Category Archives: involuntary treatment

Involuntary Treatment and British Columbia

By Susan Inman Guest Blogger with an Introduction by Marvin Ross

Introduction

On Monday, I discussed the recognition that Erin Hawkes-Emiru is receiving from British Columbia via their Courage to Come Back designation. As I pointed out, Erin was able to recover in large part because of forced treatment which she credits with saving her life. I was then going to write about the United Nations convention on the rights of people with disabilities which does not allow for the policies that saved Erin and saved countless others. However, Susan beat me to it in her article on the changes being proposed in BC which should concern us all as similar attempts are always being proposed in other jurisdictions. This is what Susan has to say:

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Susan Inman Author of After Her Brain Broke Helping My Daughter Recover her Sanity

 

BC Ombudsperson’s recommendations for improving involuntary treatment:

mostly good but also alarming

BC Ombudsperson Jay Chalke has released a new report: Committed to Change: Protecting the Rights of Involuntary Patients under the Mental Health Act. Most of its recommendations for protecting the rights of involuntary psychiatric inpatients are sensible. Chalke’s investigation, which led to this report, revealed that too often many of the procedures prescribed in the BC Mental Health Act aren’t being followed. Most of these involved failures to complete necessary legal documentation. Chalke’s plans call for retraining of hospital staff and physicians on these protections and regular audits of hospitals to ensure compliance is occurring.

However, Chalke has moved far beyond ensuring that current procedures are followed. He is now proposing that we introduce lawyers into involuntary care in ways that will likely be disastrous for many of the vulnerable people he is trying to protect. The new policy would see patients not just receive information about their options in regard to involuntary care, but actual advice (Recommendations #21 – #24). The supposedly independent staff supplying rights information and advice and then eventual legal counsel will be the taxpayer-funded services of the Community Legal Assistance Society (CLAS) , a branch of the Legal Services Society (Legal Aid BC). CLAS is not “independent” as the Ombudsperson requires. CLAS has a record of extreme opposition to contemporary, evidence-based psychiatry and therefore cannot give unbiased advice as required.

Last year, CLAS released a document about involuntary treatment, Operating in Darkness, that Chalke references in his report. A careful reading of the CLAS document shows how it is informed by an anti-psychiatry belief that involuntary treatment violates human rights. CLAS is the group, in the current charter challenge to BC’s Mental Health Act, that argues that all involuntary medical treatment of psychiatric patients, both inpatient care and mandated outpatient care, should be abolished. CLAS falsely claims, as will be discussed below, that proven antipsychotic medications are ineffective in helping recovery from psychosis and aiding release from involuntary hospitalization.

Chalke is clearly knowledgeable about mental illnesses. He writes that people who are detained are “suffering and in need of immediate treatment but, perhaps because of that illness, are unwilling or unable to accept it. In these situations, the state can step in with the greatest power it has – the right to remove a

person’s liberty by detaining and treating them.”

CLAS’s approach to severe mental illnesses is different than Chalke’s. In its 181-page document, it never acknowledges the existence of people who, when they become psychotic, are unable to understand that they need treatment. It is people with psychotic disorders, often schizophrenia or bipolar disorder, who often end up needing involuntary treatment at certain points as they try to manage these severe brain disorders.

CLAS’s approach to mental illnesses

CLAS’s Operating in Darkness strongly supports the controversial interpretation of the UN Convention on the Rights of Persons with Disabilities (CRPD) and its opposition to involuntary treatment. This interpretation is made by the CRPD Committee that is overseeing its implementation. Readers may think that because Canada ratified this document, provincial mental health acts that allow involuntary treatment are defying its principles. CLAS fails to mention that since Canada’s 2006 ratification, it has continued to maintain the right to use substitute decision makers (such as physicians) in cases where a person lacks the capacity to make a decision.

