Nancy Scott and her sister spent hours last summer scouring social media for free furniture and housewares to welcome her 37-year-old son out of jail and back to his supportive housing unit in a chaotic stretch of downtown Victoria known as “The Block.”
Within a week and a half, Daniel Scott had sold everything – including the TV, the microwave, the dresser – to pay for more crack cocaine. Half a year later, he was dead. The coroner attributed his January, 2024, death to fentanyl and another synthetic opioid, making him one of the more than six British Columbians dying on an average day from toxic illicit drugs.
Early last year, Mr. Scott and his mom had hope. After years spent in and out of jail and mental health facilities, Mr. Scott, who still showed glimpses of the charm that animated an adolescence hustling at multiple jobs, had been offered a coveted en suite room at the Red Fish Healing Centre for Mental Health and Addiction in Coquitlam, the province’s flagship 105-unit facility for people battling complex mental illnesses and substance use disorders. Their optimism faded quickly: Mr. Scott left the centre soon after joining, after numerous disagreements with staff.
His mother says his death represents a failure of the health care and criminal justice systems to help people early in their mental health struggles and, after they have spiralled, provide last-resort measures such as compulsory long-term care and treatment.
“It is messy and complicated, but the problem is not going away and they have to look at it different,” said Ms. Scott, whose son was imprisoned for shoplifting and admitted to hospitals for suicide attempts in his final years.
“Jail is mandatory, rehab is not. Maybe they need to rethink that.”
Politicians campaigning to form the next provincial government are pledging to do just that.
As sky-high housing costs push people onto the streets, and as a staggering number continue to die from toxic illicit drugs – a record 2,511 last year – or suffer irreversible brain injuries from them, progressive solutions to this matrix of misery, such as prescribing regulated alternatives to deadly street drugs, are facing major criticism.
Federal and provincial politicians across Canada are now talking about ramping up policies that would detain and treat the addicted and mentally ill against their will in psychiatric institutions, despite such places being closed en masse decades ago over concerns about human rights abuses.
Although in some individual cases, people say they have benefited from forced treatment, the intervention is not well supported by evidence – with some studies into its effectiveness finding it can do more harm than good.
Involuntary care in this new context can look quite different depending on the politician proposing it.
Under British Columbia’s Mental Health Act, a person can be committed for treatment against their will if they are a risk to themselves or others, and meet several criteria. The act allows a person diagnosed with a mental disorder who is unwilling to be treated to be detained first for 48 hours. Within that timeframe, a second certificate is required to detain the patient for a month. The certificate can be renewed for another month, and then the renewals are good for three months and then six months at a time.
But B.C. has few facilities to accommodate long-term stays for those involuntarily committed.
Last month, just before the official start of the election campaign, the NDP government announced it would create highly-secure facilities, including in jails and hospitals, to provide involuntary care for those with concurrent addictions, mental illness and acquired brain injuries.
NDP Leader David Eby told The Globe and Mail’s editorial board that more suitable facilities are needed for those patients to ensure they can receive treatment for longer, maybe even permanently in some cases. He said he expects new legislation will not be needed to treat adult patients in these new long-term facilities, and that his government would introduce legislation to compel youth to receive care if they are unable to seek it themselves.
Mr. Eby argued it is unjust to allow very sick and addicted people to continue to put themselves and others at risk of harm.
B.C. Conservative Leader John Rustad’s plan goes further than the rival New Democrats by proposing forced treatment of “those at serious risk due to addiction, including youth and adults.” He envisions new facilities to treat such patients for longer periods, though he is against using hospital beds for this purpose. His platform does not address whether patients would be required to exhibit overlapping mental health conditions before receiving such treatment.
Both leaders have brushed aside concerns that there is a dearth of evidence to support this approach.
Involuntary care is also being discussed as an option in other provinces. Alberta Premier Danielle Smith said she will introduce a law that would broaden the circumstances under which people with severe drug addictions could be placed in treatment without their consent, giving police and family members or legal guardians sweeping rights to refer people to involuntary treatment if they pose risks to themselves or others. New Brunswick has shelved a bill on involuntary treatment until after its fall election.
