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Opinion In bad Form? The rise of coercive care in Canada

The St. Joseph's Health Centre in Toronto's west end, shown last December. Anna Mehler Paperny, who has struggled with severe depression and been involuntarily admitted to psychiatric care, spent time in the hospital's Mental Health Emergency Services Unit.

Fred Lum/The Globe and Mail

Anna Mehler Paperny is the author of Hello I Want to Die Please Fix Me.

I know psych wards. I’ve been there in the wake of serious serial suicide attempts and when despair sucked me under. I’ve surrendered charger cords and earbuds, sought out privacy where there is none and spilled painful personal feelings to strangers busily scoring my level of nuts. I’ve been there in the din and buzzing chaos when I’d rather be anywhere else; I’ve been there against my will and of my own volition, seeking care and having nonetheless to give up my shoelaces. A psychiatric ward can be a vital stepping stone en route to recovery, but so often, it feels like a drunk tank for crazy. And this is where we’re increasingly putting people against their will and nobody quite knows why.

A psych ward’s where you go when you’re too crazy for your own good and a Form is what they put you on when you’re too crazy to know it. And across Canada, coercive hospitalization – when you’re locked up against your will because of a mental illness – is becoming the rule, rather than the exception.

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Between 2008 and 2017, involuntary psychiatric hospital admissions in Ontario rose almost 90 per cent and voluntary hospitalization became the exception. More than 3,700 Ontarians a month are hospitalized against their will because of a mental illness. There are different flavours of coercive care and, I found in my research for my new book, each one is increasing.

In Ontario, the number of people put on a Form 1 – the 72-hour hold I found myself on right after my first suicide attempt and following another one, years later – jumped 62 per cent in eight years. The number of people put on a Form 3, the two-week forcible stay I was put on in a converted nunnery back in 2011, increased 73 per cent between 2008-09 and 2018-19 – and I got this data when they were still accepting 2018-19 claims, so the latter number could rise. Month-long forced stays, Form 4s, which I avoided largely thanks to brown-noser good behaviour rather than any semblance of sanity, more than tripled during that time.

The number of admissions per patient also rose, which means a growing number of people are being hospitalized against their will multiple times a year. And the spike was highest among young girls. The number of hospital visits by girls under 18 on two-week certifications more than tripled; the number of month-long stays among teen girls increased sevenfold (although the starting number was small). And in more than 80 per cent of cases, these girls are being held to protect themselves from themselves.

An excerpt from the first page of an Ontario Form 1, like the one Anna Mehler Paperny was put on when she first tried to kill herself.

The trend holds true in British Columbia, where involuntary hospitalization jumped 54 per cent in seven years and went from representing the minority to the majority of all psych inpatients, according to the British Columbia Ministry of Mental Health and Addictions. Here, too, numbers rose most among young girls.

It’s true in Alberta, according to Alberta Health Services, and Saskatchewan, where I was obliged to get involuntary hospitalization data at the health-region level: The number of compulsory hospital admissions in Saskatoon increased 88 per cent between 2010 and 2016, and the number of provincewide certificates issued for involuntary electro-convulsive therapy – one of the most undeservedly feared psychiatric interventions – doubled during that time. The number of people put on community treatment orders in Saskatchewan more than tripled between 2013-14 and 2016-17.

When you’re involuntarily hospitalized and lose your right to freedom of movement, you retain other rights – the right to challenge your committal, if someone apprises you of that option, and the right to consent to or refuse treatment, for example. But increasingly, people are losing that right, too.

The percentage of Ontario psychiatric inpatients being forcibly treated rose about 15 per cent over eight years. And coercion in one domain bleeds into others: I, on a Form, years ago, starved for fresh air and freedom of movement, agreed to start taking antidepressants for the first time – I felt pressured to do so and wanted a clean bill of health from my psychiatrist to set me free and get me back to work. An ultimately smart move, I think, made for maybe not the best reasons.

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In an Ontario Form 3, doctors have to complete a five-point test to prove that the patient is incapable of consent. A separate checkbox tests whether the patient is at risk of serious harm.