CLAS also never mentions that the CRPD Committee calls for the elimination of all mental health acts. CLAS never grapples with the consequences of these kinds of policies, which are the increasing incarceration of people with mental illnesses. The CRPD Committee goes even further and calls for the elimination of the “not criminally responsible” defense. This would mean that forensic hospitals, which treat people whose mental illnesses are understood to have caused their crimes, would be eliminated. Anyone convicted of crimes leading to incarceration, no matter how mentally ill they were or are, would be regarded as fully responsible for their actions and forced into the general prison population.

CLAS’s descriptions of medical treatments for mental illness do not reflect the neutral position the Ombudsperson wants. CLAS implies that medical treatments are worse than useless. It argues that anti-psychotic medications “do not combat psychosis like antibiotics combat bacteria” and instead are just used to “have a sedative effect that alters behavior.” This description fails to mention that antipsychotic medications are used to get people out of psychosis.

Psychosis is a condition characterized by delusions, hallucinations, and disorganized speech, thoughts or behavior that can make it impossible for people to manage daily life. CLAS’s source for its information is a psychiatrist for madinamerica, a site that rejects standard, evidence-based psychiatric practices. It focuses on the views of “psychiatric survivors,” people who believe they suffered from encounters with psychiatry and medications they didn’t need. CLAS’s approach to mental illnesses resembles the ideas promoted by this group. Its advice will encourage patients to reject involuntary treatment and to use CLAS’s legal services in review panels and in court challenges.

Vast research supports the benefits of antipsychotic medications to help people manage to live with severe psychotic disorders. One of the largest longitudinal studies (over 8,000 people) and longest (20 years) was recently conducted in Finland. In following up on patients treated for first episode schizophrenia, researchers found that “The lowest risk of re-hospitalization or death was observed for patients who received antipsychotic treatment continuously….”

Besides ignoring research that doesn’t fit with madinamerica’s views, CLAS also ignores testimony of people living with schizophrenia. While its document is full of comments from selected patients who don’t want involuntary treatment, it fails to include testimony from the growing number of people living with psychotic disorders who describe how involuntary treatment benefitted them. Some like Joseph Bowers ( have been learning to live with their illness over many years. Bowers writes,

I’m near seventy, healthy, a husband and father who is retired with enough money coming in. None of this could have happened without involuntary treatment. My civil liberties were not taken away when force medicated and treated. I was instead liberated from the tyranny of serious psychosis.

Vancouver based peer support worker and author Erin Hawkes recounts in her article “Forced Medication Saved My Life” the agony of her psychotic episodes before antipsychotic medication restored her sanity.

In this BC Schizophrenia Society educational video, Vancouver peer worker Bryn Ditmars describes what it was like to be psychotic and believe he was the messiah. Ditmars and a psychiatrist from Vancouver’s Early Psychosis Intervention program, as well as a parent, offer the kind of information that madinamerica and CLAS avoid.

Bowers, Hawkes and Ditmar, like many people in psychosis, had anosognosia, a brain based inability to understand that they were ill. Anosognosia is the reason psychotic people usually don’t want treatment. CLAS and madinamerica writers won’t acknowledge the existence of this condition, because once it is accepted, the flawed thinking in using a human rights argument to ban involuntary treatment can be seen. Leaving people trapped in psychosis and untreated is not a policy that a just, responsible society adopts; it ignores people’s rights to be treated and recover.

CLAS does mention the lack of adequate psychosocial treatments in psychiatric units. Introducing people to these additional treatments during this time can not only make the stay in the hospital more therapeutic, but can give them ideas about what to pursue in the future. However, CLAS supports the inclusion of the Hearing Voices Network. The Vancouver Hearing Voices Network’s study group, funded by taxpayers, studies the works favoured by those who agree with madinamerica’s approaches. For instance, this announcement advertises the kind of writer the group favours, in this case Will Hall. Hall is best known for explaining why and how people should stop taking anti-psychotic medications.

