During the municipal election, involuntary care made it onto the ballot as the ABC’s plebiscite asked whether the city should ask the province to convert portions of the old St. Paul’s Hospital into a facility that would, among other things, provide 100-plus involuntary care beds. The results of the plebiscite will be announced on Wednesday, Oct. 21.
But beyond news headlines and political talking points, it’s worth exploring how involuntary care in B.C. works, who can be admitted and what the evidence shows.
What does the Mental Health Act currently allow?
Under B.C.’s existing Mental Health Act, individuals can be placed under involuntary care if they experience severe mental illness that impacts their ability to manage their lives safely. Four criteria must be met before someone can be "certified," or involuntarily admitted, under the Act.
First, they must suffer from a disorder that seriously impairs their ability to “react appropriately to the environment” or associate with others.
Second, that person requires psychiatric treatment through a designated facility. Third, they require care or supervision at that facility for their own protection or the protection of others; and, finally, they are unsuitable to be voluntary patients.
Generally, a person is brought to a hospital by friends or family, the police, or by a judge's order.
Kevin Love, the supervising lawyer for the Community Legal Assistance Society’s (CLAS) community law program, told Vancity Lookout that “[people are also certified] when they bring themselves to the hospital of their own accord,” he said. ”That happens more than people think.”
Normally, if someone is incapacitated, next of kin typically become the decision makers. However, when someone is certified under the Mental Health Act, the treating facility becomes the sole decision maker for psychiatric treatment.
There are currently nearly 80 facilities across B.C. where patients can be observed and detained involuntarily.
Who is being involuntarily detained?
Each year, an estimated 20,000 British Columbians experience involuntary admission, the highest rate in the country.
However, according to Health Justice, a non-profit that advocates for the transformation of mental health and substance use treatment in B.C., true rates of involuntary care are likely much higher.
Current reported numbers for those in involuntary care exclude a variety of circumstances, such as those detained by police under the Mental Health Act who are never admitted to an acute unit.
Involuntary care is not new, but over the last 20 years, the rate of those detained under the Mental Health Act has increased significantly, while rates of voluntary admission stagnated.
Youth detention under the Mental Health Act has climbed by 162 per cent over the same time period, and between 2008 and 2018, involuntary apprehensions involving the police increased 130 per cent.
Men and women are involuntarily treated at comparable rates (55.3 per cent and 44.7 per cent respectively). While data on race and Indigeneity in B.C.’s involuntary care regime is not widely tracked or publicly accessible, other jurisdictions (the U.K., Australia and New Zealand) have shown that racialized people are overrepresented in groups who experience seclusion and restraint while involuntarily admitted.
What is certification being used for?
It is a common misconception, Love said, that schizophrenia and similar disorders make up the majority of certifications – they only account for about 30 per cent of involuntary admissions.
He said that CLAS sees a “real range” of conditions, spanning various forms of cognitive disorders like dementia, as well as substance use disorder.
Under current laws, substance use disorder alone is not typically enough to justify certification. However, many of those admitted have multiple diagnoses which can complicate care. Further, an estimated 20 per cent of those who receive involuntary treatment have a primary diagnosis of substance use disorder.
“[There’s a lot of] assertions that we don’t currently detain people for substance use disorders, but we do… [the laws] are quite broad,” Love said.
What does the evidence show when it comes to involuntary care?
Jonathan Morris, the CEO of the Canadian Mental Health Association of B.C. (CMHA BC) told Vancity Lookout that the evidence surrounding the use of involuntary care for psychiatric illness is very “mixed,” and the conclusions that can be drawn from the data are highly variable.
“There isn’t a simple answer to the efficacy question for substance use disorders, concurrent disorders (mental health disorders alongside a substance use disorder) or a mental disorder alone,” he said, because it is not ethically possible to design randomized controlled trials where some people are detained and others are not, success “is really hard to measure.”
Some experts have referred to the existing research around forced treatment for drug use in particular as “an absolute dearth” of scientific evidence. While North America studies are limited, a handful of international studies suggest that involuntary drug treatment can increase risk of accidental fatal overdose upon release.
The UN has denounced involuntary drug rehabilitation programs in China and elsewhere in Asia for violating the human rights of detainees.
When it comes to involuntary treatment for other psychiatric conditions like bipolar disorder or psychotic disorders, Morris said some patients have said involuntary care “saved their life,” while others have called it “the most traumatizing and horrific experience.”
“There isn't a really widely available, approved quality framework for this form of care in British Columbia,” he said.
What do we know about transparency in B.C.’s involuntary care regime?
While some people benefit from involuntary care, the data surrounding who is being involuntarily admitted, what happens behind closed doors and following release have “concerning” gaps, that Love said “is not helpful when you’re trying to make decisions about public policy and what will work or not work.”
According to a series of Ombudsperson audits, required documentation was missing in a “significant number of patient files,” including forms outlining reasons for admission, treatment decisions, consent, and confirmation patients had been informed of their rights.
Regional health authority compliance varied significantly across the province. Vancouver Coastal Health reported the highest completion rate of required patient forms (81 per cent), but Northern Health completed just 34 per cent.