As compulsion rises, it discriminates. While – as per usual – Canada’s race-based psychiatric data collection lags behind other countries, ensuring we drag our feet in addressing deep-seated racial inequities, we know that black people in Ontario are overrepresented on community treatment orders (CTOs) – in which you agree to follow your doctor’s dictums, take your meds as instructed or be committed to hospital again. Black people made up 13 per cent of Toronto residents on CTOs between 2005-06 and 2010-11 despite comprising about 7 per cent of the population. The disparity could be because people with sub-par access to care are more likely to deteriorate to the point where coercion becomes necessary; it could be because clinicians are more likely to see a threat in people of colour and rob them more readily of autonomy as a result. Could be a combination of the two.

What’s going on more generally with the spike in involuntary admissions? No one I’ve spoken to has a good answer. It could be that fewer psych beds per capita means those that are left go to the most acute cases, which tend to be the ones who lack insight into their condition. But while jurisdictions such as Ontario have been losing psych beds per capita, that can’t be reason enough on its own: We’re seeing an overall increase in psychiatric hospitalizations. Could it just be that more people are more severely mentally sick? Maybe, although population-level data suggests approaching that possibility with skepticism.

Maybe the most seductive argument in favour of locking up crazies is the fear of fatal self-harm. And if that’s a clinician’s assumption, they’re going to err on the side of coercion, every time. (People do die and kill themselves in psych wards far too often, but that’s another essay for another day.)

I understand the impulse to ensure people’s safety (although it doesn’t explain the increase). But I question whether we’re jumping to coercive care – even out of an abundance of well-meaning caution – without exploring or examining other options.

Another argument for committal is the you’ll-thank-me-for-this-later trump card.

“People who are admitted involuntarily, the vast majority of those individuals at a later point will say, ‘Yes, that was an appropriate decision,'” psychiatrist Richard O’Reilly, who is based in London, Ont., told me in an interview. “I agree we should try to provide service in the community. But our general hospitals, our local community hospitals, are community resources. And their job is to keep people safe.”

A message written on the whiteboard at a CAMH building in 2009.

Charla Jones/The Globe and Mail

I talked with Andrew Lustig, a psychiatrist at Toronto’s Centre for Addiction and Mental Health (CAMH), who told me the most important question to be answered in a psych emerg, is, “Do they stay or do they go?”

“And that really hinges on the issue of risk: How risky is this person, and what bad things are likely to happen if they leave the hospital today?”

He said that from his perspective, clinicians aren’t any more eager to Form people now than they were a decade ago. But he said there are ways to persuade people to stay of their own accord. It starts by establishing a rapport with a patient, and by making your psych ward a less-than-awful place to be.

Outdoor areas make an enormous difference in this regard. So does better programming (therapy dogs! A chance to ask pharmacists about meds!) and a comfortable environment. Treating people with a modicum of dignity, forging a therapeutic partnership instead of a dictatorship. It can be frustrating: A patient and an orthopedic surgeon may agree the thing sticking out of your leg is a broken bone; a psychiatrist may think the voices in your head are schizophrenia while you think they’re aliens or saints or CSIS. The trick there, Dr. Lustig told me, is to find some common ground: “So maybe you can’t agree that the diagnosis is schizophrenia, but maybe you can both agree the person is under a lot of stress and that taking this medication will help alleviate the stress.”

Problem is, Anita Szigeti argues, many psychiatrists have lost the ability to persuade: They haven’t had to try. Ms. Szigeti is a lawyer who dedicates herself to advocating on behalf of people who’ve had rights suspended owing to a mental illness, making their case before Ontario’s Consent and Capacity Board, where people contest their committal or hash out who should be allowed to make treatment decisions for someone who can’t make treatment decisions themselves. She doesn’t doubt doctors want what’s best for their patients (or their clients, as she terms them). She just thinks they’re running roughshod over rights in the process. “I think, as a profession, psychiatry has probably lost a lot of its ability to just talk to the clients,” she told me in an interview. “And I think we’re definitely seeing force and forced medication where we don’t need to, if a doctor had better skills at just therapy and communication.”

