Implementing Involuntary Psychiatric Treatment in B.C.
by Maja Kolar, RPN MSN
The Mental Health Act (MHA) mandates the involuntary treatment of people with mental health issues (MHI) in British Columbia (BC). As per the Guide to the Mental Health Act, involuntary treatment is deemed essential for circumstances involving people with MHIs experiencing impaired insight and an unwillingness to accept voluntary treatment to mitigate substantial risk of deterioration, as well as harm to self or others.
In March of 2019, the Office of the Ombudsperson published a report Committed to Change: Protecting the Rights of Involuntary Patients under the Mental Health Act exposing compliance issues of legal forms. Legally required admission documents were found to be "missing, late or improperly completed including forms outlining reasons for detention, consent and description of treatment, notification of a patient's rights and notification to relatives". Across BC, all required forms were found to be completed in only 28% of involuntary admissions. More specifically, no Consent for Treatment forms were found in 24% of patient files and no Notification of Rights forms in 51% of patient files - see Committed to Change: Report Highlights, Mental Health Act Involuntary Admissions. Failure to adequately complete legal forms impacts the legal rights of individuals in care and the legality of treating someone against their will.
According to a report generated by Vancouver Coastal Health, there were several key contributing factors resulting in low compliance rates, such as: ambiguity within the forms, lack of knowledge of the MHA and awareness of forms, as well as role diffusion with clinician responsibility for form completion. A lack of external oversight and publicly available information regarding involuntary treatment processes further contributed to the overall lack of adherence.
The Ombudsperson's report contains 24 recommendations, 15 of which are directed towards designated Health Care Facilities across BC Health Authorities. Health Authorities have been tasked to integrate these recommendations into practice, which include: regular auditing of legal forms with an expectation of 100% compliance, and the mandatory education of heath care professionals interfacing with people certified under the mental health act. Levels of compliance and improvement amongst the health authorities will be released by the Ombudsperson in 2021.
This drive to ensure the completion of forms is a minimum standard for legally treating people against their will. While this addresses issues with compliance to legal forms, it fails to address the problems enforced by the MHA itself and the broader issues surrounding psychiatric treatment in BC.
Involuntary treatment - once deemed a final safety net - has become the primary means of providing psychiatric treatment in BC. Involuntary admissions have risen from "11,937 to 20,008 per year over the last ten years"; yet voluntary admissions have remained virtually unchanged with "17,659 to 17,060 per year over the same ten-year period" (Johnston, 2017, p. 13) – see Operating in darkness: BC's Mental Health Act detention system. While both voluntary and involuntary rates should have increased over time - reflecting population growth, as per Johnston (2017) these rates indicate an ever-increasing adversarial approach to engaging people with MHIs for psychiatric treatment. Involuntary treatment in the community context has increased dramatically as well. The number of those placed on Extended Leave "has nearly tripled in the eight years that the Ministry of Health has been tracking this data" (p. 24). Rising levels of involuntary admissions and treatment - alongside the use of Extended Leave, should act as a major cause for concern, seeking urgent analysis and review of the MHA and overall approaches to psychiatric treatment in BC.
Increased reliance on involuntary and coercive psychiatric treatment practices is in part due to a lack of early intervention and prevention-based community services. According to the Canadian Mental Health Association, many preventable situations escalate before meaningful care of MHIs is provided, justifying violation of rights and freedoms via the MHA. Publicly funded community mental health services remain scarce and difficult to access due to long waitlists and restrictive entrance criteria (Mental Health Commission of Canada, 2013). Private services – such as psychotherapy -- must be paid for by patients or private third-party insurance, but remain financially inaccessible for many people (Mental Health Commission of Canada, 2013). These factors make it difficult to access adequate and consistent mental health supports and services on a voluntary basis, with many being left to wait for their mental health to deteriorate before receiving access to care or treatment.
In relation to issues pertaining to involuntary treatment processes more specifically, BC remains the only jurisdiction in Canada that utilizes a deemed consent model, which assumes consent on behalf of a person. Under BC's MHA, health care providers are not obliged to obtain consent, nor is an assessment of a person’s capacity to consent completed. Some have argued that, because BC’s mental health legislation tends to be over-inclusive, it "impairs the rights of mentally ill persons in areas where they might have the mental capacity to act for themselves" (Law Students' Legal Advice Manual, 2017, p. 7). From this perspective, it has been argued that BC may be "the most regressive jurisdiction in Canada for mental health detention and involuntary psychiatric treatment" (p. 6). Due to an overall lack of consent processes, accountability and oversight concerning the MHA, BC has been "considered the most regressive jurisdiction in Canada for mental health detention and involuntary psychiatric treatment" (p. 6).
