Between 2016 and 2021, BC admitted 20,000 people per year into involuntary psychiatric treatment. At the same time, there was an eight-fold increase in the number of people on mandated treatment in the community.
BC has the highest rate of involuntary hospitalization for mental health and substance use issues in Canada. Despite its increasing use, there is a lack of evidence supporting the effectiveness of involuntary psychiatric treatment, particularly for substance use issues.
Involuntary psychiatric treatment is provided under BC’s Mental Health Act, whereby people who meet certain criteria can be detained, admitted, and treated. In 2019, the Office of the Ombudsperson noted that the use of this extraordinary power to limit a person’s bodily autonomy must balance the health care needs of the patient, while protecting their rights, as set out in the Mental Health Act.
In line with this recommendation, BC’s health authorities were directed to update their documentation practices in 2022 to conform to the legal requirements for the involuntary admissions process. In an effort to support a move beyond these recommendations and deliver equity-oriented care, a team at Advancing Health conducted a qualitative study to better understand the lived experiences of people receiving and providing involuntary treatment in BC, and how the system could be improved.
“We know that people who have traumatic or coercive experiences in health care often lose trust in the health system, and that’s a harm that has consequences,” said Advancing Health Director Dr. Amy Salmon, who co-led the study. “Our goal with this research was to contribute to building an evidence base about patient experiences in involuntary care. If we’re going to temporarily take away people’s rights because we believe it’s in their best interest, we better be sure about the care they’re receiving.”
A stressful and traumatizing experience
In order to understand the perspectives of those involved in, and affected by, involuntary psychiatric treatment, the study team conducted interviews and focus groups with people who had received involuntary treatment, people who provide treatment under the Mental Health Act, and people who provide legal support or services related to involuntary treatment.
The study was guided by an advisory committee, which included people with lived experience of involuntary psychiatric treatment, clinicians, researchers, and health care leaders. The focus groups for people with lived experience were led by peer researchers.
Despite the diversity of perspectives, the team was struck by the similarities in the discussions between the different groups. “Sometimes you do research and people have different, almost opposing, perspectives,” said Jenyo Banjo, Program Manager and Evaluation Specialist at Advancing Health, who led the analysis for the study. “In this case, whether they were receiving or providing involuntary care, there was a kind of consensus on what they were experiencing, even though they were coming at it from different perspectives.”
A notable finding centered around the “deemed consent” model and the process of admission to involuntary care. “Deemed consent means that if somebody is admitted involuntarily, then they are also considered to have consented to receive treatment,” explained Banjo.
Care providers and people with lived experience both described how this approach reduces patient autonomy and restricts patients’ rights. People with lived experience described a lack of control over any aspect of their treatment and felt they were not being informed or given a clear understanding of what was happening to them.
“In other places, the power afforded by this form of consent is limited to specific timeframes, conditions, or treatments. In BC, we take that a step further — you’re deemed to have consented to everything,” said Dr. Salmon.
Overall, participants explained how the process of involuntary admission and treatment is a stressful experience for both people receiving and providing treatment. For patients, this can lead to harm, trauma, and distrust in the health care system, which may lead some people to avoid voluntary care in the future.
Both groups agreed that compassion and connection between patient and provider was valuable. Instead of the “all or nothing” approach currently used, where all psychiatric treatments are delivered involuntarily, opportunities to listen to and respect patients’ treatment preferences could help avoid coercive or traumatizing experiences.
The thing that has helped me most was having a friend come with me to emergency…she was at least there…be a moral support.
“Some patients said they might have agreed to take the medication if they’d had a conversation about it, but nobody even asked them,” said Dr. Beth Snow, who co-led the study with Dr. Salmon. “I think this is an example of where the experience could be improved through even a brief moment of connection between patient and provider.”
Participants also described the important role that peer support can play in providing guidance and reassurance, while stabilizing an often-tense situation, but they noted that these roles need to be better integrated into clinical teams.
The need for more treatment options and data
Participating clinicians recognized the importance of personal connection, but described how workload, burnout, and staffing arrangements meant they had few opportunities to meaningfully engage with patients.
Similarly, participating clinicians described how institutional constraints and pressures mean that they typically rely on a narrow set of interventions, with an over-dependence on physical and chemical restraints and seclusion. Clinicians and patients expressed a desire to access a broader array of options, like recreation, art therapy, and outdoor access.
“People…get thrown in seclusion because nurses don’t have time…nurses see it as preserving safety…most clinicians are doing their best.”
“Clinicians discussed the need for a more well-rounded approach to determine exactly what might be helpful for people,” added Dr. Snow. “It’s about figuring out what actually helps someone regulate and get into a good place. There are a lot more than just medication.”
More broadly, clinicians described how, despite these approaches often being effective during the acute phase, uncertainty about the effectiveness and long-term impacts of involuntary treatment contributed to ethical tension and professional distress. They also questioned whether expanding the involuntary approach makes sense from a financial point of view, mentioning the costs of police, admission, and long-term hospital stays.
Narrowing the stream: What can we do to prevent crisis?
While BC’s rates of involuntary admissions have increased, access to voluntary mental health care has declined. The absence of voluntary, community-based mental health care was echoed in the lived experience of the study participants. Clinicians, patients, and advocates all noted a lack of acute, hospital-based mental health care, as well as community-based supports, which are unaffordable, unavailable, or difficult to qualify for.
Participants described how involuntary admission into hospital is, in some cases, the only way for people to get timely access to care, with clinicians noting that being admitted voluntarily was a “luxury.”
“Unfortunately, this is what happens when we under-resource a continuum of care,” said Dr. Salmon. “We know that people who come into psychiatry through involuntary care routes are more often people who have less access to voluntary treatment. This lends a sense of urgency to this work.”
“We need more upstream intervention to make sure we have exhausted the other options before people get to involuntary care,” added Banjo. “We need to narrow the pathway to reduce the number of people who are getting into crisis mode.”
“People go back to their lives that were the same as when they came in.”
While increasing access to preventive services is vital, participants also spoke about the important role of the social determinants of health — housing, transportation, social support, food, income. By attending to these foundational unmet needs, we can develop the conditions that encourage mental and physical wellness and prevent the need for acute care altogether.
“When the only recourse is the emergency room and hospitalisation under pretty extreme circumstances, with no change going on in the outside world, it’s hard to feel like we’re making good on our societal promise to deliver the right care for people,” said Dr. Salmon.