The Ombudsperson noted that the “investigation has shed light on a process often hidden from public scrutiny,” adding “even the health authorities were not aware of their facilities’ poor compliance with the Mental Health Act’s procedural safeguards.”
What was the recent Supreme Court decision on the Mental Health Act?
In July, a B.C. Supreme Court decision ruled that sections of the Mental Health Act on involuntary treatment were unconstitutional.
“There’s a difference between involuntary admission and involuntary treatment,” Love said. “This decision had nothing to do with who can be held in hospital. It has to do with what happens to them once they’re inside those walls.”
The judge found that depriving involuntary patients of their rights to consent to treatment in all circumstances resulted in unequal treatment under Section 15 of the Charter and violated Section 7 of the Charter.
While all provinces and territories have a law that authorizes involuntary psychiatric treatment, no other province grants a detaining facility unilateral power over psychiatric decision-making rights, particularly without independent oversight of a physician’s assessment of someone’s capacity.
The judge gave the province six months to remedy the constitutionality issues of the Mental Health Act. Should the government fail to do so, those sections of the Act will no longer be in effect.
“The judge didn’t say that involuntary treatment is always unconstitutional… or that involuntary treatment should never happen,” said Love. “But [it needs to happen] within constitutional boundaries.”
It will be up to the next provincial government to make those required changes.
What do experts recommend?
While Love and Morris agree that the Mental Health Act needs review, there have been some positive changes in the mental health space over the last several years.
The province opened 20 Foundry Centres, offering free mental health services to youth, Morris noted. A program at St. Paul’s Hospital significantly improved wait-times for drug detox.
Earlier this year, CMHA BC helped pioneer the Independent Rights Advice Service, a trauma-informed service that provides information to people in involuntary care to understand their legal rights.
“It helps people better understand what’s happening to them,” said Morris. “It's [also] useful to have advice service in wards so that the detaining force isn’t the same force educating you on your rights.”
Ahead of the election, the CMHA BC is calling for parties to increase investment in prevention, early intervention, and community-based support to help people before their condition reaches a crisis point.
“[The high rates of involuntary admission] is an indicator that more can be done to help people avoid getting into crisis in the first place,” said Morris.
He added that while in politics there is a temptation towards black-and-white thinking around treatment approaches, “the most valuable evidence is probably those people with lived experience with involuntary care. [We need to listen to] what they have to say about it too.”
Where do the parties stand on involuntary treatment?
BC NDP: Current Premier David Eby has moved to expand involuntary treatment capacity across the province since he was elected in 2022, including (but not limited to) opening additional involuntary care beds in Maple Ridge, Prince George and Surrey. He recently pledged to invest up to $90 million to establish involuntary care in the Okanagan.
In June 2024, Eby appointed Dr. Daniel Vigo as B.C.’s first chief scientific adviser for psychiatry, toxic drugs and concurrent disorders. Vigo released a clinical guidance document that, while not legally binding, clarified how physicians can use the Mental Health Act when treating patients with concurrent mental health and substance use disorders.
In 2020, the province attempted to amend the Mental Health Act to allow youth to be involuntarily treated following drug poisoning. However, those proposed amendments never went through due to concerns of putting youth at greater risk of overdose.
Conservative Party: The Conservative Party of B.C. has promised to expand psychiatric services, including involuntary treatment and “empower police to enforce the Mental Health Act” by amending the Act so that officers can “connect people with mandatory treatment.”
They promise to implement a “recovery-oriented system of care” focused on prevention, treatment, and recovery, and to expand detox, clinical treatment, recovery housing, and “aftercare” across B.C.
They propose to “strengthen upstream intervention for vulnerable children and youth,” through anti-drug education in schools, improved coordination between child and family services, mental health and addiction services and housing.
Finally, they promise to end what remains of B.C.’s safe supply program, deploy more police to “hardest-hit neighbourhoods,” add 500 RCMP officers and 150 civilian staff over five years in rural and regional communities and hire 50 new Crown prosecutors.
BC Green Party: The BC Green Party is the only major political party to oppose the expansion of involuntary care. It has pledged to act to bring the Mental Health Act into compliance with the Constitution, including “strengthening protections around consent, capacity, involuntary treatment and independent oversight.”
They have pledged to “examine and address disparities and any inequitable impacts of mental health legislation” based on identity and include six annual mental health professional visits under MSP.
They have proposed to integrate mental health as the fourth option in 911 emergency services to accommodate mental health crises that do not fall under traditional fire or police response options, and extend the Mobile Response Team’s psychosocial support and training.
OneBC: According to OneBC’s website, they plan to implement “involuntary drug rehab and housing for the severely addicted,” roll back all decriminalization programs, “crack down on open drug use… eliminate safe supply and drug consumption programs” and “cancel all new drug consumption sites and turn current consumption sites into drug recovery centres."
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Maddi Dellplain, Local Journalism Initiative Reporter, Vancity Lookout.
A sign indicates the northern route of the Trans-Canada Highway outside Kapuskasing, Ont., on Wednesday, April 18, 2018.
THE CANADIAN PRESS/Colin Perkel