We Spoke with the Man Behind the NDP’s Involuntary Care Proposal

In mid-September the BC NDP said it would open two “highly secure facilities” to detain people with concurrent brain injuries, mental illnesses and substance use disorders under the Mental Health Act.

Opening a “correctional centre” at the Surrey Pretrial Services Centre and secure housing at the Alouette Correctional Centre in Maple Ridge will help better address the complex needs of patients, the government said in a Sept. 15 press release. The province will also open new long-term beds for mental health patients and “modernize” 280 beds and build 140 new beds for voluntary and involuntary care.

This is “the beginning of a new phase of our response to the addiction crisis,” Premier David Eby said that day.

When The Tyee asked Eby what research the NDP had based this approach on, he pointed to University of British Columbia department of psychiatry faculty member Dr. Daniel Vigo, a psychiatrist and clinical psychologist with a doctorate in public health.

Eby named Vigo B.C.’s first chief scientific adviser for psychiatry, toxic drugs and concurrent disorders in June. The government’s strategy is “leaning heavily” on Vigo’s research, he said.

This “new phase” has been ruffling some feathers.

Mental health advocacy groups have warned about the unintended consequences of involuntary care, such as gender-based violence, and overreliance on involuntary care to the detriment of properly funding voluntary services.

Advocacy groups for people who use drugs warned about the increased risk of overdose and death that comes with involuntary treatment. They also warned of the risk that people will avoid necessary medical and harm reduction services because they fear detention.

The Canadian Civil Liberties Association called the NDP’s proposal “unacceptable,” according to reporting by CTV.

The Tyee sat down with Vigo to ask him to clarify his vision and address these concerns.

The dangers of unregulated drugs

Vigo has published extensive research on mental illness, interventions and substance use. He says his research focuses on “the most severely affected populations.” He’s worked with the B.C. Ministry of Health, the Ministry of Mental Health and Addictions and Health Canada to provide evidence-based ways to treat patients with concurrent mental illnesses and substance use disorders.

Vigo told The Tyee that “a few hundred” complex patients are currently falling through gaps in care. He said the goal of involuntary care for these patients is to stabilize their mental health, not to have them reach sobriety.

These few hundred patients have a combination of severe mental illness, substance use disorder and brain injury, and the facilities in Surrey and Maple Ridge will be used to address their complex needs, Vigo said.

He added that this “new phase” will not change how most patients interact with the Mental Health Act because most patients can already be helped while in crisis under the act.

The toxic unregulated drug supply has in part created the demand for additional services over the last decade or so because of how dangerous street drugs have become, Vigo said.

The synthetic opioids and stimulants that have “flooded” the unregulated market are so potent that they can cause brain injury even without an overdose, he said. Opioids such as fentanyl, carfentanil and nitazenes are “unparalleled” in their ability to slow down or stop someone’s breathing, and stimulants such as crystal methamphetamine can narrow a person’s blood vessels to the point where it restricts oxygen to the brain.

A brain injury can happen in just four minutes if a person’s breathing is reduced or stopped.

Synthetic opioids are extremely addictive and take over a person’s ability to regulate consumption, he added.

Repeated injury from these drugs can cause neurocognitive disorders, like Alzheimer’s or vascular dementia, Vigo said.

So how does this play into involuntary detention?

Let’s take a step back to look at all patients again, not just the complex few hundred. Vigo said that to detain someone under the Mental Health Act, a clinically trained psychiatrist needs to be able to diagnose mental impairment likely caused by a mental disorder.

Mental impairment can be caused by, for example, psychosis, Alzheimer’s, dementia, mania or depression caused by bipolar disorder, he said.

“Ninety-nine per cent of the time what gets you involuntary treatment is meeting the criteria for a current mental state of impairment that makes you unable to interact with the environment or to seek care, putting yourself or others at risk, or deteriorating if you leave care,” he said.

The Mental Health Act would not apply to someone who has a substance use disorder or someone who uses drugs — even if they are using unregulated toxic drugs, Vigo said.

But it could apply to someone if drugs caused a state of psychosis, he said. That patient could be detained until they came out of the state of psychosis. Then treatment would transition to voluntary and they would be given the choice to participate in voluntary treatment or leave.

That patient would have the right to leave even if it meant they would use drugs again, Vigo said.

This is a similar progression for other patients in involuntary care who do not use substances, Vigo said. They will be detained until their mental impairment stabilizes and then they are given the option of continuing treatment for their underlying mental disorder voluntarily or leaving.

Now back to the few hundred complex patients.

Remember how the toxicity of the unregulated drug supply can cause repeat brain injury, which can cause Alzheimer’s or vascular dementia? This can mean that a patient now has mental impairment that could require detainment under the Mental Health Act because they are a risk to themselves or others.

