The Decibel - The politics of B.C.’s involuntary care

Episode Date: September 25, 2024

Last week, days before the British Columbia election was called, Premier David Eby announced a new plan for mental health and addictions care. B.C. already has involuntary care as part of the Mental Health Act — but this would allow it for people with concurrent addictions, mental illness, and brain injuries. This move has wide support among British Columbia’s political leadership — but civil rights advocates are pushing back. Andrea Woo is a B.C.-based reporter for the Globe who has reported extensively on the toxic drug crisis. She’s on the show to talk about the possible impact of this announcement, and why we’re hearing about it now.Questions? Comments? Ideas? Email us at [e-mail]

Last week, British Columbia Premier David Eby announced a new plan for mental health and addictions care. We need to make sure that people who are sick get the care that they need, that they are looked after, and that our broader community is safe for everybody. And so we're going to respond to this situation as a family member would, with compassion and concern. This plan is focused on people with overlapping mental illness, addiction, and brain injuries. It would involve forcing them into treatment, what's often called involuntary care. Premier Eby has broad support from political leaders across B.C., but civil rights activists and people who work directly

with vulnerable populations are pushing back. Andrea Wu is a B.C.-based reporter for The Globe, and she's won awards for her coverage of the toxic drug crisis. Today, she's on the show

to talk about this new announcement, the impact it could have on people, and why the government has decided to do this now. I'm Mainika Raman-Wilms, and this is The Decibel from The Globe and Mail. Andrea, thank you so much for joining us again. Thank you for having me. Just to start here, what is the justification here? Like, what has the Premier and the government he's of the position that if someone is on the street and they're suffering from all of these conditions, so addiction, a mental health

issue, and a brain injury all at once, that it's not compassionate to leave them there on the street. So in June, he appointed Dr. Daniel Vigo. He's a psychiatrist, a clinical psychologist, and a lecturer at Harvard Medical School to be BC's chief scientific advisor for psychiatry, toxic drugs, and concurrent disorders. And it's on his recommendations on which this plan for involuntary treatment was developed. And we're going to talk about the plan, of course. I just want to ask about the timing of this announcement too, because Premier Eby announced this policy on September 15th, and then a provincial election was officially called a few days later. So I guess what does the timing tell us, Andrea? a long time. At the same time, there has been certainly a growing sense of frustration from the public about visible drug use and street disorder. And a cynic might say that he's doing this to potentially appease prospective voters ahead of the provincial election.

Have there been things that have been happening in BC that I guess are making people think about this, I guess, in a more direct way recently? There have been a few high profile violent incidents downtown was one person who had more than 60 documented interactions with police, serious mental health issues. He ended up killing one person and severing the hand of another person. And some people said that, you know, this is an example of why we need involuntary treatment, that someone like this should have been held, even if it's against their will. Whereas other people will say, well, this is actually a man who tried to get help several times and was not able to. And so it's not exactly involuntary that should be the solution, but maybe building up a voluntary system. Okay. So let's just define this term before

we get into the policy here, Andrea. When we say involuntary care or involuntary treatment, what exactly does that mean? Taking as an example, someone who is on the street and is in the throes of psychosis, and let's say they pose an imminent risk of harm either to themselves or to someone else, that person can be apprehended by police and taken to hospital where they can be involuntarily detained for a period of time after an assessment by a physician. Under the Mental Health Act, that's usually about 48 hours, and then there's another assessment at which point you can be held for 30 days, and then there are subsequent assessments. Under the Mental Health Act in British Columbia, you are deemed to consent to all forms of treatment there. So that could be, you know, psychotropic medications that you don't necessarily choose to take. Okay. And so in order to be currently placed under involuntary care with the BC Mental Health Act,

like, I guess, what are the criteria that you have to hit? So under the Mental Health Act, you would have to meet all of four criteria to be involuntarily detained. You would need to have a mental disorder that seriously impairs your ability to react appropriately to the environment and to other people. You need to be required to have psychiatric treatment in a facility. You would need to have it to prevent or further illness and to prevent harm to yourself or others. And you would have to be deemed by a doctor to be not suitable as a voluntary patient. And if you meet all of those, then you are admitted to hospital, at which point you can be involuntarily detained.