In the MHA and Guide to the MHA, references to consulting the patient are virtually absent, likely due to assumptions that individuals with MHIs lack capacity to consent and are therefore deemed incapable of treatment decision making or planning. Assumed incapacity and lack of insight furthermore act to justify the privation of meaningful and available avenues for challenging involuntary status or confronting experiences of unethical treatment. While many nurses and physicians may resist aspects of the MHA (for example, through the promotion of shared decision making and consent), the amount of unconstrained power the MHA affords, alongside the overall lack of accountability and oversight, is therefore problematic in allowing opportunity for unethical and excessive application of involuntary and coercive treatment measures.
The Ombudsperson Report's recommendations help to increase oversight and accountability for completing MHA forms. However, the recommendations do not address issues with the legislation itself or the social and structural factors contributing to increasing rates of involuntary treatment. Many feel that periodic legal review of detentions should be mandated, and we ought to remove "requirements for involuntary status under the Mental Health Act as a prerequisite for receiving mental health care and services" (Johnston, 2017, p. 175). The MHA should be reconstructed to incorporate a patient-centered approach, actively involving patients and their families to promote supported decision-making, relying on the input from those who have experienced involuntary treatment regarding type and course of treatment. In addition, equity-oriented care can be incorporated into broader psychiatric care practices through the incorporation of harm reduction, culturally safe care, gender affirming care, and trauma and violence informed care (Browne, Varcoe, Ford-Gilboe, & Wathen, 2015).
Nurses are ideally positioned to advocate for changes to the MHA and broader health systems. As health care providers, nurses can directly assist patients with the navigation of complex and often inaccessible services, policies and legislation. Nurses can also promote shared decision-making, such that their engagement in involuntary and coercive treatment would occur in exceptional circumstances only. Nurses can furthermore engage in critical reflexivity, challenging discriminatory views that may arise in the health care team’s decision making with respect to patient status, while advocating for more equitable treatment for individuals with MHIs in their workplace (Naylor, Das, Ross, Honeyman, Thompson, & Gilburt, 2016).
Change in legislation alone will not solve the problem of rising levels of involuntary treatment; nurses are therefore in an ideal position to call attention to and disrupt the social inequities and harmful value systems impacting people with MHIs more broadly, engaging in social justice and advocacy regarding the social determinants of health (Livingston, 2013). Much work needs to be done to achieve more accessible, equitable and prevention-oriented health systems and societies for people experiencing MHIs. In order to move this work forward, nurses can play an influential role within collaborative, interprofessional health care teams, ensuring that there is always a constructive and open dialogue with patients, families, stake-holders, politicians and policy makers.
Browne, A. J., Varcoe, C., Ford-Gilboe, M., & Wathen, C. N. (2015). EQUIP healthcare: An overview of a multi-component intervention to enhance equity-oriented care in primary health care settings. International journal for equity in health, 14(1), 152. doi:10.1186/s12939-015-0271-y
Canadian Mental Health Association. (2017). Policy perspective: Charter challenge of the BC Mental Health Act – Involuntary Treatment (Section 31). BC Division.
Johnston, L. (2017). Operating in darkness: BC's Mental Health Act detention system. Community Legal Assistance Society.
Law Students' Legal Advice Manual. (2017). Mental health law.
Livingston, J. D. (2013). Mental illness-related structural stigma: The downward spiral of systemic exclusion – final report.
Mental Health Commission of Canada. (2013). Opening minds: Interim report.
Ministry of Health. (2005). Guide to the Mental Health Act (Rev. ed.). Victoria: Ministry of Health.
Naylor, C., Das, P., Ross, S., Honeyman, M., Thompson, J., & Gilburt, H. (2016). Bringing together physical and mental health: A new frontier for integrated care.
Office of the Ombudsperson. (2019). Committed to Change: Protecting the Rights of Involuntary Patients under the Mental Health Act.
Office of the Ombudsperson. (2019). News Release.
Maja Kolar - RPN, MSN
Maja Kolar (pronouns: they|them|theirs) is the first graduate of the UBC School of Nursing's Master of Science in Nursing (MSN) program who is a registered psychiatric nurse. They are currently working as a Clinical Nurse Specialist for Providence Health Care, assisting with the implementation of recommendations of the British Columbia Office of the Ombudsperson's report "Committed to Change: Protecting the Rights of Involuntary Patients under the Mental Health Act." Their research focuses on exposing health and social inequity experienced by people with mental health issues.