Episode 18: Involuntary Care
Hello, I'm Jessica Samuels, and welcome to A Way Forward presented by Beam Credit Union. This podcast takes place on the ancestral traditional and unseated lands of the Okanagan Silicz people. Our topic today involuntary care, and CMHA Kelowna CEO Mike Gullick joins me to discuss about what takes place with involuntary care today, the ongoing discussion and why it can be such a divisive topic. Bean Credit Union is proud to sponsor today's episode. With deep roots in BC and a commitment to your financial journey, Beam believes wellness, mental and financial starts with support you can count on.
Jessica Samuels:Mike, thanks for being here to tackle this tough and somewhat divisive topic. Why don't we start from the top? Let's talk about the definition of involuntary care as it stands right now.
Mile Gawliuk:Okay. So, I mean, first of all, to get to involuntary care, we need to talk about the Mental Health Act that exists in BC. And the Mental Health Act is basically the legislation that defines how mental health treatment is to happen. And that includes both involuntary care and voluntary care as it comes to facilities and those pieces. Involuntary care, currently, someone can be certified and put into an involuntary care facility based on criterion within the Mental Health Act.
Mile Gawliuk:And there's four key elements of that.
Jessica Samuels:So what are they?
Mile Gawliuk:Well, again, the first is that there is the presence of a a mental health disorder. So that has to has to be there. That could be a diagnosed mental health disorder. The current conversation is around substance use. Now, substance use disorder is a disorder that's identified in the DSM-five, right?
Mile Gawliuk:Along with brain injury. So there has to be a mental disorder
Jessica Samuels:that's diagnosed or perceived.
Mile Gawliuk:Yes. Okay. Yeah. That the person is deemed to need psychiatric treatment in a facility is the second factor. And that the person needs care, support and supervision to protect themselves or others or to prevent them from deteriorating further.
Mile Gawliuk:And then finally, that that treatment can't be offered voluntarily because the person may not have the capacity to understand or the insight or those pieces.
Jessica Samuels:So four criteria. Well explained. Thank you. For me, I hear those things. And the first thing that is popping in my head is who is deciding this in real time.
Jessica Samuels:So it's great to have these on pieces of paper and theory and the diagnosis. We are in real time. And maybe my idea of when and how somebody would certify be certified is incorrect. If you're encountering an individual that meets those criteria. In the moment, how can all of that be verified?
Jessica Samuels:How can you know all of those things?
Mile Gawliuk:Well, I mean, ultimately, the certification process involves an assessment from either a nurse practitioner or a doctor. They review the information, they may communicate with the individual, and based on their assessment, they can certify the individual for up to forty eight hours. So it's that medical professional who ultimately makes the decision or determines whether or not they'll be certified. They need in order to continue to be certified within forty eight hours, there needs to be another doctor that signs off. Then that would mean they could continue to be certified for a month.
Mile Gawliuk:That can be extended for another month, could be extended for three months after that. And then after that, it could be six months and it can be ultimately ongoing. But ultimately, it's medical provider who does the assessment and assesses whether or not the individual meets the criteria for being certified under the Mental Health Act.
Jessica Samuels:Okay, so if people in community are encountering an individual like this and whether it's a PACT or Circle team or ICART team or whoever is responding in that moment, and they're determined that they, let's say, are danger to themselves or somebody else, what would be happening in that meantime while they're deciding on while these professionals are deciding on certification?
Mile Gawliuk:Well, I mean, ultimately, if one of those teams were to meet with an individual, you know, they would they would take the individual to the hospital ultimately is where that assessment is likely to take place. Yeah.
Jessica Samuels:All right. And so what are the checks and balances associated with those assessments? Because it does sound robust and I'm kind of putting you into a corner here and you probably know where I'm going. But what are the checks and balances in place? And I think this is important so folks understand that if involuntary care is not showing up in a van with people in white lab coats pulling you from your home, that I'm trying to dispel perhaps, an image that some folks might have out there.
Jessica Samuels:Yeah. Okay. So the checks and balances associated with being certified?
Mile Gawliuk:Well, I mean, there are a number of checks and balances in place. I mean, the first is the process around second signature, those pieces. I think there's a few things here that are important to speak to as well that are specific to BC, and I may end up answering your question sort of backwards. What's also important to know is that in BC, we've got the highest number of certifications under the Mental Health Act than any other province in Canada. Recent stats tell us that 20,000 people with 30,000 certifications happen within this province.