While CLAS’s anecdotes reject or minimize the value of antipsychotic treatment, my experiences in the community are very different. Antipsychotics, and brief involuntary treatment when needed, have allowed my daughter and her friends who live with schizophrenia to enjoy stable lives.

Why we need to learn from the US’s mistakes

The current situation in BC is part of a larger struggle in Canada, the US and internationally. Influential but misguided human and disability rights groups, with perspectives like those of CLAS, have exerted a wide influence on mental health legislation, policies and services. The US provides the most extreme example of what happens when these perspectives are allowed to be in control of federal government policies.

Despite its mandate to provide care for people with serious mental illnesses when it was established in 1992, the US Substance Abuse and Mental Health Services Administration (SAMHSA) experimented with promoting an increasingly de-medicalized approach to mental illnesses. It actively supported anti-psychiatry groups and policies. When a Congressional committee began investigating SAMHSA after the Sandy Hook massacre, it was headed by a lawyer. The investigations revealed that SAMHSA hadn’t include any psychiatrists or physicians among its over 500 federal employees; this discovery led to it appointing its first Chief Medical Officer, Dr. Elinore McCance-Katz. McCance-Katz eventually quit and wrote an expose ( in which she described the alternative beliefs, similar to those that CLAS supports, that dominated this powerful organization. In her article, “The Federal Government Ignores the Treatment Needs of Americans with Serious Mental Illness,” she wrote:

There is a perceptible hostility toward psychiatric medicine: a resistance to addressing the treatment needs of those with serious mental illness and a questioning by some at SAMHSA as to whether mental disorders even exist—for example, is psychosis just a “different way of thinking for some experiencing stress?”

The policies at SAMHSA had resulted in much less access to treatment for serious mental illnesses. The consequences are that individuals with serious mental illnesses like schizophrenia and bipolar disorder are now ten times more likely to be incarcerated than in a hospital bed. Finally, during the end of the Obama administration, Congress took action that resulted in the establishment of an Assistant Secretary of Health and Human Services. Appointed to that position, McCance-Katz now heads SAMHSA and a major goal is the treatment of serious mental illnesses. McCance-Katz not only recognizes the existence of anosognosia, but educates the workforce and the public about it.

One of SAMHSA’s major focuses now is the development of Assisted Outreach Treatment (AOT) programs, the extensively researched programs that reduce homelessness, re-hospitalizations and interactions with the criminal justice system. This is exactly the kind of program that CLAS actively opposes. In its challenge to the BC Mental Health Act, it made clear that it not only wants to stop any inpatient involuntary treatment, but opposes mandated outpatient treatment programs that now operate under extended leave services. People in these programs have shown that they need this additional support to avoid continual relapses. Participants are regularly assessed to see if mandated treatment is still needed.

In the US, prisons have gradually become the new mental institutions and federally funded legal advocates contributed to this problem. In its inception in 1986, the US Protection and Advocacy for Individuals with Mental Illness Act (PAIMI) was designed to protect this population from all kinds of abuses. It operates in the kinds of roles suggested for CLAS in the Ombudsperson’s recommendations. However, despite the intention, legal advocates focused on and became very skillful at blocking efforts to provide mandated treatment. PAIMI legal advocates persuade ill people who have been hospitalized to avoid treatment. In front of a Congressional committee, Joe Bruce ) explained how PAIMI legal advocates in Maine persuaded and assisted his very psychotic son to reject medications and get out of the hospital. The son went home and killed his mother whom he believed to be an al Qaeda operative. Once he was treated with medications he’d previously been persuaded he didn’t need, he came out of psychosis. He talked to reporters about how he misses his mother.

What Should Happen

The BC Ombudsperson’s recommendation for funding CLAS to provide rights advice to involuntary inpatients is dangerous. CLAS’s opposition to all involuntary psychiatric treatment will surely mean that they won’t simply provide information on rights and options for appeal. When we see how CLAS views contemporary psychiatry, we can understand how vulnerable people will be persuaded to resist treatments they need. Clinicians, like social workers and nurses, who have a background in working with patients with mental illness, can be trained to provide this service in a neutral manner. This would be much easier and less expensive than trying to train lawyers and legal advocates about severe mental illnesses if they are already ideologically opposed to involuntary treatment.