In a fee-for-service model of care, there’s also a financial incentive: Physicians in Ontario get $105 for filling out a Form 1. I hate to imagine doctors are depriving people of their freedom just to make a buck, but hospital-level anomalies suggest the question has to be asked.

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The Ontario Form 1 says the involuntary hospitalization can last for only 72 hours. But in Ms. Mehler Paperny's case, a paperwork error started the clock too late.

When one right’s suspended, others are often too easily ignored. A March, 2019, report from British Columbia’s ombudsperson found the province’s hospitals were ignoring the rights of people involuntarily hospitalized. Legally required forms were missing, late or improperly completed. Sometimes physicians failed to explain why the person met the criteria for involuntary admission. Most involuntary patients got no rights-advice form, and many had no chance to consent to their treatment. I found how easily this happens when a paperwork slip-up meant the countdown on my Form 1 several years ago started 48 hours after it should have. If that seems minor, you’ve never been deprived of fresh air and grown-up-person clothes after trying and failing to kill yourself, left pissy and prowling a windowless ward.

I spent much of my psych ward time railing against my own impotence. I paced; I was browbeaten into taking meds; on one occasion, I persuaded a psychiatrist to let me off a Form, staying of my own volition; I engaged in lacklustre interpersonal interactions that failed to win me bonus points; I tried one March to learn to walk again; I endured a dozen therapeutic seizures. But I didn’t lose my trust or faith in the medical system. Others I’ve spoken to weren’t so lucky.

One woman I spoke with had her first psychiatric encounter end with her being taken into hospital against her will – the start of a decade of coercive treatment. She’d be discharged, often into homeless shelters, arrested after a burst of rage or erratic behaviour, Formed and hospitalized again. Again and again, she felt scared and disrespected. The loss of agency, forcible treatment, physical and pharmacological restraints left lasting psychic scars and poisoned any future therapeutic relationship. Talking to me a dozen years later, this woman admitted she had issues with mental illness, anger management. Had breakdowns, would “flip out,” kick walls and mirrors, wave knives, try to slap doctors away or kick her mom off her hospital bed. She got out of hospital when she signed a community treatment order agreeing to semi-weekly injections that went on for years until her doctor said he’d let her off the order if she agreed to take a low dose of an antipsychotics voluntarily. She kicked herself in hindsight for not realizing earlier that her relationship with clinicians could have been collaborative rather than coercive. She wishes someone had told her that was an option. Meantime, she’ll never trust a psychiatrist again.

Make no mistake: Involuntary hospitalization exists as a therapeutic option for a reason. There are people who are severely ill and who by the very nature of their illness can’t wrap their heads around the danger they pose to themselves (and, yes, it’s almost exclusively to themselves). There was the woman in the Mental Health Emergency Services Unit with me at St. Joseph’s Health Centre who keened and threw ice cubes and smashed herself into the shatter-proof wall-mounted TV – would she have been safe on her own? What about one of my roommates at St. Michael’s Hospital who’d been deemed schizophrenic, refused medication and just about all treatment I could see and was contesting the months-long hospitalization she was convinced was the machination of aliens?

Forms are a necessary psychiatric tool but their use is increasing, and they aren’t benign: They can kill someone’s trust in the medical system for life, which means they don’t seek help or make use of it when they truly need it. That possibility has to be weighed against whatever harm you think will come of letting a person make their own health decisions. Whether it’s resource scarcity or a lack of that power to persuade, clinicians are increasingly turning to coercion. Perhaps if we prioritized the kind of care people wanted – compassionate, evidence-based, ready when needed in the form people need it – coercion could become a tool truly rare.

Photo illustration by The Globe and Mail


If you are having thoughts of suicide, call Kids Help Phone at 1-800-668-6868 or Crisis Service Canada at 1-833-456-4566, or visit crisisservicescanada.ca.

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