The Current - How effective is involuntary care?

Episode Date: May 26, 2025

‘It is absolutely an act of compassion,’ says Leonard Krog, the mayor of Nanaimo about the use of involuntary care to deal with B.C.’s mental health crisis — but some experts are worried that forcing someone into treatment is a violation of their rights. Matt Galloway speaks with Mayor Krog; Jonny Morris, the CEO of the B.C. Division of the Canadian Mental Health Association; and Dr. Shimi Kang, a psychiatrist with Future Ready Minds for their insight about how to provide care for mental health while protecting public safety — as Premier David Eby works to review the province’s mental health legislation following the deadly Lapu-Lapu Day festival.

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Hello, I'm Matt Galloway and this is the current podcast. One month ago today, a man drove an SUV into a crowd at the Lapu Lapu Day Filipino Festival in Vancouver. Eleven people were killed, dozens more injured. Kaiji Adam Lo has been charged with eight counts of second-degree murder. He has been ordered to undergo a mental fitness assessment to decide whether he is fit to stand trial. BC's Health Ministry said the alleged attacker was under the care of a mental health team and was being supervised under the Mental Health Act.

The Premier of British Columbia, David Eby, says there will be a review of that province's mental health legislation and this tragedy has reignited the conversation around forcing people into treatment, also known as involuntary care. To discuss this, I am joined by three guests. Leonard Krogh is the Mayor of Nanaimo, a long-time advocate for involuntary care. Johnny Morris is the CEO of the BC division of the Canadian Mental Health Association. He's with me in our studio in Toronto. And Dr. Shimmy Kang is a psychiatrist with future ready minds. Good morning, everyone.

Good morning. Good morning. Good morning. Mayor Krogh, let me start with you. You have spoken out in favour of increased involuntary care in the province for years. How would you describe the crisis that you are seeing that would lead you to take that position? I have probably 900 or a thousand citizens out of a population of 110,000 who are homeless and in the streets of Nanaimo, many of whom, not the majority by any stretch, are obviously suffering from severe

mental health, addiction, trauma, brain injury issues, some horrible combination thereof. We had a killing a couple of years ago in town of a Governor General award-winning citizen by a young fellow who was not getting the care and treatment he needed. It's obvious to me that in our desire to protect our people, our people, our people, winning citizen by a young fellow who was not getting the care and treatment he needed. It's obvious to me that in our desire to get away from the image of the one floor over

the cuckoo's nest kind of institutional care that we have lost a lot of people along the way and it has created a sense of fear in the community but it's also led to some real tragedies. And so let me just follow up if I might on this. One of the parts of involuntary care is that you forcibly take away somebody's freedom and their autonomy to put them into care. Why do you feel, given what you've described, why do you feel that your province is at the point where involuntary care is a step worth not just taking but expanding? Well, I have called for a review and revision of the Mental Health Act for over five and a half years. It's not just around secure and voluntary care, it's also about increased services so that we prevent people from getting to

what I will call the rock bottom of mental health addictions, trauma and brain injury crisis. Secure and voluntary care is not just about the individual involved themselves, it is about the safety and protection of the community. We have had some dramatic deaths and attacks happen in British Columbia but in need across this country.

I think the general public feels, and it's clear from my e-mail box, that the public feels unsafe, they want something done, and there are numerous parents and families who are public feels and it's clear from my email box that the public feels unsafe. They want something done and there are numerous parents and family members who have contacted me and said please I can't do anything with my child, my husband, my cousin, my parent, whatever. Do something, do something and frankly the state which is fundamentally created to protect its citizens is not seen as serving that function.

