Advocates say the bar for involuntary hospitalizations should be high, while psychiatrists worry fewer people will receive necessary treatment.
by Philip Moscovitch April 26, 2022 October 20, 2022
As the mother of a young man with mental illness, Joanne knows how hard it can be to get much-needed mental health treatment for a family member, especially when that person doesn’t think they need it.
Joanne (not her real name) lives in rural Nova Scotia, where there is limited access to crisis teams and emergency psychiatric care. A parent and volunteer mental health advocate, she remembers trying to convince her son that going to the ER for psychiatric care “was the best thing, and he needed to go.” He finally agreed, she said, but when they were eventually seen at the ER, she recalls being told, “It’s the weekend, and the emergency crisis team isn’t here, and the psychiatrist on call won’t be in until tomorrow morning at 10:30. So maybe you better come back then.”
Under the province’s Involuntary Psychiatric Treatment Act (IPTA), any physician who suspects a person has a mental disorder that could cause them to be a danger to themselves or others, or in danger of severely deteriorating, can be held for up to 72 hours, pending a full evaluation by a psychiatrist. In Joanne’s son’s case, that didn’t happen. Her son was later involuntarily hospitalized “to keep him safe,” she said. But the process seemed more complicated than it should have been.
“It’s exhausting,” she said in an interview. “It’s exhausting for the loved one who obviously needs help, but it’s also exhausting for you as the parent that’s trying to help them. And this is a situation that plays out again and again and again.”
On April 22, the provincial government passed Bill 120, an act amending the Involuntary Psychiatric Treatment Act. The bill was introduced March 31, and some of the changes it brought in alarmed parent advocates and psychiatrists, who were taken by surprise. The new act, they say, will make it harder to use the act, and could lead to fewer people receiving necessary treatment.
Dr. Jason Morrison is a psychiatrist with the Nova Scotia Early Psychosis Program, and a psychiatry professor at Dalhousie University. One of the hallmarks of some severe mental illnesses, like acute psychotic disorders, “is that people don’t realize they have a mental illness… or there are times the illness impacts your ability to understand information and make good decisions,” he said in an interview.
Shorter periods of untreated active psychosis correlate with better long-term outcomes. Morrison said. “That’s why we have this act in psychiatry. Because if you don’t have this, someone could be living in a state of psychosis, and never really agree to any treatment… You know, most of the folks we see go on to resume their lives. So the idea that we would have more people unable to recover and get back to their usual life was really, really alarming for us.”
Speaking in the legislature on April 20, Brian Comer, Minister Responsible for the Office of Addictions and Mental Health, implied that the government is not rushing through changes to the Involuntary Psychiatric Treatment Act, because extensive consultations have been going on since 2013.
Morrison agreed that consultations went on “for years and years and years, in an incredibly slow way,” but said he only learned the bill had been introduced when a parent contacted him. He said none of the other members of his teams or people he knew to be involved in the consultation process were aware of it either, and that some of the wording in the bill took them by surprise. “We had this very inclusive process, where everyone got a say in it, but then at the finish line, no one got to see the finished product.”
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The bill was already up for second reading on the day Morrison heard about it. “I guess really they just took all this several years of consultation, wrote up a bill, and didn’t go back to anyone about it,” he said.
While he agrees with the intent of some of the amendments, Morrison is worried about the language of others. They have to do with the bar for determining whether someone should be involuntarily hospitalized because they are a threat to themselves or others, and concerns around the role of substitute decision-makers, who act on behalf of involuntarily hospitalized patients. (The government did introduce a change to this part of the Bill 120 last Wednesday, after second reading. More on that below.)
Under the old act, a person could be hospitalized involuntarily if a physician “is of the opinion that the person apparently has a mental disorder” and as a result is a threat to themselves or others, or “is likely to suffer serious physical impairment or serious mental deterioration” and will “benefit from inpatient psychiatric treatment.”
The amendments change this to the physician having “reasonable and probable grounds to believe”(instead of “the opinion”) and that the person “will” (instead of “be likely to”) suffer impairment or significant deterioration. It’s a stronger test.
