Choice over coercion: A call for voluntary care

Despite what many may think due to the recent spotlight on the expansion of involuntary treatment in British Columbia, involuntary treatment for substance use already happens in B.C. Involuntary treatment refers to psychiatric treatment that is administered to a person without their consent and it is usually used for those with mental health and/or substance use health issues. It can happen under various acts in B.C., including the Mental Health Act. Of people detained and involuntarily treated under the B.C. Mental Health Act, 1 in 5 have a primary diagnosis of substance use disorder. This makes substance use disorder the third most common reason for involuntary treatment in B.C. Given these discussions about expanding involuntary treatment in B.C. and in other parts of Canada, it is crucial to examine the human rights violations within the existing involuntary treatment system, the lack of evidence to support its effectiveness and the potential harms and ethical concerns.

Human rights violations within the existing involuntary treatment system

Concerns about human rights violations already exist for our current involuntary treatment system. For example:

• A 2017 report by the Community Legal Assistance Society found widespread human rights violations. These violations included staff at detaining facilities interfering with people’s right to seek review of their detention (for example, by offering incentives, making threats, exerting pressure and interfering with access to review hearings).
• In 2019, United Nations Special Rapporteur on the Rights of Persons with Disabilities stated that “the Mental Health Act of British Columbia contains very broad criteria for involuntary admissions and, once detained, a person can be forcibly treated without their free and informed consent, including forced medication and electroconvulsive therapy.” This goes against the United Nations Convention on the Rights of Persons with Disabilities (Articles 14 and 25).
• A 2019 report by B.C.’s ombudsperson found that practices like forced psychiatric treatment without consent and the use of discipline in the form of seclusion and restraints constituted an “extraordinary power with little oversight or accountability.” This report contained 24 recommendations for change to protect the rights of involuntary patients under the Mental Health Act. Another review in 2022 found that only one third of the recommendations had been implemented and non-compliance with the law was still widespread.
• A 2021 report by the B.C. Representative for Youth and Children documented an alarming increase in detention and involuntary treatment of children and youth. Among many concerning findings, the report noted that the unregulated use of restraint and confinement was “unacceptable.”

Lack of evidence to support effectiveness

Evidence does not support the claim that detention and involuntary treatment are effective or lead to better long-term outcomes. In fact, research indicates the effectiveness of involuntary treatment is “limited and inconclusive”. Furthermore, people with lived and living experience of substance use “did not endorse involuntary care under the inadequate conditions of the existing health system.” The safety and efficacy of involuntary treatment for substance use is further called into question when considering that some studies have demonstrated an increased risk of overdose and drug poisoning deaths following discharge. 

Potential harms and ethical concerns

There are many potential harms and ethical concerns associated with involuntary treatment for substance use disorder. Human rights organizations and advocates emphasize that involuntary detention and treatment should not be expanded without strong legal protections to uphold rights. B.C.’s Mental Health Act already grants immense power to detain, administer treatment, discipline, seclude, or restrain individuals with mental health and substance use challenges and there is a lack of oversight and accountability of how it is being used. For example, under section 32 of B.C.’s Mental Health Act, involuntary patients are subject to the “direction and discipline” of facility staff without details about what “discipline” can entail. People with lived experience have shared with us that forms of “discipline” can include being subjected to seclusion, being restrained, or being denied access to the outdoors. Without proper safeguards, people struggling with substance use could be detained against their will in circumstances that do not adequately consider their unique needs, personal autonomy or human rights.

Another significant ethical concern of involuntary treatment is that it can potentially erode people’s trust in healthcare and support services. People detained and treated against their will can experience trauma and harm, which leads to fear and avoidance of healthcare services in the future. Studies have also shown that people who receive compulsory mental health treatment in the community are no more likely to be connected with services or to have improved mental health and social outcomes than people who access voluntary treatment.

Better access to voluntary treatment and other services and supports

Rather than addressing the root causes of substance use, such as poverty, trauma and lack of housing, involuntary treatment reinforces the criminalization and marginalization of people who use drugs. The focus should not be on expanding involuntary treatment but instead should be on expanding and improving voluntary treatment services and supports. These voluntary services should be available, accessible, acceptable and quality. We need services that prioritize choice, not coercion. For substance use health issues this could include things like:

• Increasing access to voluntary low-barrier treatment options by expanding availability of withdrawal management programs, opioid agonist treatment and wraparound support services.
• Investing in harm reduction services like supervised consumption sites, drug-testing services to prevent toxic drug-related overdoses and access to naloxone to prevent overdose deaths.
• Supporting peer-led and community-based programs. This includes ensuring people with lived and living experience are at the forefront of service delivery and policy development.
• Implementing a human rights-based approach to care and ensuring that law, policy and practice prioritize autonomy, dignity and informed consent.

Instead of expanding involuntary treatment, we must work toward approaches that respect individuals’ rights and provide them with the comprehensive, voluntary supports they need.

Health Justice is a non-profit organization that uses research, education and advocacy to transform the systems that shape mental health and substance use treatment in B.C. They work to shift the laws, policies, power dynamics and norms that lead to the growing reliance on involuntary mental health and substance use treatment in B.C. People with lived and living experience inform and guide their work because they believe in centring the communities most impacted by involuntary treatment.