John, I want to bring you into this conversation. We'll talk about the use of involuntary care in a moment, but pick up a little bit on what the mayor was saying. How do you see people have talked about a mental health crisis, not just in your province, but across the country? How do you see that? Well, I would agree that there is such a need

for improving access to care. We hear all the time stories where people have been waiting a decade for an accurate diagnosis or they've knocked on the door of the hospital system voluntarily and they've been turned away because there isn't capacity. We hear those stories from corner to corner across this country. And I really appreciate what Mayor Krogh is saying around making sure that we can truly have a system of care where people can ask for that help once and get it fast. And I think collectively across Canada, we are falling short on that mission. But this isn't about asking for

help. This is about putting people into care. The Ministry of Health, we asked to speak with the minister responsible. She wasn't available, but the ministry sent us a statement that reads, in part, some people in crisis are at risk to themselves and others and cannot seek care for themselves. It is in these situations where a patient who meets very specific criteria may need to be held involuntarily under the Mental Health Act. What do you make of that? Is that the right approach? I think the true test is, are all the services that become available involuntarily when you're held against your will and treated involuntarily, are those services available in equal measure

when you're knocking on the door voluntarily? And I don't think they are. I think all too often that knock on the door happens, the help isn't there, and people, as Mayor Croak described, deteriorate. They're experiencing a worsening of their symptoms. Families are getting more and more stressed. The real question, I think, here is, are we meeting the imperative, the state imperative,

of making sure that there's enough voluntary care available in the first place, whilst recognizing that in extreme cases, and as a last resort, the state does need to intervene, that people do need to receive care involuntarily in hospitals. Does the Canadian Mental Health Association support the use of involuntary care? We would say that as a last resort.

As a last resort. Yeah, as a last resort. Okay. Dr. Kang, how would you describe the current system of care? Is it working right now? I would say the short answer is no. I've been a psychiatrist for 25 years in British Columbia, and all due respect to my colleagues and the very hardworking people, nurses, emergency staff, and in the system, but it is a broken system and it is getting worse. And so, as I'm hearing this,

I agree with both the panel members and we don't look at involuntary care unless the individual is of not sound mind. So, you know, they have to have a mental health issue that is impairing their judgment, that requires treatment, and the numbers of people who are meeting that criteria, I would say over my 25 years, is increasing and then the capacity, the number of hospital beds or the services

has not kept up and it was never adequate in the first place. So I do think we are in a mental health crisis in this country, definitely here in BC. The wait lists are too long. We don't have the prevention, the early intervention or the tertiary care. At every point along our system we are stretched very thin. What do we need to consider if we are taking away the individual rights of somebody to care for them? So, it's a really difficult decision. I've made it many times in my career.

And we have to understand that the mental health issues is the very organ that is required to make decisions about voluntary care, is the very organ, the human brain, that isn't functioning well in that moment in time. So, you know, I don't know any doctor that does it haphazardly. It's a big decision to remove someone's autonomy and put them in a facility. But, you know, we're looking at really some obvious things like a psychosis with a clear intent to harm self or others, severe persistent illness that would deteriorate without adequate treatment. And so each of those criteria are considered. In my opinion, I feel the Mental Health Act probably isn't evoked enough because there's

no place to put them. And so even myself, I would say 10, 15 years ago, I would probably be more likely to certify someone and have them enter treatment. Now I may hesitate because I know if I send them to the emergency room, they may just wait for 16 hours and leave or get discharged. I had a young patient in Nanaimo, as I'm listening to the mayor, who was unsafe, had used crystal meth for over a month, was carrying a knife, was having vivid hallucinations, had already attacked family members, and we couldn't keep him in,

despite family advocating, despite myself advocating. So I think, if anything, we're not using the act enough because the system in the background isn't there to support the act enough because of the system in the background isn't there to support the act. John, there are very high profile, I mentioned one in the introduction, high profile incidents in which the public has seen the wake of those tragedies and said, we need to do something. This is, yes, sure, about taking away people's individual rights, but that public safety

is at risk. How do you square that circle? Well, ultimately, public safety is at risk. How do you square that circle? Well, ultimately, public safety is of critical importance. It's such an understandable reaction in the wake of such unfathomable tragedy. We're talking about significant numbers of lives lost, injuries, and life-altering impacts. There's no denying that.