Federal Conservative Leader Pierre Poilievre believes it is needed for prisoners and youths, but said he is still researching how it would work for adults.
On Friday, Ya’ara Saks, the federal minister for mental health and addictions, suggested provinces contemplating a dramatic expansion of involuntary care should first examine whether they have properly funded the voluntary system. She noted the B.C. NDP’s proposal is limited to a very specific, and small, population of people.
“Before we contemplate voluntary or involuntary treatment, I would like to see provinces and territories ensuring that they actually have treatment access scaled to need,” Ms. Saks said. “They are not there yet.”
Red Fish Healing Centre for Mental Health and Addiction, where Mr. Scott stayed only briefly, consists of seven 15-bed wings and is located on the expansive grounds of the former Riverview psychiatric hospital east of Vancouver. Riverview once housed hundreds of patients, sometimes for decades, and became shorthand for abusive asylum-style care in the province before it was shuttered in 2012.
The most controversial aspect of Red Fish is also the closest thing that B.C. has to the type of facility Ms. Scott envisions for people in similar situations as her son: The enhanced care unit, the only one of its kind in the province, is a high-security unit that houses up to 15 patients at a time against their will.
To get in to Red Fish, people must have both a complex mental illness and a substance use disorder. Most are referred for admission by their local health authority after staff determine they are unable to treat them, while others are transferred from jails or taken there after experiencing psychosis in public.
Those brought in against their will must be certified under B.C.’s Mental Health Act, but some are also streamed to the centre by the courts while on bail or probation.
To secure one of the 15 beds in the enhanced care unit, patients must have long histories of violence or aggression in other health care settings and must remain in the unit until they stabilize and improve. Stays in the locked wing top out at a maximum of nine months, the same total time allowed other patients in Red Fish.
The majority of people in the enhanced care unit are men between 25 and 39 struggling with multiple addictions. The unit has the greatest ratio of nurses and other staff assessing, monitoring and treating patients.
Red Fish was conceived by the province and its six health authorities nearly a decade ago after numerous high-profile assaults of nurses by psychiatric patients at emergency departments. Dr. Vijay Seethapathy, who oversees Red Fish as part of his duties as chief medical officer for the BC Mental Health and Substance Use Services, said it was intended for “a small subset” of people with significant mental health and substance use challenges who kept lashing out at others.
“We can’t place them anywhere in any health authority’s available beds right now, so we will treat them, stabilize them,” he said.
Two years before Red Fish officially opened, Dr. Seethapathy’s arm of the Provincial Health Services Authority commissioned an analysis on how many of these more-secure beds were needed across the province and found 45 would be adequate. BC Mental Health and Substance Use Services told The Globe that it is doing a new estimate because “this data is now dated and does not reflect the current need in the province.” Mr. Eby has said the province could use at least three such facilities and his election platform commits to one more.
Red Fish had initially mandated that people in its enhanced care unit only be kept for a maximum of three months, Dr. Seethapathy said, but staff now believe about a third of these patients need six to nine months to stabilize, and the majority stay between three to five months.
Patients who show improvements with their mental health can get passes to leave the enhanced care unit to take classes, such as art or music, in other wings before returning for the night. Once a newly-admitted patient in the unit has been sedated and their withdrawal symptoms managed, they undergo extensive counselling and group therapy. Staff ask them open-ended questions intended to challenge their understanding of their problems, such as, “Why are you here?” and “What is your understanding of the illness?” Dr. Seethapathy said.
All patients have comprehensive reviews of their progress by psychiatric staff at their second, fourth, sixth and eighth week marks, he said.
Mr. Scott did not qualify for the enhanced care unit. Although he was certified a decade ago under the Mental Health Act for a schizophrenia diagnosis he never accepted, Mr. Scott had no history of violence with hospital staff. Instead, he was given a choice: Agree to be admitted to one of Red Fish’s voluntary units, or stay in jail.
