By Marvin Ross
The Family Alliance on Severe Mental Illnesses (FASMI) believes that “the treatment and care of those living with psychotic illnesses can and must be improved”. This might, when necessary, involve brief periods of involuntary committal and treatment. But the current desperate calls to do something are often uninformed.
We would like to set the record straight.
Every jurisdiction in Canada presently allows for involuntary committal for people who are a danger to themselves or others. That involuntary committal is overseen by laws that limit the time allowed (with options for renewal) and an appeal mechanism for those who object.
No society can tolerate potentially dangerous people wandering the streets and often attacking innocent bystanders for no reason other than the delusions in their own heads.
The key difference between jurisdictions in involuntary committal is that some like BC allow for doctors to provide treatment regardless of the wishes of the patient while others, like Ontario, will not treat without consent even if the patient lacks capacity if the patient objects. In that case, they must be declared incompetent by the Consent and Capacity Board (CCB) or court.
We should all agree that someone who is totally psychotic and likely lacks the capacity to know they are ill (anosognosia) needs to be treated for their own good and the good of society.
There are numerous examples of people in that state committing unprovoked violence against innocent citizens, and it is the duty of society to protect their citizens from attacks such as people being pushed in front of subway trains, randomly attacked or, most prevalent, family being assaulted and murdered by their own relatives.
We can think of Vincent Li who, while psychotic, decapitated his seatmate on a Greyhound Bus. Yet after involuntary committal and treatment, he is living in the community and is doing well.
In certain provinces, notably Ontario, an incompetent and dangerous patient can refuse treatment while appealing to the CCB or courts and so remains a danger. Because of the potential danger, he/she cannot be discharged. Treatment cannot start until the lengthy hearing process has been completed which can take months. When the case finally gets to adjudication, the courts almost always mandate treatment. As a result, treatment success and discharge is significantly delayed and the therapeutic benefit is potentially lessened.
The patient could have been discharged much earlier but is held, essentially against their will, with no help offered. In some cases, as outlined in the study Treatment Delayed, Liberty Denied in the Canadian Bar Review volume 87 , there are patients in Ontario who were involuntarily hospitalized for years while appealing an incapacity decision because they've refused treatment.
This is being challenged by the Ontario Psychiatric Association.
The typical objection to involuntary treatment is that it is coercive and of no benefit, but rarely is the literature cited in these instances. Research studies on the efficacy of involuntary treatment are not particularly objective or definitive in large part because they are difficult to do objectively.
But an evaluation of the program found that there was a significant reduction in inpatient episodes, suicidal ideation, illicit drug use, arrests, violence and homelessness.
The dilemma facing society was best put by “Cook County Sheriff Tom Dart on the 60 Minutes episode “untreated mental illness an imminent danger?”. Chicago’s Cook County jail is one of the largest institutions in North America housing the mentally ill. Sheriff Dart said, “the irony is so deep, you have a society that finds it wrong to have people warehoused in state mental institutions but those very same people were OK if we warehouse them in jail. You’ve got to be kidding me!”
Being locked up in a psychiatric facility is not the only strategy for involuntary treatment. Community Treatment Orders (CTOs) or Assertive Community Treatment (ACT) and Assertive Outpatient Treatment (AOT) can also be used to ensure that people live in the community but get treated for their psychosis. Failure to comply can result in their being institutionalized, but this can be very effective.
One very well researched program in New York State is Kendra's Law named after Kendra Webdale who was pushed off a subway platform in New York City in 1999 by an untreated psychotic man.
It provides the largest and best collection of real-world data.
A summary of studies including by Columbia University compared mentally ill individuals receiving AOT with a control group that was not. They found: "Individuals given mandatory outpatient treatment--who were more violent to begin with--were nevertheless four times less likely than members of the control group to perpetrate serious violence after undergoing treatment."
The Columbia University research also noted that, “Studies over 10 years have shown Kendra's Law helps the seriously mentally ill by reducing homelessness (74%); suicide attempts (55%) and substance abuse (48%); keeps the public safer by reducing physical harm to others (47%) and property destruction (43%); and saves money by reducing hospitalization (77%); arrests (83%) and incarceration (87%). Surprisingly, 81 percent of those ordered into treatment said AOT helped them get and stay well.”
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