Vigo said existing services do not meet the needs of patients with concurrent severe mental illness and substance use disorder which, due to the toxicity of unregulated drugs, means they also have an acquired brain injury.

And so he is working with the NDP to create centres in Surrey and Maple Ridge to better address their complex needs.

Existing services aren’t able to meet the needs of these complex patients for a number of reasons, Vigo said.

To start, he said, B.C. has had an under-provisioned and “insufficient quality and quantity of mental health services for more than a decade.”

The inadequacy of these services has meant that complex patients can end up getting caught in a few different kinds of nasty cycles, Vigo said.

As a second point, he pointed to complex patients who have been in care for years and taking antipsychotic medications but “their baseline is still so bad” they cannot be discharged, he said.

Third, complex patients may be discharged but they end up homeless because “they are unable to regulate themselves,” but are also not able to stay in care because they are not an immediate risk to themselves or others.

Fourth, in the case of patients who cannot receive mental health treatment because they have been imprisoned, and the Mental Health Act prevents them from receiving care, patients committed under the act are “put in seclusion for weeks or months without treatment while they wait for a bed” in the Forensic Psychiatric Hospital, Vigo said.

Vigo said the government is building a designated mental health hospital in Surrey so these kinds of patients can “receive treatment right away for psychosis, complex withdrawal or whichever state put them into care under the Mental Health Act.”

They’re also building B.C.’s first “approved home” in Maple Ridge that will help address patients who cannot be discharged from care, or who may end up homeless because they are unable to regulate themselves.

Vigo said an approved home is a locked house in a community where people are given one-on-one behavioural rehabilitation. A patient may be aggressive and unable to leave their room without direct supervision, or they may be able to go to a restaurant unsupervised — it will vary patient to patient, he said.

Learning to manage behaviour may take six months or two years or a patient may never get there, so “the care is open-ended,” Vigo said.

Critics disagree involuntary care should be expanded

The Tyee spoke with three critics who all agreed B.C.’s mental health services need to be improved — but cautioned against expanding involuntary care, saying it should only ever be used as a last resort.

B.C. already has one of the highest mental health detention rates in Canada, so a review of the existing system is needed before that system is further expanded, said Jonny Morris, CEO of the Canadian Mental Health Association BC Division.

“If the plan is to detain more, we need to be enforcing standards and rigour of quality to make sure people don’t get hurt,” he said.

If you are detained under the act, the right to make your own health-care decisions “goes out the window” and a patient is considered to have given “deemed consent,” to “any form of psychiatric treatment the doctor chooses,” Morris said.

“There’s no requirement to check if [the patient] can make those decisions,” Morris added. “That means you can be restrained, pinned down and forcibly injected.”

Patients can also be given electroconvulsive therapy and aren’t allowed to have care decisions made by loved ones, said Shaely Ritchey, who has more than a decade’s worth of personal experience with voluntary and involuntary care and does mental health advocacy on Vancouver Island. Ritchey uses she/they pronouns.

“It’s really terrifying,” they said. “The amount of trauma I’ve experienced and seen other people go through from involuntary care — often it just causes more harm than anything else.”

Morris said that while it’s “really bad” to have patients in jail waiting for care, you also “don’t want people who are incarcerated to also be forcibly treated.”

Dr. Ryan Herriot, a family doctor and addiction medicine specialist who worked at Vancouver Island Regional Correctional Centre for five years, said medical facilities in jail “are not healing environments.”

VIRCC had mental health units for patients who would likely be found not criminally responsible or who had “significant mental health issues,” he said.

If anyone’s mental health improves in a prison’s mental health unit, “it’s not because of the environment but despite it,” Herriot said.

Let’s take a moment to consider all people in provincial correctional facilities who could be certified under the Mental Health Act.

Herriot said that when this happens, inmates are separated from the general population into a mental health unit and go on a waiting list to be transferred to a forensic facility where they can get care. They cannot be treated under the Mental Health Act while in corrections. Currently there are “inappropriately long waits” and inmates’ sentences often end before they can be transferred, he said.

Occasionally someone will be found not criminally responsible and will require long-term supervised mental health treatment, Herriot said, but the “vast majority” of people with illnesses that cause psychosis, such as schizophrenia, are not given not-criminally-responsible rulings.

Vigo said the Surrey facility will help patients access treatment while in corrections so they won’t have to sit in limbo waiting for beds to open up at a forensic facility. However, Herriot said the beds at the Surrey facility will be a “drop in the bucket” to address the large number of inmates waiting for care.

For a different approach, Morris pointed to the United Kingdom, where if an inmate becomes mentally ill, they have to be transferred to a civil hospital for care within 28 days.

Requiring opioid agonist therapy?