There's palpable anger, grief, fear. I mean, that to me is we just have to recognize that. There's palpable anger, grief, fear, and I mean that to me is we just have to recognize that. And at the same time, thinking about a quality mental health system can work hand-in-hand with that ultimate aim of public safety. Interestingly, there have been other high profile cases in other jurisdictions like the UK. Big systemic public inquiries into those investigations have found that actually the involuntary carousel worked. It was effective. Where things fell apart is the adequacy of the resourcing and community, that the tools and the resourcing of the community mental

health teams, that's where things have fallen apart in other jurisdictions. And hopefully, with the previous call for an inquiry into this inequality review, we'll be able to learn what's happening in community to prevent tragedies like this happening again. Mr. Mayor, how comfortable are you in taking away, not you individually, but the system taking away the rights of an individual? The system should be comfortable doing it in appropriate cases. I'm not a psychiatrist. I'm not a mental health expert. I'm just a fairly experienced aging lawyer mayor who has seen a lot of change in his community.

Let's ask this question. How would you like to be the individual who perpetrated some horrible attack or murder? And when you're on your meds and when you're getting the proper care and treatment, you have to look back and know that you were responsible for that. Now, yes, you had both a legal medical excuse or explanation for it, but you have to live with that too. You see this as an act of compassion in some ways. It is absolutely an act of compassion. Look, I see the misery in my streets every day.

The people who are in the streets are unhappy, the families are unhappy, the pyramids, the firefighters, everybody's unhappy. So let's, with great respect, pardon me for saying this, fix the bloody thing, put the resources in place. This is not the way you treat people in a 21st century modern liberal democracy. You will not see this on the streets of Europe

to the same extent you see it in the United States. We both followed suit. You shut down the institutional care. Said we were gonna provide halfway houses and support groups and homes, et cetera, et cetera. And it didn't happen. And now you layer on a toxic drug supply, a mental health crisis, poverty, a housing crisis.

And what do we have? We have what we see in our streets today. People, as I say, they know it's not right. They want something better. By now, you're probably not surprised at how quickly political fortunes can change. At Power & Politics, we cover the latest twists and turns in Canadian political news every

weekday. I'm David Cochran, and I speak to the people who wield power and those who seek it. For your daily dose of democracy, follow Power and Politics wherever you get your podcasts, including YouTube. What evidence is there that involuntary care works, that in the short or long term that it helps the people that we're talking about here. This has been well researched around the world and the systems that do use it. And I feel like when we say take the rights away,

we just really want to emphasize this. This is a temporary invocation of a legal act because of a mental health issue that is taking the person out of a sound mind. I mean, that's the language that is used, that the individual's rights are being taken away. Is there, from your perspective, better language, more appropriate, more accurate language that we could use?

Yeah, it's a good question. I think language does matter. When I certify someone, I do it my best in a very compassionate way, and I say, right now, I'm not allowing you to leave this facility to go back to the streets or go back to the substance use. I know you're suffering. This is to help keep you safe and to really initiate treatment. Once you're feeling better, you can change that decision. You can make a different decision. You can

talk to oversight, and then we explain the process there. But I feel that getting to your first question, the spectrum of mental health issue is very broad. There's some people who may have mild anxiety, there's others who have that intersection of severe mental health addiction, head injury, trauma, brain injury, all of it. And yes, we do know that when we keep people who initially don't want to be in the hospital, but we hold onto them long enough with nutrition, with sleep, and it's not always about medications.