If, as recommended in the Ombudsperson’s report, legislation is proposed to hire CLAS to supply legal advocates to provide advice, to argue at every review panel, and to pursue court challenges of review panel decisions, there should be extensive publicity about these plans. Impartial lawyers on review panels are already present to ensure legal procedures are followed.

Investing significant funds to greatly expand the role of lawyers in mental health care will come at the expense of already underfunded mental health services.

For instance, for several years there has been great interest in having evidence-based cognitive remediation programs implemented in BC. The common cognitive losses accompanying schizophrenia and other psychotic disorders are extensively researched; these losses frequently appear before any other symptoms or any treatments begin. Cognitive losses include difficulty with concentration, problem-solving, short term and working memory, and judgment. It is these losses that are considered to be the biggest factors in the ongoing and widespread disability of this population.

The many families that I know who are supporting people with severe mental illnesses did not hear about any consultations that occurred in creating these alarming recommendations. Family caregivers for people with severe mental illnesses should be consulted about the services they want protected, those that need to be implemented, and their opinions about those that pose dangers. People struggling with severe illnesses are part of a population who are unable to represent themselves in contentious public debates, and they are certainly not represented by the psychiatric-survivor community with whom CLAS communicates.

Life is hard for people who, through no fault of their own, develop serious brain disorders. The larger community must ensure that misguided policies don’t make life even harder.

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Coming in January: Mind You The Realities of Mental Illness A Compilation of Articles from the Blog Mind You

We have decided to publish a book on the best of our mental illness blogs over the past 4 and a bit years. The book will be available in print and e-book formats everywhere in early 2019.

Below is the introduction:

We began this blog in October 2014 in order to provide commentary on the state of mental illness and its treatment for the lay public. What we provide is a viewpoint from that of a psychiatrist with many years of experience (David Laing Dawson) and a family member of someone who does have schizophrenia (Marvin Ross). Aside from his personal experience (or lived experience as it is commonly referred to), he is also a medical writer, advocate and publisher of books that take a unique look at mental illness.

To date, we have had close to 75,000 views and have been read in 151 different countries since 2014.

We also write on other topics but these are the ones on mental illness covering topics like recovery, treatments, suicide, addictions, and alternative treatments (or pseudo science).

When we began, we had this to say of our purpose:

 Welcome to the launch of Mind You. While we intend to post on mental illness,mental health and life, we decided on the name Mind You to reflect that not everything is black and white. There are ideas and opinions but then mind you, on the other hand, one can say…….

And that is what we would like to reflect. Ideas about mental illness,health and life that can be debated and discussed so that we can come to a higher understanding of the issues. And, we have separated out mental illness from mental health because, despite their often interchangeability, they are distinct.

The National Alliance on Mental Illness defines mental illness as a medical condition that disrupts a person’s thinking, feeling, mood, ability to relate to others and daily functioning. Just as diabetes is a disorder of the pancreas, mental illnesses are medical conditions that often result in a  diminished capacity for coping with the ordinary demands of life. Serious mental illnesses include major depression, schizophrenia, bipolar disorder, obsessive compulsive disorder (OCD), panic disorder, post traumatic stress disorder (PTSD) and borderline personality disorder.

On the other hand, the World Health Organization defines mental health as a state of well-being in which every individual realizes his or her own potential, can cope with the normal stresses of life, can work productively and fruitfully, and is able to make a contribution to her or his community. That is quite different from mental illness.

Unfortunately there is a tendency to confuse these and organizations like the Mental Health Commission of Canada have a tendency to talk about mental health issues and problems which are not the same as mental illnesses.

