Now that the accolades are done with, and the congratulatory high fives finished on Canada's new mental health strategy, it's time to get down to the really difficult task at hand, one that was largely ignored in that strategy. That task is to deal with the question of those with serious mental illness who pose a danger when they are not treated.
The current controversy over the day pass for Vincent Li exemplifies the commission's biggest omission. Li is the infamous Greyhound Bus beheader who has been sent to a mental health facility in Manitoba after being found not criminally responsible for his actions because of an untreated mental illness. There are a significant number of people with serious mental illness who, because of their illness like Li, are incapable of recognizing that they are ill. Because they do not believe they are ill, they refuse treatment. The condition is known as anosognosia and occurs with serious mental illness, Alzheimer's, and some other neurological diseases. This video and article are good explanations.
The mental health strategy recognizes this phenomenon when they say in the summary:
"Some people do not recognize that they have a problem, whether from lack of knowledge or because the illness itself can prevent people from understanding what is happening to them and that help would make a difference.
Unfortunately, the commission offers no solution other than to say that "the mental health system should be there for everyone who needs it".
The only solution for those for whom voluntary treatment is not possible is some form of involuntary treatment. Unfortunately, this option is not explored by the commission. Instead, they have recommendation 2.1.4 which suggests strengthening the use of advanced directives when someone deteriorates, but who recognized ahead of time that this might happen and they might need help.
That is a positive step, but one which has been available for quite some time with little uptake. It does require that the sick individual has insight when well enough to realize there may come a time when he or she is not well and needs treatment.
Not only is that asking a lot, but the individual requires a family willing to monitor them and to take appropriate action. But built into this advanced directive is the possibility that the sick individual may demand that no treatment be given when he or she deteriorates. If the directive to not treat is honoured, it may allow for someone to remain potentially dangerous and to continue to deteriorate.
These provisions for advanced directives likely impact only a small proportion of the ill anyway. What of those who have never been sick before, or who do not have friends and family to monitor them?
All that is said about involuntary treatment in the strategy is that Canada is a signatory to the United Nations Convention on the Rights of People With Disabilities. This agreement is designed to protect the rights of the disabled and calls for assurances that those rights are protected. Canada, however, reserved the right to continue to use substitute decision making, and asserted that there are sufficient safeguards in place now anyway to protect those whose rights have been temporarily suspended.
Despite that, the commission has a committee set up to evaluate the extent to which the rights of the mentally ill are protected, rather than to determine how to ensure that people receive the best treatment possible while protecting society.
As for protecting the rights of the sick, a number of courts have already found that current committal laws do not violate the Charter of Rights and Freedoms.
Going back to Li, it is interesting to note that he was released from an Ontario hospital, but refused follow up treatment and there was no legislation that existed to ensure that he got the treatment he needed. If a community treatment order had been available to him, he would not have become delusional and Tim McLean would be alive today.
In my book, I talk about one young man in suburban Toronto whose family desperately tried to find treatment for him. They could not and he ended up murdering his parents whose bodies he thought had been taken over by other people (Capgras Syndrome). He is now in a forensic facility, but undergoing treatment and doing well.
An excellent summary of the issues on involuntary treatment was provided to the Ontario Select Committee on Mental Health and Addictions by Dr. John Gray.
Dr. Gray has not been consulted by the Commission but he is the lead author of the book Canadian Mental Health Law and Policy, the author and/or co-author of 14 papers relevant to this topic, and a former president of the Schizophrenia Society of Canada. He told the Ontario committee that in Ontario it is possible to be locked up because you pose a danger, but to still refuse the treatment needed to make you well ("Treatment Delayed--Liberty Denied" by law professor, Robert Solomon, and co-author, Dr. Richard O'Reilly. It is published in the Canadian Bar Review.)
That paper documented people who have been detained without treatment for five years, two at 20 years and one at 25 years. The cost of incarcerating them is about $600 a day for an estimated waste of $4.38 million for 20 years. For what purpose, when they could be treated and cease to be a danger.
Dr. Gray made the point that involuntary admission with treatment works and that people are discharged from hospital "in an average time of three weeks, and sometimes considerably less." As an aside, Li is reported to have improved considerably now that he is being treated. "Community treatment orders, he went on to say,.... have been shown to reduce readmission, reduce criminalization and reduce homelessness. Involuntary treatment is, unfortunately, essential for some people, to start them on their road to recovery."
Victoria Maxwell is one person who has been restrained and committed against her will. She is a playwright, actor,and lecturer on her 'lived' experiences of bipolar disorder, anxiety, psychosis and recovery, and she writes a regular blog for Psychology Today.
At one point, her father took her to the emergency in her native British Columbia where she grabbed a pair of scissors to cut out her ego. Her conclusion over that incident is:
"Being committed to the psych ward was really the only and therefore best option at the time. Only in hindsight do I recognize this and that it must have been a devastating choice for my father to make. Now years later, I know he did the right thing."
Would it not have been better for Li and his victim, Tim McLean, for Li to have been hospitalized, treated, and then released with a treatment order that he continue to accept treatment or go back to hospital? What guarantees will be in place if and when he is released from hospital at this time?
The commission has some serious work to do which they have ignored to date.
Follow Marvin Ross on Twitter: www.twitter.com/dysdads
In my understanding of the Ontario Mental Health Act, Vince Li would not have qualified for a Community Treatment Order (CTO) when he was hospitalized in the Greater Toronto Area prior to the Greyhound Bus killing.
The law stipulates that to be considered for a CTO, a person must have been hospitalized several times within a specific time period for the same mental condition, and also, the treatment previously given must have been effective.
But Li was hospitalized only once and he walked out without being officially discharged before receiving treatment. Apparently, hospital staff did not follow up to see how he was doing, even though Li's condition was of enough concern that the doctors had strongly advised Li to remain at the hospital.
This points to three areas the Mental Health Commission of Canada (MHCC) should focus on:
1. Accountability of doctors at hospitals to ensure that someone they think might be dangerous is detained under the Mental Health Act for further assessment;
2. Accountability of doctors at hospitals to follow up a person thought to be at risk of dangerousness who has walked out of the hospital before being assessed.
3. Provisions for a CTO for individuals who have not been hospitalized more than once, but do meet the criteria for being detained in hospital.
The MHCC has a responsibility to address the needs of this small, specifically defined -- but highly important -- group of people.
It is a travesty of justice that families are forced to accept a no-treatment decision,knowing full well it can mean suffering and death for their loved ones The SMI, can and do die, all because some stranger has the power to refuse the lifeline that could save our loved ones. Even though they do not know our beloved children,or refuse to believe that anasognia should be an vital factor in their decision making.
They know not what they do!
DJ Jaffe
http://mentalillnesspolicy.org
The report did not focus on CTO, which is probably because it is not the most pressing issue in mental health treatment. Almost 4,000 people die from suicide every year in Canada. Focus on that instead of the very few cases where the murderer is a person with mental health issues.