Sometimes they just need detox from the drugs and substances they're using. So that the brain is allowed that time to heal, to go through what we call withdrawal or post-acute withdrawal, to rewire, to settle down. In my 25 years, if anything, I've had families and patients thank me for invoking the act. It's very tough at the beginning, that patient isn't happy with me, but ultimately the outcome, I've never had a patient complain about that. Are you concerned at all about, and I take your point about what you've gone, what you've

experienced with the patients you've worked with, but that that might alter someone's trust in the healthcare system? I haven't experienced it. Like I said, I feel if anything, they had faith in the healthcare system because the goal is for them to get better. And if they do get better and have some insight, they realize why the act was invoked. And relationship is really important. Respect, dignity, treating people with dignity at every point, including when we have to restrain them.

It's not an either or where we either it's all voluntary or they have no rights. There is that middle place where with the proper training for all of the different people involved, you can maintain that sense of compassion and safety and then move that person towards a more of a collaborative decision-making model. Johnny, is it fair to be concerned about how this could impact somebody's experiences with the healthcare system broadly and how they would interact, how they would fear, how they – just how they would relate to that system? I really, really respect my fellow panellists' comments.

I would say we've heard, particularly with news of expanding voluntary care from people with lived experience who are very scared. They're very worried. Worried that they will be subject to this. Yeah, very much. People, including someone like me, living with a mental illness, we think through at what point do our rights

or how might we end up in the care of the system. What do you think about? What do I think about? Yeah. You said me personally. Yeah, I mean, I think if I ever get to a place, I live with depression myself, if I ever get to a place at what point might the state intervene in my care, what might happen, particularly in BC where we have something called deemed consent.

It's the subject of a charter challenge in the next couple of weeks, where in BC deemed consent means as soon as you're admitted, the director, the state, is actually full control over your care. That kind of regime isn't in place in other parts of the country, so there's no choice around medicine. There's no choice around having family involvement in your care. So I do think there's a chilling effect. And I do think we have to critically look at the oversight, the accountability, and

the quality. Like truly, are we caring for people in hospitals? And I think with full respect to my colleagues in the health system, there is care that happens. But I've just seen far too many examples where it really is a hold. It's detention. You are being held. Treatment isn't being made available. And because of those pressures that Dr. Kang described, before you know it, you're discharged. Shimi Kang, do you want to pick up on that? Yeah, absolutely agree with all of it. You know, I have had patients who have been traumatized,

I would say, by the mental health system. I've diagnosed PTSD, post-traumatic stress disorder, based on their experiences, whether in emergency rooms or in hospital, because of the holes in the system. And I would say a system where we have to... Everyone's human, human and you know, mistakes do happen and compassion often is missing and I feel it's getting worse is my own

assessment because of how stressed the system is. So that is a real factor that we have to consider. However, we don't want to throw the baby out with the bath water. It's not an either or. We either have this act or we don't. And what I'm worried about, as the mayor said, our streets are the place where when you walk through that, and I've worked in many countries around the world, Canada really is in trouble when we look at what's happening in our city streets.

Mayor Crowe, as somebody who is an advocate for involuntary care, what is the goal here? Is it to get dangerous people off the street, or is it to get them to a point where they can successfully be back a part of the community? It's absolutely both. Nobody wants to see somebody in institutional care any longer than it has to be, but you have to accept

that there are people who need some form of institutional care. It's very obvious that we have many people who require care, who are not getting access to the supports they need along the way, who are being victimized in the streets, who are falling into addiction, exacerbating their existing condition. The goal is to create a society where people get the care they need when they need it, and the public is protected. John, what do you think the goal is here? Well, I'd agree with Mayor Croak that it's nuanced and varied.

I think for some it is about removing public distress from sight. We've seen that in other jurisdictions where legislation has been changed to enable more removal from the streets, so out of sight, out of mind. Or making sure that those streets are safer, if that's a public safety concern. Absolutely, as a corollary for sure. Yeah, and again, public safety is very, very important. So I would say, first and to the goal is, as Dr. Kang was saying, to get that reprieve, get that stabilization.