Mile Gawliuk:And what's some of the criteria that's leading to that has been an increased number of people being certified under the Mental Health Act related to substance use. Now, terms of the checks and balances in place, it becomes this is where it also becomes controversial because there is a section of the Mental Health Act. I believe it's Section 31 where there's a term deemed consent. Again, it's the only we're the only province in Canada to have this. And the deemed consent provision basically assumes that the individual has consented to treatment.
Mile Gawliuk:How it plays out is when someone is certified, they don't have a say over what treatment they receive. That is decided by their care team, their medical team. They don't have the ability to shape that. Their family doesn't have the ability to shape that. And so it starts to go into the question of human rights.
Jessica Samuels:That's the involuntary part of
Mile Gawliuk:the That's the involuntary part is that if you're under involuntary care, you've deemed to give consent to any treatment. You have no say over that. And the treatment team ultimately decides what treatment you'll receive.
Jessica Samuels:See, that's the scary part, I think.
Mile Gawliuk:Well, I think certainly it's one of the things that is is concerning, you know, you know, like again, hearing about certain situations where someone has been certified and have been put on a certain medication, which makes them extremely groggy and drowsy and doesn't allow them to function very well. You know, even that conversation. It's up to the doctor to make the decision whether there's a med change or anything else, Right. So it is scary. The checks and balances that are built into the system are that people do have rights for those that are involuntarily detained.
Mile Gawliuk:There is the ability to request a hearing with a review board, and that's made up of a lawyer, a doctor and a citizen from the community. Now, if you look at those numbers of 20,000 people, I looked up data from 2024 and the number of requests for hearing that came to the review board was around two eighty seven. And I believe the number of cases that were heard were around 140. So that's a mechanism that's in place, but it's not being well utilized.
Jessica Samuels:No, we don't know why it's not being well utilized, though.
Mile Gawliuk:No, we I mean, we don't know. There's the reality that as well when people are, you know, detained, they're to be made aware of their rights under the Mental Health Act. That is one of those. There's also the ability to get a lawyer and to go to court as well. But again, what we know is those mechanisms that are in place aren't necessarily being utilized in a robust way compared to the number of people that are ending up within involuntary care.
Jessica Samuels:Let's go back to that twenty thousand number every year being detained 30,000 times. What does that number say to you? That seems really high. And is before we, I don't know, I don't want to judge and say like, that's a good or bad number. What does that reflect about what's happening in community?
Jessica Samuels:I mean, you certainly talked about substance use. But also, I guess what's going on that the system, the health care system, the resources that we have available?
Mile Gawliuk:Yeah, I mean, I think it's likely multifaceted and I'm not necessarily going to have the correct answer. But what I'm going to suggest is a few things. You know, the world changed dramatically when the drug poisoning crisis started, like having been in this field before, being in the field after that has changed things so dramatically. That's a factor that wasn't there. Again, based on the 20,000, 30,000 piece, what's what's been identified again is there's increased certification around people who use substances.
Mile Gawliuk:So I think one of the connections that you can make is the drug crisis that we're currently facing. I think it also speaks to, and this will be part of the conversation, that we don't necessarily have a robust enough voluntary care system. So that means anything from what we talk about prevention to early intervention to counseling to specific care teams that focus on individuals with diagnosed mental illnesses and up to bed based care. There's a lack of those resources within our province. And so as a result, there becomes some reliance on an involuntary approach to care.
Jessica Samuels:Do you think this is because folks are not able to get the treatment, early enough that they are then in a situation where involuntary care is required? Or do you think it's because involuntary it's it's it's an either or it the folks who are responding to scenarios and situations that you mentioned have the kind of the single thing that they can rely on to try and get this individual the help they need?
Mile Gawliuk:I mean, I think I think I would say ultimately in a scenario where we don't have a robust voluntary care system, people end up getting sick and they end up getting sicker and they get to the point where that becomes the choice. In an ideal scenario, you have those services so that you get to people sooner, you help in terms of their health and the rest of it. It doesn't have to go down that road ultimately. As far as increased use of that as a tool, practitioner, I'm not so I'm not just going to say that this is the only tool that being used. I would say, again, it's more a reflection of not having a full system of voluntary services available.