Okay, so that is what is currently in place then in BC. As we're talking about this, I guess I just wonder about the history too of mental health facilities in British Columbia. How has this gone in the past in the province? So the famous, or I guess infamous example is Riverview Hospital in Coquitlam. It opened more than a century ago. And in its darkest days, there were lobotomies, there was forced sterilization, electroconvulsive therapies, like it was very one flew over the cuckoo's nest. 50 or 60 years ago, there was a move to deinstitutionalize people with psychiatric disorders. This coincided with the introduction of very effective antipsychotic medications and this understanding that, you know, we're not trying to lock people up. This is not the healthy way to do this. People were gradually phased out,

and there was a pledge to build up mental health supports within the community. And the big criticism that stemmed from that is that we did not do that adequately. And at the time of Riverview's official closure in 2012, its former patients made up about 10% of the people who ended up on the downtown east side. Wow. Okay. So there's a real connection then between that history and where we are now. So Andrea, let's turn our attention then to this new plan that's currently on the table. What exactly was this new announcement? So according to Dr. Vigo, there's been a lot of confusion around the Mental Health Act that treatment for a person can vary depending on the receiving physician. So he says, for example, there is confusion around whether someone with a substance use disorder can be detained under the Mental

Health Act, to which he says that, you know, anything that leads to this person meeting all four of those criteria can result in an apprehension under the Mental Health Act. So he says he's going to be sending a memo out to clarify the existing rules. But it does sound like there will be an expansion of these detentions. And I think that's sort of evident in the need to build up these facilities and to identify new sites. Yeah. And what do we know about that? Like this, this potential expansion? What have they said about that? Well, so this is one of the things that concerns some people. When you ask Mr. Eby and Dr. Vigo, they say this is not about sweeping the streets of the downtown Eastside, for example, that this is a very small population of people that will not seek help themselves. However, the concern from advocates is that we already have

a higher rate of people being detained under the Mental Health Act than all other provinces. And the fact that we are identifying new sites, it does sound like there is an intention to be putting more people in involuntary care. And so under BC's current Mental Health Act, do we know how many people are getting involuntary care? So this is supposed to be an intervention of last resort, that people are just around the corner from very serious harm. And yet we've seen apprehensions and involuntary treatment under the Mental Health Act steadily climb for at least the last 10 years.

Comprehensive province-wide data is very hard to collect, but it does exist through individual health authorities and through the BC government. And according to the most recent figures from the Canadian Mental Health Association, there are about 20,000 people being involuntarily treated about 30,000 times. So that's 20,000 people, 30,000 times. So more than one apprehension per year for many of these people. And that's the highest rate of all provinces. And add to that, the fastest growing group in there is people with substance use disorders. Okay, so actually a lot of people are already affected by involuntary care. And

Andrea, you had mentioned that new sites were now being identified as part of this plan. So tell me about that. What does that refer to? So under the proposed plan, people who have been held on remand or have been sentenced would initially go to Surrey Pretrial Services Center, which is a correctional facility. They have identified another site for people who have not committed any crimes, but it also happens to be at the site of a correctional facility in Maple Ridge. And the rationale for that is that it's available with minor renovations. The BC government is also looking to identify other sites that could offer highly secure care. And as well, they are planning to add more mental health beds to hospitals that would also facilitate involuntary treatment. And so you said correctional facilities there for those first two.

So I mean, essentially prisons then? Correct. We'll come back to that because I do want to talk more about that. But I think we should just clarify too, you said this is a proposal. Essentially, the NDP would have to win this election in order for this to be put in place, right? This plan specifically, yes. However, the other major party who's running in this election, the BC Conservative Party, has also pledged to expand involuntary care. Okay. So we've been talking about involuntary care, Andrea, but let me ask you about voluntary care, right? It's care that someone is actually agreeing to. Why is this form of care not enough to help people in BC? Voluntary care in an ideal scenario, you phone up a place, you're scheduled in, you're assessed.

