Call to reform involuntary care under Mental Health Act

Proposals from British Columbia’s premier to expand involuntary mental health treatment in British Columbia are renewing debate around the state power to hospitalize someone against their will.

That power has shaped journalist Rob Wipond’s family for more than 20 years since his father was detained in Kelowna after seeking mental health support for the first time in early retirement. Wipond went on to report on issues of involuntary mental health care in Victoria and Vancouver.

More British Columbians are now being involuntarily detained and treated under the Mental Health Act than ever before, according to data from the Ministry of Health. Reports from the B.C. Ombudsman and legal advocacy groups outline patients’ legal rights were upheld in less than half of cases in 2019 and dehumanizing practices are commonplace.

Many families and advocacy organizations say B.C.’s broad laws allowing health-care providers to do so are essential to keeping their loved ones safe when they aren’t able to ask or accept help for themselves. They support better human rights adherence and fear changing laws would increase barriers to support and deprive their loved ones of care.

Wipond’s first book, published by BenBella Books last month, takes aim at the lack of public oversight and barriers to accountability for people who have been harmed by involuntary treatment. Your Consent Is Not Required traces the growth of involuntary detention across North America, arguing it is not the solution to complex problems many believe it to be.

What follows is an interview with Wipond about his reporting on the rise of involuntary detention and where B.C. might go from here.

Question: The book starts off with a very personal story of your father and your family’s experience with involuntary mental health treatment in Kelowna. How did that experience affect your understanding of these issues?

Rob Wipond: It certainly raised a lot of questions for me, and so did the speed with which it happened with my father. And the fact that it didn’t seem surprising to the hospital staff that they were taking a person with absolutely no history of mental health issues of any kind and suddenly declaring him to be a certified mental patient worthy of being treated against his will. All the good fortune that you would want to have if you were in such a situation, my father had all that. And nevertheless, he lost so many rights so quickly. I immediately started wondering, who else is this happening to?

Question: What should British Columbians know about our mental health laws and what do you think readers of your book will be most surprised by?

Wipond: B.C. has the most draconian, aggressive mental health laws in North America.

There is the deemed consent provision, which means that you can be locked up in a psychiatric hospital and forcibly treated based on the decision of one physician, with a nominal sign-off by a second physician. Certainly, some doctors try to be polite around their use of that particular power, but the power is there and you don’t have an independent hearing to decide your competency if it’s not an emergency. Every other jurisdiction has a capacity or competency requirement that says that if you’re able to make reasonable decisions, to have the capacity to think reasonably clearly, then you have the right to make your medical decisions. B.C. does not allow that for involuntary patients.

People also need to understand that these laws are far broader than I think most people really imagine. For example, in B.C., you can be involuntarily detained if you are a danger to yourself or others, but that term itself is not clearly defined anywhere and can be interpreted really loosely. It’s not simply somebody picking up a knife and threatening themselves or anyone else. In fact, that’s relatively rare. And B.C. has gone further than others by saying you can be detained if you’re at risk of mental or physical deterioration. But there is also no set way to define that.

Question: I’ve spoken to people in my reporting who experience distorted reality in psychosis and suicidal ideation, and have said they would not be able to make sound medical decisions in those states. How do you think about a lack of insight in these discussions?

Wipond: Even those people, I’ve found, never want the forced treatment to continue forever. They always want to get their own agency and control back. Those people could write up an advance directive for when they’re in crisis and get what they want again. But they shouldn’t be suggesting, and no one should extrapolate from such perspectives, that everyone should be happy about being forced all the time. The best studies we have show that the vast majority of people are forever after traumatized by being forcibly treated.

This whole idea of “insight” is a toxic contribution to the public dialogue. It is a term appropriated from studies about stroke survivors’ perceptions of reality, but in a mental health context, it has no basis in science. It’s an insulting, paternalistic way to deny people’s basic humanity and rights. And in B.C., it’s irrelevant anyway, because there’s no requirement under the B.C. Mental Health Act to formally test anyone for their level of competency or insight.

Question: Just to be clear, then. How concerned are you about a person’s capacity to make decisions given the characteristics of some serious mental illnesses include disconnection from reality and delusion?

Wipond: I’ve never met or heard of anyone who was so “crazy” they weren’t worth listening to. Just because you have beliefs that other people don’t agree with or don’t think are valid, does not mean you have completely in every single way lost all touch with reality.

Having insight has been interpreted in courts and in standard formal assessments to mean a person agrees with the psychiatrist’s diagnosis and to treatment. But if we actually ask people, why do you refuse these diagnoses and medications, the most predominant answer is they don’t help me, I can’t handle the adverse effects of the medication. And if they’ve been through this before, the diagnosis is inextricably linked to losing all their rights, and they’re trying to avoid it. So these common answers people give to refuse treatment are not completely disconnected from reality, even if they do have thoughts and beliefs about reality others don’t agree are true or logical.

Everybody has a basic humanity. And so we need to still ask them, what do you want? What do you think would help? And I’ve found that often they give pretty smart answers, they’re things like, I would like housing, I would like voluntary support in my life to help me go shopping, because I’m scared of the shopping market, or other things that make a lot of sense that should come before they have to say, I want someone to give me a drug that I’ve already tried that I don’t like.

Question: Several people and organizations I’ve spoken to are very outspoken about maintaining the current broad powers to detain people who won’t otherwise agree to treatment in B.C. Many of these people are family members who have described to me very difficult situations with their loved ones, seeing them in pain or suffering and needing help to keep them safe. How do you engage with their experiences and viewpoints in your reporting?

Wipond: We have to separate what people believe from reality and open up the dialogue. People have been taught to believe that these are only medical problems that need only medical solutions. We need to be understanding of families that believe that antipsychotic drugs are always the best choice for their loved one, even if their loved one doesn’t want them, because they’re being told that.

The whole system needs to be more honest that we don’t have good solutions for a lot of these problems. It’s not like a simple matter of “Oh, give them a drug and the person is miraculously happy.” That almost never happens.

You can always go to extremes to find a situation where involuntary treatment appears to be the only solution. But the reality is that the vast majority of situations are in a gray area where family and loved ones are disagreeing with the individual about what’s best for this person.

And this issue has become very polarized. It’s really a war. We hear a lot of people saying we need more forced treatment and that it’s good for people.

We don’t often hear from the people who are being subjected to those laws and to that forced treatment.

Continued Tomorrow Feb. 23