There are just a few hundred brain-injured people in the province with such severe mental illness and addiction that they require involuntary care, says a psychiatrist who is advising the province on the toxic drug and mental-health crisis.
Dr. Daniel Vigo said only about 2,500 people in the province have a combination of mental illness, substance use and overdose-related brain injury, and an even smaller number “remain extremely intractably disturbed” despite interventions, including hospital stays under the Mental Health Act.
Vigo, who is regional lead psychiatrist for Assertive Community Treatment teams and a professor at the University of B.C., was appointed in June by Premier David Eby as his chief scientific adviser for psychiatry, toxic drugs and concurrent disorders, tasked with leading a team to chart a course for more involuntary and voluntary services.
Eby told the Union of B.C. Municipalities this past week his two goals are to provide care and support to those visibly struggling, “whether they’re just lying face down on a sidewalk or whether they’re yelling and screaming and causing fear and confusion and concern in the community,” while ensuring residents feel safe in their communities.
Last weekend, the province announced about 400 psychiatric beds at new and expanded hospitals are coming on line throughout the province, providing a mix of voluntary and involuntary care.
The first secure housing and care facility for those with concurrent mental-health and addictions issues will open “in the coming months” on the grounds of Alouette Correctional Centre in Maple Ridge because it was the easiest facility to customize and open quickly.
Future sites for this population are being identified throughout B.C., and could be on hospital grounds or any other municipal or provincial grounds appropriate for bringing people with severe impairments back into their communities, said Vigo.
Meanwhile, the first secure psychiatric and addiction treatment inside provincial correctional facilities will begin with 10 beds at the Surrey Pretrial Services Centre. Until now, those dealing with mental health and addictions issues couldn’t receive treatment under the Mental Health Act while in a corrections facility. Post-stabilization, they will ideally transition to voluntary treatment back in the community, Vigo said.
In the week since the plan was announced, Vigo has realized that the province’s plan might be getting muddled in translation.
“The main thing that is being misinterpreted is that what we are doing is suddenly increasing the people that are going to be forced to treatment, but if these things are implemented, there will be less people forced to treatment, [and] they will be the right people,” said Vigo.
He said voluntary-treatment beds and services that were supposed to be created in communities following the 2012 closure of Riverview Psychiatric Hospital in Coquitlam, as well as appropriate drug therapies, will be expanded.
“We’re providing more high-quality voluntary care for most of the people, and we are creating stuff that didn’t exist for a very small group of patients who really need our help,” said Vigo, who responded to other questions raised since the announcement.
Will we institutionalize people forever?
Vigo said people treated involuntarily don’t need to be kept “one minute more than strictly needed” and that institutionalizing them is “the old model.”
Under Section 22 of the Mental Health Act, care of a patient can continue after discharge from a facility, he said.
“Thanks to our Mental Health Act, we can actually treat them on extended leave, where they are with their families, where they are with their friends, where they’re living, at their homes.”
Is the Mental Health Act being changed?
“We are not changing anything about the Mental Health Act at this point,” said Vigo. Instead, the act will be clarified so it can be used for the right people at the right time, he said.
In the short-term, Vigo plans to prepare a memo for all health authorities on how the Mental Health Act can be used to provide voluntary and involuntary care when people have concurrent disorders with brain injury.
And in the next legislative session — depending on whether the NDP continue to govern after the Oct. 19 provincial election — any changes to the legislation would provide clarity to “ensure that people, including youth, can and should receive care when they are unable to seek it themselves,” according to the province.
One of the main sources of confusion is whether people with a substance-use disorder can be treated under the Mental Health Act, due to “many interpretations that have been volunteered over the years by many, many different groups of people,” Vigo said. Under the act, any disorder that causes a mental syndrome that makes a person unable to regulate their interactions with the environment and others and makes them a danger to themselves or others “should be treated involuntarily,” he said.
Also, there’s the mistaken belief that people treated under the Mental Health Act cannot be given opioid agonist (prevents withdrawal) or opioid antagonist (blocks the effect) therapies, said Vigo.
If a patient is being treated under the Mental Health Act for concurrent schizophrenia and substance-use disorder, it’s up to the judgment of the psychiatrist what type of care to provide, said Vigo.
Long-acting anti-psychotics and partial opioid agonist therapy might be needed to stabilize a person’s psychosis and craving for crystal meth and fentanyl and “allow this patient the possibility to thrive in the community” rather than return to the psychosis that maybe resulted in random acts of violence, he said.
Vigo said while some people with brain injuries along with mental illness and substance-use disorder lose their ability to be autonomous, others “would be able to engage with voluntary services if they existed in sufficient quantity and quality.”
Another important focus, he said, is youth. Under existing laws, mature minors have the right to dictate their own care, but Vigo said that was never intended to prevent supportive and involved parents from intervening when a child with a mental disorder under the Mental Health Act is choosing to use drugs that are deadly.
The backlash
This week, Anaïs Bussières McNicoll, director of fundamental freedoms with the Canadian Civil Liberties Association, called B.C.’s plan “unacceptable” and forced treatment “unconstitutional.”
Bussières McNicoll said forced treatment affects a person’s right to liberty and is likely to disproportionately target marginalized groups.
The B.C. branch of the Canadian Mental Health Association said the province already has “significant legal powers under the Mental Health Act,” suggesting that each year, B.C. sees around 30,000 apprehensions under the act of around 20,000 individuals, the highest rate of all provinces.
The CMHA said people with substance-use disorder are the fastest-growing population being detained under the Mental Health Act, citing a lack of evidence to support its effectiveness. It said studies suggest the risk of overdose death following release is increased because of the patient’s lowered drug tolerance.
The association said there are too few voluntary treatment beds and services, and pointed to “concerning accounts out of psychiatric wards across the province, including the inappropriate use of restraints and seclusion rooms, the coercive use of sedation and a lack of trauma-informed care.”
Vigo said, however, that many of the studies involving involuntary care are not randomized — because you can’t have a control group that isn’t given help — and that many such patients are not given the medication they need in treatment to sustain their health once back in the community.
The province’s plan also includes incentives along with streamlining of licensing of international graduate doctors and nurses to attract more clinicians to the field. “Otherwise we will never have enough people,” said Vigo, noting the current payment structure makes it so that psychiatrists can make more money in offices with moderately impaired patients than working in these highly complex environments. “So we are also changing that.”
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