually closed.

In 2018, during his first term, Trump delivered a speech after the Parkland shooting in Florida. Instead of addressing the issue of access to firearms, the president said: “We used to have mental institutions… You have these people living on the streets.” He suggested that bringing such institutions back could help prevent mass shootings.

In 2019, Trump repeated the same argument — this time after mass shootings in El Paso and Dayton. According to him, “mental illness and hatred pull the trigger, not the gun.” The president called for revising involuntary commitment laws in order to isolate “dangerous” people with mental illnesses, and he again proposed bringing back homes for the insane. Strangely enough, in 2017 Trump had actually made it easier for people with serious mental disorders to access firearms.

Despite the president’s rhetoric, data show that only a quarter of mass shootings are committed by people with actual mental illnesses, and even in those cases a much larger role is played by easy access to firearms and such stress factors as past trauma, early childhood violence, and personal crises. Nevertheless, Trump returned to the topic of mental health in 2020, when during the election campaign he promised to increase funding for relevant programs, and he raised the issue again in 2024 when he promised to deploy the National Guard to dismantle homeless encampments and send people with severe mental illnesses “back to mental institutions where they belong.”

Each time, Trump’s statements directly linked severe mental illnesses and homelessness. Unfortunately, this is not an accident or a stereotype, but a reality in today’s America. The country is experiencing two major crises, and they are closely intertwined.

New York: Mental illness, homelessness, and violence

In January 2022, 44-year-old Michelle Go died in the New York City subway. She had worked at a consulting firm, lived on the affluent Upper West Side, and provided free advice to struggling families, including those forced to live on the streets. On a Saturday morning, as Michelle waited for a train at Times Square station, a man approached her from behind and pushed her onto the tracks in front of an oncoming train.

The killer turned out to be 61-year-old Martial Simon, who had lived on the streets of New York for more than 30 years with a diagnosis of schizophrenia. In 2022, Simon became a symbol of America’s failing psychiatric system. He had cycled through dozens of hospitals and jails, yet he remained on the street without sufficient help — even though he wanted to receive it. In the end, the failure to provide that help resulted in the death of an innocent person.

New York, like the rest of the country, faces a catastrophic shortage of beds in psychiatric facilities. Since 1995, their number in state psychiatric hospitals has fallen by roughly 95% — from 340 beds per 100,000 people back then to just over 11 per 100,000 in 2016. Many experts consider 50 beds per 100,000 residents to be a critical threshold.

Such a shortage of beds is the result of deinstitutionalization. Previously, state-run facilities provided 80% of all beds, but by 2002, more than 68% of places for people with mental illnesses had moved into the private sector. The remaining publicly funded beds are now most often occupied by people deemed insane and convicted in criminal cases.

This means that if someone wants to be hospitalized with a serious mental illness, there is a high chance there will simply be nowhere for them to go. And if a bed is found, they will face the problem of paying for treatment in the hospital. These expenses are covered (partially, at least) by special programs financed by the federal government or state authorities, as well as by insurance. Medicaid, which previously helped cover treatment in psychiatric wards, has sharply cut reimbursements for long-term stays, making it unprofitable for hospitals to keep people with mental illnesses.

As a result, patients are discharged as quickly as possible. Simon, who suffered from schizophrenia for decades, constantly complained to other homeless people about doctors and hospitals. He said he was released far too early — before he felt capable of living on his own.

Moreover, New York’s modern psychiatric care infrastructure does not allow the city to track what happens to someone like Simon. Before killing Michelle Go, he was already known to various authorities as a former inmate, as a patient who needed medication, and as a regular patient of psychiatric wards. But this information was never combined into a single system.

Under these conditions, hospitals and psychiatrists are increasingly discharging patients who should not be left on their own, says Dr. Xavier Amador, a schizophrenia expert who spent decades working in New York’s psychiatric programs. According to Amador, psychiatrists in the United States are forced to favor short-term solutions. “They are no longer taught to develop long-term treatment strategies,” he says. “They have been turned into mechanics who must get a patient ‘back on their feet’ in 72 hours or a week and then say with relief: ‘I’ve done my job.’”

After a short hospital stay, patients are prescribed medications for a brief period and released — often directly onto the street — with no further treatment plan. According to data from the U.S. Department of Housing and Urban Development, in 2024, 22% of homeless people had severe mental illnesses. That is significantly higher than the 5.5% recorded among the U.S. population as a whole.

Meanwhile, the homelessness crisis in the United States has reached its highest level since recordkeeping began in 2007. In 2024, the country had more than 771,000 people without stable housing following an 18% spike over the course of the previous year (and from 2022 to 2024 the overall increase exceeded 32%). The causes, as always, are complex: a severe housing shortage, surging rent, the end of pandemic-era benefits (such as financial assistance or the eviction moratorium), and inflation. New York, with its high rents, is the epicenter of both crises.