Mile Gawliuk:Right. Yeah.
Jessica Samuels:We were talking about, we started this conversation of what involuntary care looks like today and thank you, gave a really kind of in-depth background, a kind of a state of what we're facing. What's interesting to me as this topic, which in the not so distant past really was had such a negative connotation to it. And that is no longer the case. In fact, this is, you know, we in recent months, we have service providers and we have political entities calling for, an increase in, the involuntary care system. There's some very specific caveats, associated with this.
Jessica Samuels:So, let me ask you with, do you think this is in response to, you said the drug crisis and the drug poisoning crisis? Like what has perpetuated now the state where we are, where involuntary care is being proposed and actually pushed in our province.
Mile Gawliuk:Yeah, I mean, certainly in part. And so this isn't just in British Columbia, like Alberta is moving quickly in that direction. I think it goes hand in hand with the fact that there's been an increase in the number of people who are unhoused. That has a role to play. You visibly see people struggling.
Mile Gawliuk:And I think in some cases, you know, where compassion and compassionate people have become tired. You know, we talked earlier before we started around business owners. And I get it if you're a downtown business owner and you've had your place broken into or your vehicle has been broken into or you had someone on your doorstep and they're really struggling. Compassion has sort of shifted and there's a level of exhaustion and fatigue. And I think people are looking for the answer.
Mile Gawliuk:They're looking for the solution to, again, a very complex problem. I think it's interesting how it's been described because some people say involuntary care. Some are saying compassionate mandated care. At the end of the day, I think they're both the same thing. I would hope that any individual that enters the system and receives mandated care is treated with compassion.
Mile Gawliuk:I would also want to see that that system is set up in such a way that evidence based services that we know are effective and have impact are part package. Of For example, when it comes to substance use, the gold standard treatment at this point for opioids happens to be opioid agonists, so methadone, Suboxone, those kinds of things. People talk about people, well, just go to detox and get better. In the case of opioids, what is known and understood is that if you come off of opioids and you don't replace it with one of those other options, you have a ninety eight percent chance of relapsing. And when you go from where you are, what you've done is you've taken your drug tolerance when you went in was here.
Mile Gawliuk:Your drug tolerance has now come down to here. And if we know that you have a ninety eight percent chance of using drugs, you're loading the gun. I have faith that evidence based treatments, like what I just described, will be part of a mandated compassionate care process. But begs some questions. Think the other piece is we hear about people with mental health issues, people with substance use issues and people with brain injury.
Mile Gawliuk:And so I think there needs to be a level of precision in regards to who it is that qualifies for this level of care. And we're hearing announcements and certainly we're seeing the advocacy that's coming around these Well, it was announced by our premier. 50 units in Prince George and 50 units in Surrey are getting added and there's more to come. So I would suggest that what we've seen in our communities as far as a burgeoning population of unhoused people, combined with some fairly high profile incidents like physical attacks. There was that incident in Vancouver during that festival where tragically eight people were killed.
Mile Gawliuk:They got run over by somebody. I think the seriousness of those kinds of scenarios also demands some level of intervention and is also a driving force behind this kind of approach and legislation. And then ultimately, all communities in British Columbia, big and small, are grappling with this issue of public safety. So this as well becomes, in theory, an approach that could impact public safety in communities.
Jessica Samuels:What's the track record for this approach as it stands now to actually work or success? I don't know language to describe it, but that folks stabilize their lives and enter into recovery, whether we're talking about substance use or mental health issues.
Mile Gawliuk:Well, I think I mean, what I would say first is the question of how do we know it works? Yeah. It's an interesting question because in terms of when the person is in an involuntary setting, if they're safe, recovering, then for that time that they're in that system, that works. The research and certainly in taking a look at things, there has been research that's been done. There's challenges with the research in terms of methodology and other things, but the research has indicated that ultimately an involuntary approach has had either sort of no effect or a negative effect.
Mile Gawliuk:In that case, it becomes an issue where, again, what works? What happens afterwards? I think the research good research hasn't been done in terms of comparing those in the involuntary system and those in the voluntary system and those that get no help at all to assess well what that looks like. But ultimately, the research hasn't demonstrated a whole lot of positive impact down the road. And you hear people talk about their own experiences and people that have been under involuntary care.