 Both Dr David Laing Dawson and I (Marvin Ross) will be posting on a regular basis on a variety of topics.

The posts we have selected for this volume are the most widely read over the past 4 years.

Mind You, ISBN 978-1-927637-31-9, 193 pages distributed by Ingram

 

The Absolute Discharge for Vince Li was wrong

By Dr David Laing Dawson

Vince Li has been treated now, for his schizophrenia, for 8 years. He has been living in the community and attending classes. The Review Board has given him an “absolute discharge”. He is, we are told, recovered, insightful, remorseful, and willing to take his medication regularly. Thus he is not a threat and qualified for absolute discharge.

He may well remain healthy and compliant with his medication for the rest of his life.

Perhaps the odds are slight that he will stop his medication and become ill again.

But, here are two realities about psychotic illnesses, schizophrenia in particular:It is hard to catch a relapse.

  1. When a patient stops his medication he will feel fine for a while. And when the relapse begins the first thing to become impaired is insight. One can monitor mood, but not one’s own cognitive processes. So very few people with schizophrenia who stop medication and feel good for a while, are then able to detect, on their own, the early signs of cognitive changes. As the illness worsens the prospect of insight lessens. It is the nature of schizophrenia. It affects thinking.
  2. When relapses of psychotic illnesses occur, the original delusion returns, if not exactly word for word, almost word for word. Thus if the original delusion was relatively harmless, in a relapse the patient’s returning delusion will be relatively harmless. “They are listening to my thoughts from the TV so I don’t ever turn it on.” “It is happening again.” But if the original delusion was dangerous: “I must kill to rid the world of the devil”, then when the relapse occurs the person in question will once again become dangerous.

Thus, even if the possibility of a relapse of illness for Mr. Li is small, such a relapse would be far more dangerous than for most people with this illness.

And if this occurs, if Mr. Li relapses and hurts or kills someone else, the cost will be much wider than Mr. Li and his victim. “Let’s talk about it” will certainly not be enough to reduce stigma then.

Such an occurrence will undermine the compassion and civility of the “not criminally responsible” finding.

The average citizen has trouble buying this defense now, for various reasons, especially when the crime is horrifying. If Mr. Li relapses and commits a crime, the community outcry will be very strong. A relapse and repeat by Mr. Li could thus do great harm to all mentally ill in Canada.

This could have been remedied simply: a discharge (though not absolute) that continued a lifetime of monitoring compliance with treatment. Not overly intrusive or restrictive. Simply making sure that Mr. Li continues his treatment, that he continue to take his pills every day or his injections every two weeks.

If Mr. Li stops taking his anti-psychotic medication, one year or ten years from now, the illness will relapse. And the delusions of this illness always return in the same form.

Psychiatric Refugees? Give me a Break!

By Marvin Ross

For years, we’ve had a small group of very vocal people who call themselves psychiatric survivors — people who have had psychiatric treatment, do not agree with it and consider that they have survived it. Now, thanks to CBC radio, we have someone dubbed a psychiatric refugee — a woman who fled British Columbia for Ontario to escape her involuntary status in a B.C. hospital. And, it was said, she is not the only so-called refugee.

Comparing yourself to people who survived a genocide like the Holocaust or saying that you are comparable to Syrians and others fleeing in leaky, dangerous boats from war is absurd. But what is also absurd is the story that this anonymous person called Sarah by the CBC told. It is just not logical but it is being used to justify the Charter challenge to the B.C. Mental Health Act that I suggested was misguided.

People deserve to know and to understand what the Mental Health Act is about. They deserve to know the processes that are in place to commit someone against their will and to treat them. And they need to know the safeguards that are in place to prevent excesses and protect the rights of the individual. These are never explained.

First, I encourage you to listen to the interview. To begin with, Sarah said that she went to the emergency at a hospital with her mother because of troubling life events and she wanted help. She was admitted, she said, voluntarily but then her status was changed to involuntary.

