Front Burner - The debate around involuntary care in B.C.

Episode Date: September 24, 2024

B.C Premier David Eby says that, if re-elected, he would expand involuntary care for those with severe addiction and mental health issues. The announcement came just a few weeks after a couple of unprovoked, violent attacks in downtown Vancouver where one man died, and another was severely injured. Many Vancouverites were shaken by what happened, and Premier Eby cited the attacks when he spoke about the need for more involuntary care in the province.But many public health experts and civil liberties advocates question whether this is the best approach to dealing with public safety concerns and a drug poisoning crisis.Journalist and writer Anna Mehler Paperny has done a lot of reporting on Canada’s mental health care system. She helps us navigate the complex debate.For transcripts of Front Burner, please visit: https://www.cbc.ca/radio/frontburner/transcriptsTranscripts of each episode will be made available by the next workday.

In the Dragon's Den, a simple pitch can lead to a life-changing connection. Watch new episodes of Dragon's Den free on CBC Gem. Brought to you in part by National Angel Capital Organization, empowering Canada's entrepreneurs through angel investment and industry connections. This is a CBC Podcast. Hi, I'm Elaine Chao, in for Jamie Poisson. On Wednesday, September 4th, at around 7.40 a.m., Vancouver police got a report about a man who was attacked downtown, at Richards and Dunsmuir, just a couple of blocks away from where I am now, at CBC Vancouver.

He had been stabbed multiple times and was found bleeding from his head and his hand severed. About 10 minutes after, officers got a call about a second man who was attacked just a few blocks away. First responders tried to save him when they got there, but they weren't able to. The police say that the attacks were random and unprovoked, weren't able to. The police say that the attacks were random and unprovoked, and that the suspect behind them had a long history of mental health-related incidents. Last week, BC Premier David Eby brought up these violent attacks when he announced that if re-elected, the province would be expanding involuntary care for those with severe addiction and mental health issues. It is costly for the people struggling with these conditions. They are not safe.

And increasingly, I'm concerned that the way that they are interacting in our communities is making everybody less safe. The announcement has a lot of people in B.C. talking about whether involuntary care is the best approach when it comes to dealing with public safety concerns and a drug poisoning crisis. Anna Mailer-Paperney is here to help me navigate that complex debate. She's the writer of Hello, I Want to Die, Please Fix Me, a memoir about living with depression and trying to get help for her condition. Anna is also a journalist who's done a lot of reporting on Canada's mental health care system. Anna, I think it would be helpful to just start with the basics.

What is involuntary care? So essentially, it can mean a couple of things. It can mean involuntary hospitalization. It can mean you're being put in hospital against your will. It can mean involuntary treatment, which means you're getting treatments or getting some form of therapy against your will. And that can be medication. That can be other forms of treatment. In some provinces, those two things are separate. For example, in Ontario, there's one form that you go on when you're being involuntarily hospitalized and another form when you're being involuntarily treated. And in British Columbia, on the other hand, once you've been hospitalized against your will, you were deemed to be consenting to treatment, which means you can also be treated

against your will. consenting to treatment, which means you can also be treated against your will. So it can mean a couple of things, but frequently it means being subjected to some form of psychiatric treatment. And usually it means being held in hospital when you don't want to be there. Right. And under what circumstances does it typically get used? Okay. And under what circumstances does it typically get used? There are different rules in every jurisdiction, but overwhelmingly the constant tends to be that you need to be deemed a danger to yourself or others. Overwhelmingly, what we've seen is that it's people who are deemed a danger to themselves. Most people with severe mental illness are not a danger to others. Most of them are not violent, especially not to other people. So predominantly what we've seen

is that the reason given for subjecting somebody to involuntary care is that they're seen as being a danger to themselves. I should point out that BC's Mental Health Act allows police to apprehend people against their will and for doctors to detain people if it's determined that they're at risk to themselves or others, like you mentioned, or at risk of getting worse if they leave medical care. And Anna, who typically gets to make that call around putting someone into involuntary care? Ultimately, it's a doctor, but often it can be initiated by a police officer. So for example, somebody could be apprehended under the Mental Health Act and brought in to be assessed. And then a medical professional determines whether they do, in fact, qualify under