His path through the mental health system was circuitous. His mother said the family doctor that served them at the start of these troubles grew tired of her son’s refusal to take his prescription and told Mr. Scott to find another physician. Without a family doctor, getting a referral to a psychiatrist was impossible; Mr. Scott only secured such care after attempting suicide.
In 2016, after multiple hospitalizations, Mr. Scott was approved to enter the psychiatric program at the University of B.C.’s hospital. But within two weeks, he had appealed his certification and was allowed to walk out.
“That was so frustrating because it had taken a lot of effort to get him there,” said Ms. Scott, a retired provincial bureaucrat who considered that placement a positive step.
Seven more years of court hearings for petty thefts and hospital visits for suicide attempts followed before her son accepted the referral to Red Fish last April. Ms. Scott said she felt like she had won the lottery, and that he was in great spirits about the opportunity as she checked him out of jail.
“He told me ‘I’m going to do the work, mom,’ ” she recalled.
At Red Fish, he had to agree to a two-pronged program of drug treatment and mental-health counselling. If he didn’t participate in the daily classes and group therapy check-ins, staff would revoke his various privileges, such as smoke breaks outside or day trips into the surrounding community. If he breached the conditions of his bail, he would be sent to jail.
In a May, 2023, phone interview with The Globe from the facility, Mr. Scott said that his case worker told him it may not be the best program, but advised him to try it as it would get him out from behind bars.
“They didn’t tell me how long; they just said that the course is three to nine months,” he said.
But three weeks after he arrived, Mr. Scott was bristling at the various rules and desperate to get out.
“There are a dozen workers there and they do the same speech,” he told The Globe.
He checked himself out, preferring the North Fraser Pre-Trial jail where he returned to await an outcome on charges of assault and theft under $5,000. He was eventually sent back to jail on Vancouver Island and then put on house arrest at his supportive housing unit before being convicted on the shoplifting and assault charges and released on parole shortly before he died in January.
Ms. Scott remains frustrated that there was no way for her son to be compelled to stay somewhere and accept treatment for his addiction and mental illness.
“If you can come and go, 99 per cent of the people I’m sure are going to get to a point where they’re going to say, ‘I want some drugs,’ or something else is calling them to leave,” she said.
Critics maintain that locking people up for their mental illnesses infringes on their human rights and creates more trauma, leading them to distrust the health care system when they need it most.
Marina Morrow, chair of York University’s School of Health Policy and Management, has interviewed hundreds of involuntary patients over more than two decades – as well as the professionals at Red Fish – and has concluded that this model of care harms more than it helps.
“Lots of people I’ve talked to have said, ‘Yes, I finally got help because I finally got into a hospital,’ but it was so traumatic, it had some damaging effects on them,” said Dr. Morrow.
Research supporting the involuntary model of care is equivocal. A report examining the evidence behind involuntary psychiatric hospitalization, published September, 2022, in the American Psychiatric Association journal Psychiatric Services, cited ethical and practical concerns as key reasons for a lack of traditional research, such as randomized controlled trials comparing involuntary care to outpatient care.
Because of these challenges, observational studies have been the mainstay of research on the topic, the report said. It cited as an example a 15-year study on more than 145,000 cases of inpatient admissions in Germany, finding that treatment in unlocked psychiatric units was associated with decreased probabilities of suicide attempts and absconding compared with treatment in locked units.
A systematic review in 2015 of involuntary treatment for drug dependence, including institutionalization and forced medication, led by researchers at Toronto’s International Centre for Science in Drug Policy, similarly noted a dearth of evidence. The paper found only nine of 430 potential studies met the criteria to be included; the remaining lacked specific data on compulsory treatment, did not focus specifically on illicit drug use or constituted reviews or editorials.
Of those, three reported no significant impacts of involuntary treatment, two showed neither positive nor negative results and did not compare against control groups, two showed positive results on criminal recidivism and drug use, and two showed negative results regarding the same.