Morrison said he is even more concerned with the section dealing with a patient’s ability to understand the consequences of making decisions regarding hospital admission and treatment. Under the current act, a doctor needs to assess whether a patient “fully understands and appreciates” the nature of their condition and the risks of either accepting or refusing treatment. The amendments weaken that to what Morrison calls the “more ambiguous” language of having the “ability, with or without support, to understand information relevant to making a decision” and the consequences of that decision. So, again, a higher bar.
Involuntary hospitalizations are on the rise in the Nova Scotia Health’s Central Zone, NSH data shows. In 2021, there were 888 hospitalizations under IPTA — the highest number in the last five years. That was an increase over 816 in 2020, and 768 the year before that. There are some one thousand involuntary hospitalizations per year across the province under the act.
Anna Mehler Paperny was involuntarily hospitalized after her first suicide attempt, in 2011, and has spent time in psychiatric wards several times, as both a voluntary and involuntary patient. The author of the bestselling 2019 memoir Hello, I Want to Die Please Fix Me, Paperny said in an interview that she can’t speak specifically to the Nova Scotia legislation, but that the bar for involuntary hospitalization needs to be high.
“There is definitely a place for involuntary hospitalization, and even involuntary treatment, but it’s never a first choice. It’s never the ideal choice. And I don’t think we can go to it as a treatment option until and unless we’ve exhausted everything voluntary,” she said.
She added that society accepts people making all kinds of bad decisions “up to a point,” and when it comes to mental illness, “It’s up to the legislators, hopefully informed by people with thoughtful experience, to decide where that point is. But I feel a lot more comfortable about involuntary hospitalization and involuntary treatment when it’s something that is used extremely judiciously.”
Paperny said the number of involuntary hospitalizations is higher than it needs to be because “we do so, so reprehensibly little when it comes to prevention, and when it comes to early intervention, and when it comes to making treatment the kind of thing you would want to avail yourself of, even if you don’t believe you have a mental illness … I do think we should look at any increases in the use of involuntary hospitalization and treatment with a degree of wariness. And we should ask ourselves… are there opportunities for intervention that we’re missing that would allow us to provide necessary care in a voluntary way?”
People involuntarily hospitalized in Nova Scotia can be held for up to 30 days. At that point, if the medical team feels they should be held longer, they have to apply to renew the order. Patients also have the right to appeal involuntary hospitalization orders, although, Morrison said, appeals are usually heard three weeks after hospital admission, by which time many patients have already been released.
In 2021, 120 involuntary hospitalizations were challenged, but review board hearings only took place in 38 of those cases, or 32%. The figure for the previous year was 38%.
Joanne, the parent in rural Nova Scotia, said her son only got treatment after coming into contact with the police. “We had to call the police to do a mental wellness check. So, once the police were involved, things happened pretty quickly after that,” she said. “But it was very difficult. Like any parent, it was very difficult to to take that step.”
Paperny said she has talked to parents in this situation too. “I’ve talked to family members who found themselves hoping that their relatives would do something deemed serious or criminal enough to get the police involved, and then they could get mental health care — which is, of course, horrifying, because when you criminalize people with mental illness, you put them in this awful pipeline of incarceration and inadequate at best mental health care. And it’s so awful that people end up there.”
CBC reporter Jean Laroche reported that, outside, the legislature, Comer seemed to dismiss criticism of the amendments, by saying there are a lot of different points of view: “You could talk to 10 different psychiatrists and have 10 different opinions essentially.”
Morrison said that’s not true. In an email to the Examiner, he described Comer’s characterization as “inaccurate.”
“Psychiatrists as a group are uniformly concerned about this,” he wrote, “and had there been more time to address these sudden changes you would have seen position statements from our provincial organization and the Dalhousie Department of Psychiatry.”
After hearing criticisms, Comer did make changes to one section of the act, dealing with substitute decision-makers (SDMs). In some provinces, people hospitalized involuntarily may still be able to make their own treatment decisions. In Nova Scotia, that responsibility falls to a substitute decision-maker, who may or may not have been named by the patient.