the Act for involuntary care. So we're still waiting on a lot of the finer details around what's being proposed here in BC. But we do know that if re-elected, Premier David Eby would create 400 involuntary care beds in prisons and hospitals, and they would be for people with severe addiction and mental health issues. BC Premier David Eby announced that a billion dollars has been set aside to provide involuntary care under the Mental Health Act for people with severe addiction, mental illness or brain injuries. This is a group of people that need intensive interventionist support. They are not able to ask for help for themselves.

They will not benefit from voluntary treatment. And when it comes to involuntary addictions care specifically, like what do we know about how effective that is? The evidence is mixed at best for subjecting somebody to mandatory addiction care, in part because addiction treatment is so often not a linear thing. It often takes multiple attempts. There are times you need substitution treatment with some sort of, for example, an opioid agonist. There are times you need methadone. You know, you might need an extended period of time in treatment. One of the concerns is that if you subject someone to involuntary addiction care and then discharge them, that period of

abstinence can make them vulnerable to overdose because their tolerance has dropped, but they might not have actually bought into the care they were getting because it was forced on them. While all involuntary care tends to be controversial and there are of fentanyl, that people's likelihood of experiencing an overdose is even higher. No substance dependence we know is a reoccurring condition. Many people have many episodes of relapse. And so in that context, a fatal overdose is really risky. And so I really worry that... Exactly, exactly. The degree of toxicity that's out there, the lethality of the drugs that are being used makes them so much more dangerous for people in the unregulated market. And this

becomes more dangerous when you're coming out of a period of abstinence, your tolerance is lowered, and you're reentering that sort of toxic soup of drugs. Something that Cora Debeck also pointed out to me was that one of the questions she has about this proposal is kind of around what happens after the treatment is over. within the continuum of care so that people have support, not just when they're in treatment, but also when they leave treatment, that they have housing, that they have employment opportunities, that they have community and connection, all those things that we know that support the journey towards recovery. Those are all absolutely... I'm wondering if you can speak to kind of just how crucial kind of that time is after treatment and what happens next.

It's incredibly important. I think we often discount the importance of transitions when it comes to any discharge from hospital, but certainly a mental health discharge and especially a substance use discharge. When people are in hospital, they're sort of in a state of suspended animation. They're not at home, they're away from

both their supports and a lot of risk factors. And we frequently don't plan discharges with transitions in mind. So there may not be even a warm handoff to a community care provider. a warm handoff to a community care provider. There may not be a warm handoff to a pharmacist. There may not be a seamless transition to housing, which is so crucial for so many of these people. So without accounting for those transitions, it's really hard to see how this intervention will play out. And I want to emphasize, we don't have details, right? Nothing's on the tables. But given what we do know, there are a lot of questions about how this will play out. What do you make of the fact that at least some of these beds, these new beds will be in correctional facilities? How helpful is that for long-term treatment? It seems telling that that's where we're putting sick people.

It's a little bit ironic because we so often bemoan the fact that many of the people in correctional facilities already have severe mental illness because people who get caught up in the criminal justice system are frequently people with various forms of the most severe mental illness. And what we know, and corrections officials have said this as well, is that the carceral system is not a good place for sick people. They don't get adequate care. They often deteriorate. They're often victimized. These are supposed to be sort of specialized beds. So I'm not sure exactly what that will entail. But the fact that we're putting non-justice-involved people in carceral facilities with the stated aim of getting them better,