Now, for her to have been declared involuntary, she would have had to have satisfied all four of these criteria (page 18 of the guide):

  • Is suffering from a mental disorder that seriously impairs her ability to react appropriately to her environment or to associate with others;
  • Requires psychiatric treatment in or through a designated facility;
  • Requires care, supervision and control in or through a designated facility to prevent her substantial mental or physical deterioration or for her own protection or the protection of others; and
  • Is not suitable as a voluntary patient.

If she was involuntary, a licensed physician must have assessed her and certified that she met the criteria. Then, another independent physician conducted an examination with the same criteria to extend the stay beyond 48 hours.

( See form 4 where the reasons for the involuntary decision must be listed.)

At the end of one month, she would be examined again to determine if she still met the involuntary admission criteria and the proper form would be filled out to extend her stay a further month (page 20 of the guide). If she no longer needed to be involuntary during this period, the doctor can cancel it and she can always appeal her status to a review board at any time.

Once a patient has been deemed involuntary, they are given a form 5 (consent to treatment) (page 173), which explains to them what treatment is being given. Note that Sarah told the CBC that no one ever discussed treatment with her. They had to.

In addition, Sarah’s rights would have been explained to her and she would be given a form 13 to sign (page 182). She did say she had to sign something but she was not sure what it was. The person having her sign would have told her that she had a right to a lawyer, that she would be regularly examined by a doctor to ensure she was being held appropriately, informed that she could apply to a review board to assess her capacity, go to court to challenge the doctor’s decision and/or request a second opinion from a different doctor.

Next, she would be given a form 15 (page 186) to fill out so that she could nominate a near relative to be informed of her status. She did say that her mother went to the emergency with her so I have to ask where her mother was in all this. Surely she would have been liaising with the hospital staff over diagnoses and treatments. While her mother would have no authority under the act, most doctors do encourage family participation. During the CBC interview, Sarah said that she wished her mother could be involved in her treatment and there is nothing in the act that says she can’t be.

Sarah told the CBC that she absconded during a smoke break and that a form 21 (page 193) had been filled out. That form obligates a peace officer to return her to hospital. Sarah said she went to police in Calgary and told them, and that they called her psychiatrist but they did not hold her for return. The form 21 is only valid within British Columbia, but if 60 days had expired, it would not be valid and she would be deemed discharged.

There are so many holes in what she told the CBC that cast doubt on all she said. It is important for people to understand, particularly in light of the court challenge, what protections there are for an individual who is involuntary. This is not something that anyone takes lightly and is done for the best interest of the patient and for society.

The infamous Vince Li, who beheaded Tim McLean on a Greyhound bus, was initially picked up by Toronto Police in 2004 and taken to hospital. He left hospital against medical advice as there was no mechanism with which to keep him.

Imagine what would have happened if he had been treated initially? Tim McLean would be alive, his family would not have suffered the pain and anguish they did, and the first Mountie on scene might not have developed severe PTSD and eventually taken his own life.

As for Vince Li, he has done so well on treatment that he is now living in a halfway house. I can only guess at the pain he must feel knowing what he did while psychotic and that he would not likely have done if he had been properly treated at the outset.

Vancouver resident Erin Hawkes has written extensively on how the so-called forced treatment had saved her life. She has written in the National Post, numerous times in the Huffington Post and in the Tyee.

The CBC should interview her as well on the court challenge and they should do better fact-checking. If the plaintiffs in this Charter challenge call Sarah as a witness, we will see how well her story holds up to cross-examination.

Note: this first appeared in the Huffington Post on September 26. One person criticized me for attacking mothers which is not what I intended. I pointed out that Sarah’s mother has gone to the ER with her and I likely had input. When I asked where she was, it was a comment directed towards Sarah who said that she wished her mother could have been involved and I suspect she was. I realize that not all doctors and mental health staff are open to families but enough are. My own experience as a family member is that I have always been involved.