There's a health care team that determines what treatment plan might be best for you. For some people, that might mean detox and stabilization in a bed-based setting. For others, it might mean outpatient care, like you start medications for opioid use disorder. There's flexibility, there's autonomy. That is the ideal scenario. But the reality is that there are significant limitations with our voluntary system here. So we have a considerable health human resources challenge in BC. And so for example, that means detox beds are often sitting empty because we don't have enough nurses to staff them. And so in turn, that means that wait lists can balloon to several weeks. And when the wait list is that long, the no-show rate is very, very high for someone who has

reached that point where they're feeling desperate, they want help. And to be told that it might be a few weeks for you to get in, it doesn't work for a lot of people. But as well, there's no required reporting mechanism for our voluntary system of substance use treatment services. So when the BC government says 5,300 people accessed bed-based treatment last year, we don't actually know what that means. We don't know how many people months later are in recovery. We don't know how many people were immediately kicked out of treatment. we don't know the outcomes of that. And we hear all the time about people who desperately tried to get into treatment and just were not able to. And so I don't think anyone would disagree that there's a lot that we can do to build up an evidence-based, on-demand, voluntary system that is accessible to everyone who

wants it. We'll be right back. Andrea, let's talk about the backlash to this announcement. What have critics said about it? So one of the main concerns about voluntary care is that there is not much evidence to support it with ethical and practical concerns being a key reason for a lack of traditional research, such as randomized controlled trials. Of the research that there is, there's very little that shows that there are significant positive outcomes. And in fact, there is some evidence to show that it may be more harmful than good.

So with substance use, for example, someone who has an opioid use disorder, who is forced into treatment, even if you have medications while you are in care, the chances of relapse are extremely high. And so when you are released from care, if you do relapse, the risk of overdose is significant, and especially so in today's climate when the drugs are as volatile as they are. On top of that, you know, the act of forcing someone into treatment, if they have a bad experience there, that may deter them from seeking help in the future. And especially so for young people, which Mr. Eby had said was a considerable factor in why he had mulled this over for so long. Yeah, I guess that gets to the point that, you know, the individuals we're talking about here, I mean, they're already at risk of a lot of things too, right? And this might potentially put them at more risk of other things. That is actually a really good point because I think when we talk about involuntary, there's this idea of people who are just very dangerous and, you know, they pose a risk of harm to themselves or to other people. And we think of, you know, attacks

downtown in downtown cores. But the reality is that this is an extremely small portion of people who may be committing acts of violence. And according to the Canadian Mental Health Association, about 3% of violent crime in Canada is related to mental illness, but 7% is related to substance use issues. And the reality is that people with serious mental illnesses are more likely, like significantly more likely to be victims of violence than the general population. I want to come back to the idea of using correctional facilities here, Andrea. The premier announced this as part of the plan. So far, they said they're going to open beds at Surrey Pretrial Services Center, like you said, and also at Alouette Correctional Center. What are the implications of using correctional facilities here?

The idea of being involuntarily can be very traumatizing and detrimental to someone who is experiencing significant physical and mental health challenges. Do we know what they have said about how, I guess, they're going to protect people in this situation who might be in a vulnerable place? It sounds like the early stages of this plan would fall under the existing Mental Health Act with possible changes to legislation later. And under the existing Mental Health Act, there are certain safeguards for people who are involuntarily detained. That includes a notification of the rights that you have, an opportunity to meet with an advisor. You, in theory, can access review panel hearings and get a second medical opinion on proposed

treatments. However, critics have said that these safeguards have failed to adequately protect people, that the Mental Health Act violates people's chartered rights, and a legal challenge that started in 2016 actually continues to this day. Of course, we know that Indigenous people are overly represented in the justice system in this country. What has the response been from Indigenous communities in BC? Do we know? When Mr. Eby made this announcement just over a week ago, he had with him at the news conference Musqueam Indian Band Chief Wayne Sparrow, as well as Squamish Nation General Counselor and Spokesperson Wilson Williams. Mr. Williams spoke to Indigenous people being disproportionately