I think should give everybody pops. Dragon's Den free on CBC Gem. Brought to you in part by National Angel Capital Organization, empowering Canada's entrepreneurs through angel investment and industry connections. Hi, it's Ramit Sethi here. You may have seen my money show on Netflix. I've been talking about money for 20 years. I've talked to millions of people and I have some startling numbers to share with you. Did you know that of the people I speak to, 50% of them do not know their own household income? That's not a typo. 50%. That's because money is confusing. In my new book and podcast, Money for Couples, I help you and your partner create a financial vision together. To listen to this podcast, just search for Money for Couops. You know, we've been talking about involuntary care specifically, but what do we know about

even the availability of voluntary care for people with concurrent addiction and mental health issues here in BC? That's an excellent point. I've heard from so many people who've said that they and their loved ones have tried to get care for substance use disorders, and they have not been able to access it. The beds aren't there, the space isn't there. You know, they feel pressured, or they feel like they have no option other than to pay out of pocket for care, which is often unregulated. And also incredibly expensive, right? Exactly, exactly. It can be very expensive. So often what we hear is that when somebody wants to get care, the care isn't there. So what they've asked, what people are asking me, is why not invest in voluntary care and sort of build a need in that regard before moving to expand involuntary care. And to the province's credit, and other provinces as well, they are expanding

voluntary care. I think the question is just a matter of, is it scaling up adequately? Is it scaling up fast enough? And crucially, is what's being built and what's being established, is it meeting the need? Is it effective? And so often we find we don't know. So without that knowledge, it's really hard to evaluate what's out now and what's being developed. Why do you think there's been such a priority placed now on expanding involuntary care? Yeah. Yeah, because this is, I mean, you know, we're talking about the situation in BC, but we have seen proposed expansions in Alberta. The premier has directed Minister Dan Williams to move forward with developing what the province is calling compassionate intervention legislation.

There's not a compassionate way to deal with these people is let somebody live on the cold streets of Edmonton with schizophrenia and an opioid addiction and say that we're just going to let them stay there and suffer. In New Brunswick, the minister responsible for mental health and addictions, Sherry Wilson, says the province will press pause on a controversial piece of legislation that would have allowed some people to be forced into addiction treatment against their will. It was clear more time is required to ensure we get this right. The bill will likely rest on the outcome of the provincial election this October.

This is part of a wider Canadian trend as well. I think politicians feel that they're facing a crisis. On the one hand, Canada is in the midst of a toxic drug crisis. People are dying of drug poisoning in rising numbers. And that's tragic for any number of reasons. That's tragic for any number of reasons. At the same time, there's this heightened fear around public acts of violence allegedly British Columbia, for example, that have been cited by the Premier and others as justification for this expansion of involuntary care. And while we know, and the Canadian Mental Health Association has said, that about 3% of violent crime involves mental illness, and about 7% involves problematic substance use.

So it's a relatively small percentage. But because it's so high profile, because it's so scary in the public imagination, I think they see little choice politically, but to take what's seen as aggressive action. Something else that David Ibe brought up when he announced that expansion is that the NDP would change the law in the next legislative session to, quote, provide clarity and ensure that people, including youth, can and should receive care when they're unable to seek it themselves. So he specifically brought up the story of 13-year-old Brianna McDonald.

Her parents say Brianna was admitted to a Surrey hospital earlier this year after another suspected overdose. Her parents say they wanted her to stay in care but she was ultimately discharged. I begged them and I cried. I said can you please not let her go. I said she's going to hurt herself or somebody else. Police say last month Brianna was found unresponsive and died on this block in Abbotsford. Her parents say it was a suspected overdose. And I'm curious as to what you've heard from families in similar situations, you know, who have relatives with persistent mental disorders. It's hard.

I've talked to, both in this context and in other contexts, I've talked to families who are desperate to get their loved ones care and get their loved ones into care. And I've heard from people who are just in agony over those kinds of decisions. It's a balancing act, I think, between individual rights, the right to make your own decisions, and the obligation the state has to keep you well, even when that's not what you want. Now, the question when it becomes minors, when it relates to minors, is more complicated. And I believe Alberta has had, I don't know for how long, but I believe Alberta has special provisions for minors as it relates to substance

use. I would want to look at the results and see, is this keeping people safe? Are they having good outcomes as a result of these measures? And if the answer is yes, then maybe it makes sense to expand it to be seen elsewhere. I think these are incredibly painful conversations. And I think the answer, frustratingly, is complicated and it's difficult to sort of fit into a press release. to sort of fit into a press release. Something I've heard from experts as well, kind of in regards to like forced treatment for minors, that the risk of breaking trust like that is really quite high. Absolutely. And I mean, that's the case regardless of age.

