Should people with substance use disorder and severe mental illness be forced to undergo involuntary treatment?
In the current provincial election campaign in B.C., the rival New Democrats and Conservatives have both answered “yes” to that question, while the Green Party has said the evidence isn’t there to support such a move.
But involuntary (or, if you prefer, coerced) treatment is an issue fraught with complexity and nuance – not the type of discussion that’s easy to have during a deadly toxic drug crisis, let alone a partisan campaign.
There are civil rights and human rights issues to consider, such as bodily autonomy, and not being punished for being sick. Then there are more practical issues like: Does involuntary treatment work and, if so, for whom? Given the severe lack of access to mental health care services now, how would any new programs be staffed and financed?
The first thing we need to recognize is that there is already a lot of involuntary treatment. In fact, the majority of people admitted to psychiatric hospitals don’t go willingly.
The B.C. Mental Health Act – and similar legislation that exists in every province and territory – allows for people to be detained and treated if they pose a danger to themselves or others.
People in crisis can be “certified” or “sectioned” or “formed” (the jargon varies by jurisdiction) and held in hospital or a psychiatric facility for up to 48 hours so a health professional can determine their fitness. For longer detention, a more formal hearing is required. In rare cases, people can be held indefinitely. The courts can also “sentence” people to a forensic psychiatric institution if they are charged with a serious crime and found to be not criminally responsible.
The key question is: Does a person have the capacity to make decisions and therefore consent to or refuse treatment?
There is no question that involuntary treatment can be a lifesaver, particularly for people suffering psychosis. Many, if not most, agree to voluntary care after the initial crisis passes.
But, in their newfound enthusiasm for coercive care, politicians seem to be suggesting that people should be forced into care even if they are compos mentis, of sound mind, and that is a disturbing road to take. People do all kinds of things that are not good for their health, nor the health of those around them.
But when should we intervene? When there are criminal acts, of course. And that should be an opportunity for alternative sentencing, such as community treatment orders.
But, like it or not, people have the right to make decisions not everyone would consider rational. For example, many people take drugs, from alcohol to opioids, and that is their business.
The person who smokes crack on Vancouver’s Downtown Eastside and the Bay Street executive who injects heroin in a Toronto penthouse have the same rights.
The former should not be institutionalized because they are more visible than the latter. The proposal that “care” be provided in jails also sends the wrong message – that being sick is a crime that needs to be punished.
The evidence for involuntary treatment of drug users – the target of politicians – is weak at best. There are complex reasons people take drugs – trauma, homelessness, pain, brain damage, and more – and brief periods of enforced abstinence don’t change those.
It certainly won’t work for people with brain injury, a problem that doesn’t get near enough attention. There have been 47,162 toxic drug deaths in Canada since 2016. But 600,000 or more others have suffered drug-related brain injury, most often caused by repeated overdoses.
This legion of chronically ill people is perhaps the most bedevilling problem we have: Under the promised new laws, do we plan to institutionalize them all?
Community supports would certainly be more useful and cost-effective but we have failed to invest adequately in community programs for decades, since deinstitutionalization.
The other implied message in all the talk of involuntary treatment is that it will provide a substitute for harm reduction programs. It can’t. A complex problem like we are seeing on the streets of most Canadian cities – homelessness, poverty, open drug use, public disorder, and more – requires a full suite of solutions.
Most of all, there needs to be a willingness to do what is necessary and not necessarily popular – and includes not promoting simplistic out-of-sight, out-of-mind solutions like involuntary treatment.