America spent decades emptying its state psychiatric hospitals. On Saturday, the World Health Organization urged governments to accelerate a global shift away from long-stay psychiatric institutions and toward community-based care.
The United States, however, has started moving in the opposite direction in some cases. The Trump administration has directed federal agencies to encourage broader use of civil commitment for some people with serious mental illness, while Texas is adding state psychiatric capacity.
Those competing moves revive a question America has wrestled with for generations: What happens when a society closes institutions but never builds enough care outside them?
WHO released a 146-page deinstitutionalization guide Friday. The guide says long-stay institutions can isolate patients, consume substantial mental health resources, limit autonomy and expose people to coercion or human rights violations. WHO says deinstitutionalization requires governments to build community mental health services, housing supports and continuity of care rather than simply discharge patients.
The scale of that transition remains uneven.
WHO found that only 9% of reporting countries had fully shifted to community-based mental health care, while 53% remained in the early stages. More than one in four people admitted to psychiatric hospitals, 28%, stayed longer than six months.
From 559,000 Patients To 36,542
A 2026 Milbank Quarterly study traced the collapse in state psychiatric hospital populations. In 1955, state and county mental hospitals housed roughly 559,000 people. By January 1, 2025, state psychiatric hospitals housed an estimated 36,542 patients.
The researchers described that as a decline of more than 90% from the 1950s.
No single policy caused the change. The researchers describe shifting psychiatric practice, changing views of individual rights, court rulings, Medicaid financing rules and federal disability benefits as forces that helped move people out of traditional institutions.
President John F. Kennedy signed Public Law 88-164 on October 31, 1963. The law authorized federal grants for the construction of community mental health centers, part of a plan to expand treatment closer to where people lived.
The promise proved harder to fulfill.
The Milbank researchers conclude that the United States never fully built the community system envisioned for people with serious and persistent mental illness. They point to fragmented governance, gaps in housing and family support, and funding structures that often emphasize clinical services over the broader supports some patients need to live successfully outside institutions.
Emergency departments show one consequence of those gaps.
An American Psychiatric Association resource document describes psychiatric boarding, in which patients can wait for hours or days in emergency departments for appropriate treatment or placement. The document identifies inpatient bed shortages and inadequate lower levels of community care as major contributors.
Dallas Now Has A New State Hospital
North Texas now sits in the middle of that national argument. The Texas Behavioral Health Center in Dallas accepts direct transfers from facilities in Dallas, Collin and Denton counties as UT Southwestern opens the hospital in phases. The state-funded psychiatric hospital will house 292 beds when fully operational, including 200 adult beds and 92 beds for children and adolescents.
The Dallas Express previously covered the center’s June opening. UT Southwestern admitted the first adult patients at the end of June, making the facility the first state-funded psychiatric hospital in the Dallas-Fort Worth area.
At the same time, homelessness data show why policymakers must avoid easy explanations. Housing Forward counted 3,513 people experiencing homelessness in Dallas and Collin counties on January 22, including 1,077 people without shelter. Among 3,050 adults in the count, 27% reported a serious mental illness.
That figure does not mean mental illness caused homelessness for those adults. Housing Forward notes that the count captures a single night, that unsheltered surveys rely on self-reported information and that the survey does not identify the underlying reasons a person lacked shelter.
Two Different Answers
WHO calls for governments to replace long-stay institutional care with person-centered services in the community and to involve people with lived experience in designing those systems.
President Donald Trump took a different approach in a July 2025 executive order. The order directs federal officials to encourage civil commitment in appropriate cases involving people with mental illness who pose risks to themselves or the public, or who live on the streets and cannot care for themselves. It also calls for flexible civil commitment, institutional treatment and step-down treatment standards.
The policies do not create a clean either-or choice.
WHO focuses on ending inappropriate long-term institutionalization and building community support. The White House focuses on people whose illness can create serious safety or self-care concerns. Both approaches depend on a system having somewhere appropriate for a person to go.
That brings the debate back to the question America never fully settled: How much involuntary care should government allow, for whom, and what should exist between a sidewalk, an emergency room and a locked psychiatric ward?
Provided by Dallas Express