Mile Gawliuk:Some people will indicate that that's the thing that saved their life. Others will indicate that, no, in fact, it created a greater distrust of the health care system and it reduced that person's ability, motivation to present themselves to the health care system when they had a need, right? Or I was listening to a mom who struggled with a teen who was using substances. And for the longest time, they really were pushing for voluntary care. I believe they're from Alberta.
Mile Gawliuk:Alberta has specific legislation for youth around substance use. Their daughter ended up detained twice under that legislation. After she was discharged, I think it was within a month, she tragically died of a drug overdose. So what works? I would say what's necessary is there's how you got into involuntary care in the first place.
Mile Gawliuk:And then there's the key question about what happens when you move on from that that resource. So you're maybe stable, you're well, you're on medication, whatever that looks like. There has to be a system there. And we can talk about when people step down from that level of care. What does that look like?
Mile Gawliuk:Who is the who is the team that's attached to that person? What does the ongoing follow-up care look like for that individual? And I think when that's in place, the chances of people being successful longer term is possible. I think when that's not in place, the reality is it leads to challenges. Discharge from institutional care like hospitals, youth that age out of foster care is shows that there's a lot of people that when they're discharged from those institutions are discharged back into homelessness and being unhoused.
Mile Gawliuk:So again, I would hope the goal and the outcome of that is that and this is why, again, having a voluntary care system is going to be important on the back end of someone who has been either involuntary detained or has received compassionate mandated care in order to maintain a level of wellness. What I would suggest that I don't know, I haven't heard, but be really interesting as this model grows within the province is what kind of evaluation research is going to be attached to it as well. I think there's an opportunity here to take a look at it and study this approach to create some evidence around does it work, doesn't it work, the rest of it. And I think ultimately that's important. I don't know where that fits within the plan, but I think it's ultimately necessary.
Jessica Samuels:And also to make sure that we don't have overrepresentation of marginalized groups.
Mile Gawliuk:For sure. I think that's again one of the concerns. One of the risks ultimately is certainly in the justice system, you see an over representation of Indigenous people when we're looking at unhoused people and point in time counts that are being done across the province. Indigenous people, again, are overrepresented in those population groups. So I think we have to also consider the reality that marginalized groups may be further marginalized by this.
Mile Gawliuk:That's something that really has to be paid attention to, that we're not replicating colonial approaches. Yeah, so that's definitely a concern.
Jessica Samuels:Okay. Yeah. So as we wrap up, Mike, and I feel as usual, I feel like there's so much that we could talk about more. I just want to ask you then. So do you and CMHA Kelowna, do you feel that there is a place for this model of care, involuntary care, when we talk about the spectrum of care for folks who are struggling?
Mile Gawliuk:Yeah, I mean, what I would what I would say is that there is absolutely a place for involuntary care. I'd say we see it as a last resort, ultimately, when a voluntary care system has been exhausted. But there is no doubt that there are people who are struggling, who are unwell, who require that level of care. Again, as it's been mentioned across the province, it's been identified that it's a very small number of people that require that. So in that case, again, as a last resort, there's a need for that approach for sure.
Mile Gawliuk:Again, in advocating again to build out that voluntary care system. And the concern that that, you know, again, lean into involuntary approaches and that becomes the solution. I think it's all part of a bigger picture and it needs to be taken in context of that bigger picture. But yes, if you ask me if there's a place for it again, as a last resort, there are people that are going to need a level of care that isn't currently available in the voluntary system that will require an involuntary approach.
Jessica Samuels:All right, Mike, thank you so much.
Mile Gawliuk:Thank you.
Jessica Samuels:Big topic, lots to talk about. We will include a lot of these links, including the Mental Health Act, some information about the current status of involuntary care and some of these expansions that are coming out across the province, as well as the Mental Health Review Board, which is the method or the resource that individuals could use if they want to, I guess, protest or have a review of their certification. We will include all of that on the A Way Forward podcast page at cmhacolona.org. And if you have any questions about this topic or any of our topics, you can always email me awayforwardcmhacolona dot org. In the meantime, please do take good care.
Jessica Samuels:This episode is supported by Beam Credit Union. With deep roots in BC and a commitment to your financial journey, Beam proudly backs mental health conversations that help build stronger, healthier communities.