affected by substance use, incarceration, suicide, and other social issues. And he called the announcement a significant step forward for all. On the flip side of that, it's also been argued that the legacy of colonization has resulted in this over-representation and that forced care may represent a continuation of colonial policies and state repression of Indigenous people. Maybe we can talk about this in the context of another policy as well, Andrea, because earlier this year, we saw the BC government walk back their decriminalization effort. And now with this announcement on involuntary care, it kind of seems like BC is pulling away from some of their more progressive policies here. What should

we make of that? Premier Eby has been asked about this. He says, you know, if you try something and it's not working, it's good policy and it's good governing to pivot. Critics would say that Decrim was never really given a chance to succeed. And at the face of some criticism, it was immediately abandoned one year into a three-year pilot. I understand that actually Premier Eby did start some of his career working on the downtown east side. Can we just talk a little bit about his career and maybe what people expected from him? It's a really interesting trajectory. So Mr. Eby, he was the executive director of the BC Civil Liberties Association from 2013 to 2019. And before that, he was a lawyer with the Pivot Legal Society,

which is a legal advocacy organization based here in Vancouver's downtown Eastside. And I guarantee you in both of these roles, he would have been the first person out there talking to media, denouncing involuntary care, saying it's a violation of charter rights. And in fact, both organizations have come out very much against this recently. Pivot issued a position paper saying that involuntary treatment is criminalization by another name. The BC Civil Liberties Association says this is a violation of drug users' civil liberties and it increases the risk of death. And I believe the Canadian Civil Liberties Association has issued something denouncing this as well. Okay, so even if Premier Eby with that experience and his NDP government

are moving away from progressive policies, I mean, I guess, what does that tell us? Like, could BC kind of be a bellwether here for other provinces in Canada as well? There are other provinces looking at expanding involuntary or introducing involuntary. Alberta, for example, has been looking at it for some time, and it's expected that legislation will be tabled next spring, while New Brunswick, they were also looking at it. They have shelved a similar bill, which was expected to be introduced last spring. They've shelved that until after that province's fall election. And what about at the federal level? Like, have we seen party leaders comment on this idea of

involuntary care? So interestingly, Pierre Polyev, leader of the Federal Conservatives, who has been very outspoken in his opposition to harm reduction, you know, very adamant that treatment, recovery, sobriety is the way forward. He was actually asked about involuntary care on a federal level, and he said that he would need to see more evidence before taking a position. Okay. Do we know how the general public feels about this issue of involuntary care? I have not seen polling on the issue, but I've seen and heard a lot of people talking about it. There are, of course, certain groups that say that, you know, this is a very carceral approach, that this is not the way forward, that people will die from this. On the flip side, there have been many people saying,

why has this taken you so long? Why are you only doing this now on the eve of an election that we've allowed people to flounder on the streets for years? And this was a long time coming. Regarding the youth piece of this, too, there have been parents over the years who said that they genuinely feel if they could have forced their kid into involuntary treatment that maybe their kid would be alive now, but they died because that was not an option before. So it's a really polarizing issue. So, Andrea, before I let you go, of course, you mentioned the election. British Columbians are going to the polls October 19th. If EB's government does win, I guess, what can we expect to happen next then for this policy?

There will probably be at least a slight increase in involuntary apprehensions that these two sites will start taking on patients, these two correctional facilities. And further down the line, we could potentially see changes to legislation that would allow for young people to be involuntarily committed against their will. And if the BC NDP does not win, and we see a BC conservative government, conservative leader John Rustad has also pledged to expand involuntary care. I asked him last week how his plan would differ from Mr. Eby's and he said that he doesn't like that Mr. Eby would be taking away hospital beds from other patients. So it sounds like his plan would focus more on separate facilities that are outside of

the hospital system. What that looks like exactly is to be determined. So this is a close race between the conservatives and NDP. So it sounds like either way, we're going to see some movement in the coming months on involuntary care in BC. Correct. Andrea, thank you so much for your reporting here and for taking the time to do this.

I really appreciate it. Thank you for your interest. That's it for today. I'm Mainika Raman-Wilms. Today's episode was edited and mixed by Allie Graham. Our producers are Madeline White, Michal Stein, and Allie Graham. David Crosby edits the show. Adrienne Chung is our senior producer, and Matt Frainer is our managing editor. Thanks so much for listening, and I'll talk to you tomorrow.