A separate study published in 2022 by Swedish researchers at the Department of Public Health Sciences at Stockholm University examined involuntary drug treatment and noted the high risk of someone dying immediately after discharge, in part owing to reduced tolerance.
Systematic reviews led by scientists at the University of B.C. that examined treating substance use and mental illness concurrently – the model Red Fish follows – found such an integrated approach of care is more effective than conventional models, despite being rare in current medical systems. The reviews suggest policy makers could benefit by better integrating existing forms of care for those who want it.
The courts present another hurdle for governments looking to expand involuntary care.
A legal challenge to the constitutional validity of B.C.’s Mental Health Act, initiated in 2016, continues today, with activists arguing the current system is not humane.
Kevin Love, a lawyer with the Community Legal Assistance Society, which is representing the Council of Canadians with Disabilities in the case, referenced a report by B.C.’s ombudsperson that noted involuntary admissions have climbed every year since 2011, while voluntary admissions remained stable.
“What is truly spellbinding about this is that people are saying things are getting worse, but at the same time our use of involuntary care is increasing,” he said. “So, essentially, we’ve been using this tool extensively for a long time now, and everyone seems to agree that it isn’t producing better results.”
Red Fish is involved in a five-year study examining its treatment and patient outcomes, including what happens to people after they were held against their will in the enhanced care unit. The project also involves patients from three other sites: the neighbouring Forensic Psychiatric Hospital for those not fit to stand trial or found not criminally responsible for a criminal offence, Vancouver’s Heartwood clinic for women and an acute inpatient ward of a hospital in Hamilton, Ont.
The analysis is tracking 1,500 people from the four facilities to analyze how and why they may be relapsing into addiction or backsliding into complex mental health crises months after their discharge.
Supporters of involuntary treatment view it as showing compassion to people with mental health and addiction problems who are unable or unwilling to help themselves.
Nearly two decades before Red Fish opened, Bryn Ditmars said he was forcibly confined in both the criminal and civil mental health facilities. He now speaks publicly across the province and educates recruits at Metro Vancouver’s police college on his experiences and how he achieved a better state of mind.
The 45-year-old had his first psychotic break at 23 – a common age for those with undiagnosed schizophrenia to deteriorate – and that led to his first of seven involuntary hospitalizations. Mr. Ditmars, who now pursues creative writing and art after a decade working as a peer support worker with an integrated police and mental health team in Vancouver, is adamant he wouldn’t be alive without these interventions.
One time, he was convinced his common-law wife was an extraterrestrial vampire endangering their newborn son so he attacked her and tried to kidnap their boy from his in-law’s home on B.C.’s Sunshine Coast. Mounties arrested him and he was transferred to jail, where he received no treatment for an eight-day stretch he spent in acute psychosis lying on his bed and praying the world wasn’t ending.
“If I had been incarcerated with Type 1 diabetes they would have given me my insulin every day, but because insulin is a medicine for a physiological disorder somehow it’s okay, in their minds, to provide that but not antipsychotics,” said Mr. Ditmars.
While under arrest, he was transferred to the Forensic Psychiatric Hospital next to the land now housing Red Fish and was given an injection of antipsychotics, which brought him back to reality within a day or two. After about six months, he was found not criminally responsible for the attack and released to live with his mom near Granville Island.
He says he has since patched up his relationship with his son and his former partner. He argues that while his experiences with involuntary care have been traumatic, these interventions have helped him when he couldn’t help himself.
Nancy Scott now feels more empathy for those she sees in crisis in public. She’ll often grab a coffee from McDonald’s and go sit and watch the raucous activity out on The Block, where her son was living, her inner voice often lamenting, “Why are there so many kids?”
She and one of her seven older siblings, Mary Gardner, returned to clean out her son’s room after his death. Among his various notes strewn about, she found a bucket list of what he would do once his next big business venture succeeded. The only personal aspiration on the note was to quit using cocaine, she said. The rest of his goals centred around helping the community through acts of service, and the “Top 10 people” he would help give a better life.
“Me and Mary were on the list.”
With a report from Alanna Smith
