In the decade since the last patient was discharged from Riverview Psychiatric hospital in Coquitlam, it’s become apparent that the promise of alternate, community-based care has not been met. The evidence is all around us.
It’s been estimated that, on average, a third of the homeless men we see on city streets and camped out in city parks suffer some form of mental illness, most often schizophrenia. The percentage of homeless women who are mentally ill is even higher.
Before we come to what can be done, it’s worth considering how we got here.
At its height, in the 1950s, the hospital housed 4,300 patients. The decision to close the facility was made, in part, due to concerns about potential maltreatment of patients, in part due to a growing belief that even seriously mentally ill people had a right to live their lives as they chose.
The 1975 movie One Flew Over the Cuckoo’s Nest, featuring Nurse Ratchet as a tyrannical bully who ruled her ward with an iron hand, captured the emerging sense of psychiatric institutions as an offence against morality.
The patients basically had no rights. There was little or no oversight, and certainly not down to the bedside level.
Unfortunately, the decommissioning of the hospital, which began in the 1980s, was a case of idealism colliding with reality. There was little chance that thousands of seriously ill patients could be discharged into the community, to live where they chose, and that outreach services would find and treat them.
There was even less chance that once discharged, those patients could organize for themselves what the hospital offered — a roof over their heads, three meals a day, a warm bed and proper drug therapy. Logistically, it was impossible.
The impact on downtown communities has been overwhelming. Parks are taken over, shop doorways used as latrines, loud noise at night, petty theft and violence. Our city centres are being hollowed out, to a degree never before imagined.
It’s estimated that a fifth of all policing activity involves responding to a mental-health crisis. As well, some part of the huge increase we’ve seen in drug overdose deaths is likely due to mentally ill folks self-medicating.
In one respect, that’s understandable. Even second-generation anti-psychotics, while more easily tolerated than the first generation, are still hard to live with.
Weight gain, drowsiness, loss of clarity in thinking, dizziness, difficulty sleeping and body tremors are all common side-effects of these medications.
The question is: What can be done? For patients with mild to medium symptoms, community-based outreach, along with development of affordable housing, can certainly help.
But for those whose symptoms render them incapable of caring for themselves, such assistance, no matter how well organized and supported, is often insufficient to provide the essentials of life.
Yet can we face the challenges, both moral and practical, of resuming in-patient care in the form of a psychiatric hospital? Civil-rights organizations would certainly be opposed.
Politicians would shrink from taking such a step.
The practical difficulties are even more formidable. The Mental Health Act, under which people can be involuntarily committed, is nightmarishly complex.
To commit a patient to a psychiatric facility for more than 48 hours requires mountains of paperwork. Physicians, already in short supply, must produce voluminous monthly reports on the patient’s progress, alternate forms of care and risk assessments if the patient is discharged.
All of this makes sense, up to a point. No one should be deprived of their freedom without the most thorough review.
But realistically, the standard for committal has been set so high, it’s difficult to imagine our mental-health system working its way through several thousand homeless patients.
The resources are simply not there to do it.
This is perhaps the moral dilemma of our time. At what point do the rights of the individual yield to the rights of the community?
By refusing to tackle this dilemma, our politicians have failed in their duty, both to the seriously mentally ill, and to the city streets they call home.