But what really is required is shifting that focus from the involuntary care side and back to Mayor Croak's early comments is that safety net? Because inevitably many, many people return to community. They come back home. And that's always been the vision, closer to home care in community. And is that safety net in place? I'm happy to share some examples of things that are working for sure. But I think there are multiple goals. We just have to be careful that removing distress from sight is a goal that won't work. Well, give me an example of that. What's the way forward?

What have you seen that might offer a way forward? Well, I'm very grateful for the province's investment in us and others. We've launched community crisis response teams. And so this prevents early contact with the criminal justice system and policing when someone's in a mental health crisis. So we have five teams that are public across BC. Toronto has a number of teams here. We're batting an average where 99% of those crisis call-outs avoid the need for police attendance. So it's relieving pressure on the system and it's been a bold investment by the province in BC. You know, that's a great example. Well-resourced community-based mental health teams, assertive community treatment teams, community mental health teams where they're not managing ridiculous caseloads

is another great example. I have a family member living with severe mental illness in another jurisdiction and community mental health teams, well-resourced teams saved his life and kept him in community safe and sound and the community around him safe and sound. And the beds for people who want care, we know that across this country there's a crisis in terms of people who are looking for care who just can't find it in a timely fashion. Absolutely. We hear day in day out from family members who are have been asking for voluntary care for many many years years. And that help isn't forthcoming, right? So people deteriorate. We have seen a striking shift in the number of people

presenting voluntarily asking for a hospital bed. There's huge emphasis on the involuntary side. Those numbers are important, I think, to reflect upon too. For a community like yours, Leonard, what is at stake if this is not done in the right way? I'm going to disagree somewhat with Johnny. Um, I think there is still an enormous reservoir of compassion out there, but it is

drying up, uh, and if we don't fix it with compassionate care that includes involuntary care, then others will call for the out of sight, out of mind approach that some people feel. Are you, are you already seeing that in your community? Absolutely. There are some folks who you know full well,

just don't care, just get them off the streets, so to speak, out of my sight, stop them from stealing or breaking into my store, harassing me or chucking objects at me or having a psychotic episode in front of me or attacking me when I come to city hall to pay my taxes. Yes, there is that element, but they are not the majority yet. But the public is getting tired and they want

solutions. Dr. Kang, to you just finally, I mean for the people that you treat, if the system as it exists right now is not working, what's at stake? Their lives. Their lives are at stake. Their well-being is at stake. You know, just some examples, I actually have young people in their 20s who are looking into MADE, which is Medical Assisted Death, because they've suffered with mental health issues for over 10 years beginning in their adolescence and the system they've tried themselves to get help, and they're that desperate. And so it is a crisis point,

and that's where the individual for society, it is becoming increasingly unsafe. This hits very close to home. My husband was just attacked by someone on the street, walking in the morning, and it was really difficult because that same person, it might have been my patient. And I was able to see it through a different lens.

But for sure, that part of me wanted to just have that person arrested, and they're still out there. So we are at risk of losing compassion when it's hitting closer and closer to home, and people are feeling very unsafe. But the hope here is just to finish and I agree with all the initiatives, but also using the school system to teach mental health, well-being, social emotional skills, coping

skills if we can bring those in early, we won't need so much emergency crisis care. We have now a population that's able to self-regulate, identify their symptoms early. And I am grateful to see that the school system has done a great job and I just hope it continues to have this conversation on mental health and how to manage it and how to ask for help. Is your husband okay? He's okay. Thank you. Yeah. This is a really complicated story. Is your husband okay? He's okay, thank you. Yeah.

This is a really complicated story, and we will talk, I'm sure, again, about it as it unfolds. It's not just in British Columbia that this is playing out, but across the country. But I'm glad to put the spotlight on that province and glad to have you all here to help us walk through it. Thank you very much. Thank you.

Thank you. You've been listening to The Current Podcast. My name is Matt Galloway. Thanks for listening. I'll talk to you soon. For more CBC podcasts, go to cbc.ca slash podcasts.