The Trump administration cuts funding

Under these conditions, the idea of forcibly hospitalizing people with severe mental disorders may actually seem reasonable. However, Trump’s proposal — and the executive order “Ending Crime and Disorder on America’s Streets,” issued on June 24, 2025 — must be understood in a broader context. The order effectively declares war on the existing homelessness assistance program Housing First, which prioritizes efforts to get a stable roof over people’s heads before addressing any underlying issues connected with addiction or severe mental illnesses. Similar programs exist in many countries around the world, including in Europe, and in the United States, they have been actively implemented over the past 20 years.

Trump’s order proposes a return to the old model of Treatment First, under which a person could receive help with housing only after receiving medical care, kicking addictions, and finding a job. The White House is rolling back more progressive initiatives mainly through major cuts and reallocations of grants and funding that housing first programs previously depended on.

A clear example is the in July 2025 closure of a dedicated suicide-prevention hotline for LGBTQ+ people. The project was launched in 2022 in order to address the specific mental-health challenges faced by LGBTQ+ people — including family rejection or discrimination — which have led to a disproportionately high suicide rate among the community. Funding allocation and rulemaking in the fields of addiction treatment and psychiatry (including oversight of the hotline) fall under the Substance Abuse and Mental Health Services Administration (SAMHSA), a federal agency within the U.S. Department of Health and Human Services. The agency explained the closure by saying that LGBTQ+ people can receive help through the general hotline and that there is no need to create a separate structure for them.

Under Trump, the official tasked with making decisions about what exactly to cut and how to reshape the system is Robert F. Kennedy Jr., head of the Department of Health and Human Services. RFK Jr. has claimed that vaccines cause autism, suggested that Jews and Chinese people are immune to Covid-19, and called for limiting access to the medications used to treat mental illnesses (in a report titled “Make America Healthy Again,” no less). Throughout 2025, many physicians and psychiatrists urged the White House to remove the secretary from his position. Needless to say, the Trump administration did not listen to them.

Under Kennedy’s leadership, SAMHSA underwent massive cuts that saw around 400 of its 900 employees laid off. The organization still plays a critical role in distributing grants focused on facilitating the provision of psychiatric and addiction care while also helping to train specialists nationwide, but its future appears uncertain. “SAMHSA funding is the backbone of the mental-health care system in this country,” says Rachel Winograd, a psychologist at the University of Missouri in St. Louis. “If these grants disappear, we’re doomed.”

Why “community care” does not work in the U.S.

Involuntary hospitalization already exists in America, but the decision to send a person to a psychiatric facility against their will must be made by a special court tasked with determining whether an individual poses a threat to themselves or others. Civil-rights advocates and attorneys argue that such reasoning is often subjective and may rely on unverified information. This kind of hospitalization is limited in duration and rarely includes a long-term treatment plan for the patient. It is also costly, with the financial burden falling on the person themselves and often leaving them in debt after they are discharged from the hospital. The second option is involuntary outpatient treatment, under which the patient is obliged to follow a certain regimen while still living in the community. It is often assigned to those who have been hospitalized multiple times.

Before Trump, a community-based care (CBC) approach was becoming far more prevalent. The foundation of this approach is the Housing First program described above, along with services providing constant access to urgent and non-urgent psychiatric care that were fully covered by insurance such as Medicaid and delivered by mobile teams operating 24/7.

The goal of CBC is to provide a person in need with basic security (a roof over their head) and conditions in which they would want to recover and reintegrate into society. This approach is successfully implemented around the world and is recognized as a leading model by the international psychiatric community.

This practice replaced involuntary hospitalization and in the United States was meant to take the place of the harsh legacy of “homes for the insane.” But in the U.S., unlike the free programs in Europe, New Zealand, and other countries, community-based care has a major difference — people have to pay for it.

Many experts believe that community-based care has failed in modern America. The first reason is underfunding and fragmentation of the system. The federal reform of the 1960s, aimed at deinstitutionalization, was overly optimistic in its assumptions. Reformers believed that if hospitals were simply eliminated and funding given to communities, local authorities would build support systems for people with severe mental illnesses. Instead, the old infrastructure was dismantled without an adequate replacement emerging.

The lack of specialized infrastructure led to rising homelessness and crime among people with severe mental disorders. Meanwhile, services built on community-based care chronically lacked funding, and the assistance system remained fragmented. In many states, prisons became the only alternative to psychiatric institutions.

According to data from the Commonwealth Fund, the United States currently needs more than seven thousand additional mental-health specialists, which is why the wait for a mobile crisis team can take months in some areas. Low Medicaid reimbursement rates deter physicians, who opt out of community-based care programs. Nearly half of Americans live in areas with a shortage of such specialists.

