As mental health, addiction crises surge in cities, B.C. looks to involuntary treatment for aid

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The patients at the Red Fish Healing Centre for Mental Health and Addiction are here after failing all treatment options at B.C. hospitals, with more than two thirds also having become violent either with health care staff or while committing a crime on the street. All of them are battling severe addictions to drugs.

And more than half of the 100 or so patients are here against their will after being certified under British Columbia’s civil Mental Health Act.

Once they have settled into their five-to-nine-month stint at Red Fish, these patients can spend their days attending hour-long courses that include art therapy (sketching and adult colouring books), music (a talent show was held last month), money management and guided sessions at the gym. They also must attend a half-our check-in each day with the other 14 members of their wing.

“The patients who haven’t done well anywhere else in the province are coming here and the vast majority of them are getting better,” Nick Mathew, Red Fish’s medical director, said during a media tour of the facility Wednesday.

Red Fish’s leaders say colleagues around the globe are very interested in their model, which they have been presenting at international conferences. And B.C. Premier David Eby is now pointing to involuntary treatment as a potential – though controversial – solution to the conundrum of what to do with people battling homelessness, mental-health issues or addictions, who continue assaulting strangers on city streets.

Mayors from across B.C., to Toronto to major cities in the United States are grappling with a crisis that has prompted politicians and health care providers to question whether forcibly treating people with such entrenched disorders should be re-examined decades after facilities once called asylums were shuttered because of wide-scale human rights violations.

In fact, the $130-million Red Fish facility is located on the sprawling grounds of the infamous Riverview Hospital, which first opened just over a century ago and, in the 1990s, began deinstitutionalizing its 900 beds.

Around the time Riverview officially closed in 2012, its former residents made up about 10 per cent of the 18,500 people living on Vancouver’s Downtown Eastside, according to Dr. Mathew. Without a wide range of supports, those with severe mental health problems will keep spiralling into homelessness and substance use disorders, he said.

“You can’t just detox people, you have to have a full suite of treatment to help them get through their addiction as well,” Dr. Mathew said. “Almost all of the patients that come into Red Fish had to have failed all the addiction and psychiatric treatments in their home health authority.

“So we’re taking people that have failed everywhere else and we’re bringing them here and what we do have is specialization of resources.”

Those significant resources – there are only about 20 addiction psychiatrists in the whole province and 10 of them work at his facility – are leading to more successful outcomes, he said. Red Fish’s internal data show 92 per cent of patients have improved their mental health by the time they are discharged, about that same percentage of alcoholics recover during their stay and three quarters improve their substance use disorders, Dr. Mathew said. A study is now looking at how Red Fish patients were doing two years before they entered the facility and two years after they left, he added.

Every other day, one of these people will fail to return on time after getting a special day pass to leave, though Red Fish says these patients often return on their own within three days. (The local RCMP detachment in Coquitlam says it has opened nearly 400 missing persons cases for patients since Red Fish opened in October, 2021.)

Micheal Vonn, chief executive of PHS Community Services Society and former policy director of the BC Civil Liberties Association, said Red Fish’s model of care will work for some people – but not all. She cited as an example that the centre’s focus on abstinence from illicit drugs can present a barrier for some of the hardest to reach.

Ms. Vonn believes that a dearth of low-barrier mental health and addiction treatment options – those that embrace harm-reduction approaches and allow pets and cigarette smoking, for example – has left a large contingent of people with unmet needs, whose personal crises are now playing out on city streets. That, in turn, has fuelled the current discourse about involuntary or coerced treatment.

She noted compulsory, or mandated, treatment is often a highly traumatic experience that raises ethical concerns. As well, such involuntary care is not well-backed by evidence, and has been linked to increased risk of overdose upon discharge. Meanwhile, coerced care, in which a person facing prison can choose treatment instead, could conceivably be ethically sound, but creates problems when a person cannot freely consent to medical decisions.

What is needed is low-barrier treatment options coupled with housing and other supports, she said.

“We simply have to respond compassionately, at a community level, and do the things that we know count, starting with housing. I don’t know what you do when you go into a mandated program – even if you were successful in that program – and step out into street homelessness. What does that look like?”