Anna Mehler Paperny is the author of Hello I Want to Die Please Fix Me: Depression in the First Person.
Coercive care is having a moment. Alberta, which hinted at expanding involuntary treatment for drug users, is eyeing that option. British Columbia Premier David Eby has mused aloud about it. In Toronto, mayoral candidate Anthony Furey says he wants to explore more opportunities for mandatory treatment. New York City and California are exploring expansions to involuntary care.
It can seem a beguiling prospect: Help the most visibly needy, the people unable or unwilling to help themselves. Get disorder off the street and salve a spooked public, while you’re at it.
It’s not that simple.
For one thing, while the most visibly needy are often the visibly homeless, not all of them suffer from mental illness, and even if they do, the core problem may be their lack of a home rather than their disordered brain.
But more to the point, locking up people with mental illness is no cure-all. We know that because it’s already happening. Canadian jurisdictions have been involuntarily hospitalizing and treating people with mental illness for ages – and, clearly, the problem of inadequately addressed mental illness persists. We’re using coercive care more: A study found involuntary hospitalizations of British Columbians older than 15 increased 65.7 per cent in a decade, with police apprehensions increasing 128.7 per cent. In Ontario, the number of people placed on a 72-hour hold increased 55 per cent over the past decade, while the number of people hospitalized against their will for two weeks increased 71 per cent. The number of people on month-long stays tripled. Meanwhile, the number of people found incapable of consenting (or withholding consent) to treatment increased 29 per cent.
Does coercive care work? It depends on who you ask, and what you mean by “work.” Yes, it can keep you safe from yourself and others for a period of time; it can give you a chance to access care, at least in the short- to medium-term. (Granted, Canadians with severe mental illness are often discharged into a treatment abyss; one can be sick enough to warrant coercion, but apparently not sick enough to warrant continuing care that could prevent future deterioration.)
But involuntary care can also set people up for relapse and drug poisoning, if they use substances and lose tolerance. And traumatizing experiences in such care can seed a deep mistrust of the medical system, making it less likely that they ever seek out care on their own.
I’ve been there. I’ve spent weeks locked in psych wards because I was deemed a suicide risk; I know how awful and disempowering it is to lose agency behind those auto-locking doors. But I got lucky: The doctor who ordered the extension of my first involuntary stay, a decision I cursed him for at the time, became my outpatient psychiatrist and a lifesaver. He treated me – still treats me – as a human with wishes to be respected. He just didn’t think I was able to make this one decision at that particular point in time (though I happen to disagree). It is possible to deprive someone of one right while respecting others, to recruit patients as collaborators in their own care. But this happens too rarely.
On another occasion, my status was made voluntary, and the change felt monumental: I could make decisions about my own care. This, too, is all too rare.
Anosognosia – the state of lacking insight into your condition – is real. But people want to feel good and solve their problems. If we can craft and provide care plans that do that, maybe people will avail themselves of them.
It’s become fashionable to bemoan deinstitutionalization as having effectively dumped severely unwell people into the world without supports. But the problem isn’t that people were discharged from indefinite, often abusive lock-up; the problem is that they were discharged without community supports that would have helped attenuate their suffering, disability and risk.
Locking up more people with mental illness doesn’t solve the broader problems. We are not providing continuing care for chronic, debilitating conditions. We are not making evidence-based care accessible, equitable, attractive, or preventive enough. If we really cared about the human beings that mental illness so excruciatingly affects, this is where we would instigate change.
There is a role for coercive care. It’s arguably necessary for some people, sometimes. But used injudiciously, it can sour people on care and set them up for failure.
Canada’s legislators and courts have said the bar for depriving someone of their basic rights should be high. In discussions around curbing these rights, let’s keep in mind how fundamental they are, and how rare their abrogation ought to be.