One of the biggest risks of involuntary care is that you scare somebody away from this health system, potentially for life. These are often already people who have been marginalized. They're often already people who've survived trauma. They may have a very good reason not to trust those in power or in authority, including those in the health system. Forcing them into care, while it doesn't have to be an awful or dehumanizing experience, I think it risks re-traumatizing them and it risks turning them off care so that they don't seek help in future, which is scary when it comes

to substance use because we know that so many of the people who die of toxic drugs die alone. Because we know that so many of the people who die of toxic drugs die alone. And if people are driven to use the bone, they are more likely to die. And that can be very scary. You've spoken in the past about being involuntarily hospitalized yourself. And given that experience, do you think that there are situations where getting care is more important than a person's right to make decisions for themselves? Where is it that the line should be drawn? It's a great question. It's a question I ask myself a lot.

Because I was hospitalized against my will on multiple occasions. It's an awful experience. It steals your agency in a really destabilizing way. And that's at the best of times. That's with, you know, compassionate health providers who respect all of your other rights. I can understand why they decided to put me on what's called a form in Ontario. I can understand why they hospitalized me against my will, because I was a suicide risk. Now, I would argue, and perhaps we would disagree, that I ceased

to be a suicide risk at a certain point, and I could have been hospitalized voluntarily, which would have given me more freedom of movement. But that's a discussion for past Anna. To answer your question more directly, yes, I think there are times when involuntary care is necessary. But I think what's crucial is to make it a last resort. So to ask yourself, like, A, is it really necessary for this person to be behind hospital walls? Is it really necessary for this person to get this care? And if the answer to both those things is yes, is it possible to establish a rapport with this person so that we can convince them to voluntarily avail themselves of this care that, as a medical health professional, I think is so necessary? Make the care not only accessible, equitable, effective, evidence-based, but attractive so that somebody will want to get it. And then create a therapeutic relationship in which it's possible for somebody to voluntarily access care. I think, yes, there are times when somebody poses enough of an immediate risk to warrant involuntary hospitalization or treatment, but I think we need to be judicious about it. You know, due to kind of public safety being a concern,

seems to be an impetus for these proposals, public safety, the drug crisis. You know, what do you think needs to happen to better address some of these issues that do very much appear to be the impetus for the proposed expansion around involuntary care? It's hard. I don't want to pretend this isn't a hard discussion. And politicians aren't coming up with these suggestions because nothing's wrong. Like, there are very clearly deep-seated and concerning problems that needed addressing. I guess my questions would be twofold. First of all, what exactly is going wrong? In the case of the attacks in Vancouver, for example, we know that this person had prior involvement with police and with the justice system.

We know that they consented to psychiatric treatment. I don't think we know whether they received any. So where is the breakdown there? Either they received it and it didn't help, or they didn't receive any. Both of those are problems that need to be addressed. If the question is, how do we address a rampant drug poisoning crisis? Is the problem that people in need of care aren't accessing care because they don't want it? Or are they not accessing care because they cannot? And depending on the answer to that question, we should structure our interventions accordingly. But the other question is, what has been shown to work?

These aren't new problems. They feel very urgent, but they aren't new. What has worked when it comes to addressing substance use and addiction? And what are the outcomes of interventions that have been tried elsewhere? And I think once we can answer those questions, we're in a better position to determine how to move forward. And it's hard. I don't want to pretend it's not hard.

But I think it goes beyond soundbites. Anna, thank you for talking to us about this and walking through this debate with us. Really appreciate it. Thank you so much for having me. That's all for today. I'm Elaine Chao. Thanks for listening to FrontBurner. For more CBC Podcasts, go to cbc.ca slash podcasts.