Substitute decision-makers are entrusted to act in the patient’s best interests, and in accordance with their previously stated wishes. In the original amendments, the SDM could counter a patient’s instructions only if “the patient’s instructions would endanger the physical or mental health or safety of the patient or another person.” That’s now been changed to the SDM having “reasonable and probable grounds to believe that [a patient’s wishes] would endanger the physical or mental health or safety of the patient or another person.” (Emphases added.)
Bill 120 would also have made SDMs responsible for informing patients about treatment decisions. Sometimes SDMs are out of province, making this impractical. And often they are family members who may be perceived by patients as being responsible for their hospitalization. Rather than potentially exacerbating the SDM’s relationship with a patient, clinical teams usually deliver that information. The government backtracked on a change that would have given SDMs this responsibility.
Morrison thinks those changes are a step in the right direction, but writes, “still the idea [of] asking a substitute decision-maker to prioritize the ‘current wishes’ of an acutely mental ill person is puzzling.” He worries an unintended consequence of the change could be patients spending more time than need be in the hospital.
Like Paperny, writer and visual artist Anna Quon has been hospitalized both voluntarily and involuntarily. “When I went to hospital voluntarily it was because I was at the end of my rope, and wanted to be somewhere I could break down but be safe from my suicidal drive,” she wrote in an email to the Examiner.
Quon, who participated in consultations on the Involuntary Psychiatric Treatment Act amendments after being approached by a local mental health organization, said she is sure she would be “grateful” to be involuntary admitted if it saved her life, and if there were no other means. “But why are there no other means? I can’t help but think the systems, including the mental health ‘care’ system we have created, are part of the problem. Mental health conditions that are not addressed in a timely, skilled and compassionate manner, with adequate follow-up and supports at home and in community, mean people spiral into crises which become emergencies.”
She added, “Involuntary admission to hospital is an extreme measure, and whether it helps other people learn to recognize the warning signs unique to them and their condition for the long run, I don’t know.”
Morrison said that many people hospitalized involuntarily are, understandably, “really angry” and “upset.” But in his experience with patients, “The great majority of people, when they’re well — they don’t feel great about the whole hospital experience, but they acknowledge that a difficult decision had to be made, that’s ultimately led to good.”
Paperny said hospitalization can be “scary,” but that being held involuntarily also is frightening on an emotional level, “especially when you are there against your will, because you’re told you lack the mental capacity to make decisions for yourself. It’s a dehumanizing thing to be told… that you have this scary illness, that there’s such a high risk of harm to yourself or others, or there’s such a huge risk of deterioration, that you need to be kept in this scary place, I know it’s not scary to everybody. To me, at the time, it was scary. You think, God, there’s got to be something really wrong with me.”
In 2019, she wrote in the Globe and Mail: “A psychiatric ward can be a vital stepping stone en route to recovery, but so often, it feels like a drunk tank for crazy.”
Ideally, Paperny said, if a person has to be admitted involuntarily that should only happen once, with them getting good follow-up care after that. After her first stay, she said, “I got ongoing outpatient treatment. And I emphasize that because it’s so reprehensibly rare in Canada, and in North America broadly. And that’s awful, because these are chronic illnesses.”
Quon said she was generally given medications during hospital stays in her 20s, but for various reasons did not keep taking them, “Either because I thought my problem was purely emotional/spiritual, because the side effects were weird or difficult to tolerate, and most often because the meds seemed ineffective against my misery.” She has come to realize how medication can be helpful, but that didn’t come out of her hospital stays.
Regardless of the specific legislation in place, Paperny said if “involuntary hospitalization is really necessary, try and make that the only involuntary hospitalization this person will go through. Like, figure out what you’re going to need to do to get them on board with treatment. And that’s not easy. But I think it’s necessary.”
On Friday, Lisa Lachance, the NDP critic for Mental Health and Addictions, introduce a motion to send Bill 120 back to committee. Speaking in the legislature, they said, “Many people were involved in the discussions about this bill over a long time and yet at the end, in the rush to get here, they were not engaged.” Liberal MLA Patricia Arab spoke in support of Lachance’s motion, saying Bill 120 was “a well-intended bill that could potentially have disastrous ramifications.”
The motion was defeated and the bill subsequently passed.
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