There is also an insufficient number of psychiatric ward beds, and in most states, community-based care is primarily focused on crisis intervention rather than providing for longer-term stays. In addition, unlike Medicaid, most standard insurance plans do not cover psychiatric services based on community care, meaning that even if a person with a severe mental-health condition has not become homeless and has another type of insurance, the likelihood that they will be able to receive necessary help without going into debt is low.

Involuntary hospitalization will not solve the problem

Everyone agrees there is a problem, and Trump is not the first to call for bringing back involuntary hospitalization. Many Democrats support the idea as well.

New York governor Kathy Hochul has spent several years trying to increase the number of forced hospitalizations. The case of Martial Simon (who pushed Michelle Go onto the tracks) became a turning point in her policy. In 2025, Hochul finally approved amendments that will now make it easier to involuntarily hospitalize a person, particularly a homeless person suffering from severe mental illness.

Although the public is generally supportive of Hochul’s policy, many specialists have expressed skepticism or concern about her initiative. Joan Simon, chair of the New York State Assembly’s Committee on Mental Health, said that without investments in long-term home-based treatment plans, involuntary hospitalizations will have limited success, as they address only part of the problem.

Patrick Wildes, a former social-services adviser to Hochul, said that these changes are driven more by short-term political gain, since sustained investment in this field is “hard to sell politically.”

“It’s absolutely correct that we need to get severely mentally ill people off the streets and out of awful conditions and into some sort of care,” adds Dr. Talbott, former chief physician of Manhattan State Hospital (now known as the Manhattan Psychiatric Center). “But we have destroyed the care system in large part. I don’t know how to do it overnight.”

Involuntary hospitalization may seem like a simple solution to America’s crisis, but internationally it is no longer considered viable — let alone humane. First, there is the question of who makes the decision to hospitalize someone and under what conditions. Most initial assessments of whether a person should be admitted are conducted by agencies working on the streets. In the U.S., these are most often police officers, who lack the qualifications to assess a person’s psychiatric condition. The criterion of “danger to oneself or others,” which courts rely on, is also subjective and already leads to discriminatory practices. For example, in New York, Black people are disproportionately more likely to receive referrals for involuntary outpatient treatment.

Second, forcibly placing a person in a psychiatric facility can cause additional trauma — psychological, social, and financial. Involuntary isolation can undermine a person’s attempts to reintegrate into society while simultaneously worsening their financial situation. Legal advocates note that people may be held in psychiatric units for several days without access to an attorney, and any attempt to challenge such detentions can be interpreted as a symptom of illness and used as evidence that the person poses a danger to themselves or others.

At the same time, evidence for the effectiveness of involuntary isolation is clearly insufficient. Its implementation does not reduce the number of repeat hospitalizations or arrests, does not improve quality of life, and does not bring people off the streets and back into society. However, there is research demonstrating its harm. For example, the more involuntary hospitalizations occur within at-risk populations, the higher the suicide rate.

Evidence for the effectiveness of involuntary isolation is clearly insufficient
In addition to the community-based care model and voluntary treatment mentioned above, Europe also uses mobile multidisciplinary teams to provide emergency psychiatric and other assistance. They monitor homeless populations and intervene during crises. Such teams exist, for example, in the Netherlands, Sweden, and the United Kingdom.

Another approach prioritizes giving a person a roof over their head. For instance, the Soteria model involves creating special homes where people with severe mental illnesses live independently in a safe, therapeutic environment, using medications only minimally. Soteria does not require large numbers of psychiatric specialists, costs less, and delivers outcomes comparable to — or better than — traditional methods. This practice exists in New Zealand, where such homes are run by the residents themselves or by people with lived experience.

As an alternative to involuntary hospitalization, various countries are developing and testing community-based mediation and intervention methods aimed at persuading a person of the need for treatment. A leading example is the Open Dialogue initiative developed in Finland. It provides for urgent interventions that bring together the person experiencing a crisis, their family, their friends, and a multidisciplinary team of specialists.

The goal of this approach is to avoid hospitalization and minimize the use of medication. Results from a ten-year study show that adolescents who received assistance through this program needed less follow-up treatment and were less likely to receive disability benefits than those who received standard care. The overall per-capita costs were also significantly lower.

A very important distinction of European programs is that they are funded through taxes, government insurance schemes, and nonprofit support systems. These programs are free for patients, and governments can provide them thanks to strong infrastructure and large budgets for social and medical assistance and support.

None of this exists in the United States, which is the main reason why similar practices fail to take hold there. The return of involuntary hospitalization, of course, will not solve the problem, and it remains unclear why the Trump White House is insisting on the revival of ineffective, expensive practices rather than opting for an approach that is both more humane and more cost effective.