Vigo said a patient cannot be detained under the Mental Health Act for just a substance use disorder, so if they were detained it would be because they have a mental impairment, often caused by a mental disorder, as well as substance use disorder.

That patient would require “holistic psychiatric care,” which may include antipsychotic medication and opioid agonist therapy, Vigo said. This care could include “any psychopharmacology that the psychiatrist thinks they need to stop their mental and physical deterioration and hopefully overcome their state of mental impairment so they can continue their work voluntarily,” he said. “In the meantime, they need holistic care, which can include antipsychotic and an OAT.”

Morris said there is a high risk of overdose after someone leaves substance use treatment because their drug tolerance rapidly decreases while in care.

Vigo said the research about overdose risk is less clear when you’re talking about patients who are being involuntarily treated for mental impairment and/or mental illness and substance use, because it’s harder to compare patient populations who were supposed to receive involuntary care and didn’t, with patients who did.

Vigo said holistic treatment includes giving “that person buprenorphine or whichever OAT is needed to give them so that when they get out they don’t die of an overdose.”

But not everyone who is prescribed OAT finds it meets their needs or maintains the prescription, Herriot said. They might not like how methadone makes them feel, or their work schedule might not allow them to visit a pharmacy every day, he said.

If it were as easy as writing people an OAT prescription, Herriot said, then treatment centres would have high success rates. “We don’t have that,” he said.

Approved homes pushback

Morris said he’s waiting to hear more details about the approved homes. He’s concerned that “out-of-sight care” could lead to abuse.

Ritchey said that in their experience with involuntary care, patient abuse is “not the exception,” but rather a common occurrence.

“I’ve seen nurses scream at patients that they have no rights; I’ve seen people seriously harmed,” she said.

In one highly traumatic experience in 2015, Ritchey, who has an eating disorder and experiences depression and suicidal ideation due to a lack of sufficient services for eating disorders, said they “nearly died” while in involuntary care due to a combination of sedatives, restraints and medications.

When you’re committed, everything is taken away, even your underwear, Ritchey said. You’re given pyjamas and put in the same room as all other patients, where there are small, close-together chairs that fold into beds. The nurses mostly are on the other side of a plastic wall and “barely come out to see you.”

“You feel like you’re under arrest for having a mental illness, and anything that you say is used against you,” she said. You “sit there and stare at the wall and wait and wait and wait.”

Mostly mental health care feels like containment, not care, they said.

When The Tyee asked Vigo about what oversight exists to ensure institutionalization isn’t abused, he pointed to mental health review boards and rights advisers.

Review boards act as judiciaries where patients can have their case reviewed unlimited times and their psychiatrist has to convince the board the patient requires involuntary care, he said. Rights advisers work with patients detained under the Mental Health Act to let them know what rights they have and what procedures should be followed. There’s also “stringent” auditing of the forms and compliance with the processes used to detain someone under the act, he said.

But there could be more, Vigo said. He’d like to see more auditing processes that check both that people are being treated with high-quality services and that they are not being unjustly held.

Community-based care and preventive care

Ritchey said it would be a lot better if patients could stay in community whenever possible, surrounded by friends and family, and access community-based services that met their needs.

Morris said the Canadian Mental Health Association wants to see patients maintain connection with community and loved ones, living in safe and accessible housing and able to maintain their work or vocational life.

“When these things are in high supply, people thrive,” he said.

More work needs to be done in preventive care because most mental illness is very treatable if addressed early, he added.

Herriot said social housing and services will help get people off the streets, and providing community-based counselling and OAT for those who want it will help people thrive.

He added he’s worried talk of involuntary care or treatment will further push highly vulnerable, street-entrenched patients away from medical care.

“It’s incredibly difficult to get the patients I serve to agree to attend the hospital even when they have the most life-threatening of infections or other conditions,” he said.

Vigo said the government is working on other initiatives to help improve longitudinal provincial mental health care so patients are able to access care long before they end up in crisis.

He said they’re expanding Assertive Community Treatment teams, which provide wraparound care and treatment for people living in community with complex mental health needs, or concurrent mental illness and substance use disorders. B.C. currently has 34 teams but needs “many, many more,” Vigo said.

They’re also addressing staffing shortages by creating financial incentives for team members and by working with licensing boards to speed up the process of licensing needed mental health workers, Vigo said.

The government is also creating long-term mental health beds in Northern, Interior and Island health authority regions, expanding access to certain medications like clozapine, used to treat schizophrenia, and cutting red tape around OAT prescriptions, he said.

Vigo said building out these new services to address patients with complex needs and building out longitudinal services will help reduce the province’s overall reliance on involuntary care because patients will get help before they are in crisis and patients with complex needs will get adequate help as soon as they are engaged in care, instead of entering and exiting care multiple times.

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