Involuntary Treatment

Involuntary treatment refers to detention in a hospital, for the purpose of providing mental health and substance use treatment against a person’s will. [6] It is often time-limited, and intended to be delivered to individuals who:

1. Have a mental health and substance use issue that could result in serious harm to themselves or others, or if they are at risk of serious physical impairment, and;
2. Decline voluntary treatment and/or do not have the capacity to make decisions about treatment.

It may also be referred to as forced treatment or compulsory treatment, although some provinces are now using terms such as “compassionate treatment”, or “compassionate intervention”.

[6] Involuntary Treatment (Science Direct)

Treatment for substance use can also be voluntary and is offered as part of the continuum of care. Treatment can consist of community-based supports and bed-based treatment. A bed-based care treatment program may offer both withdrawal management (i.e. detox beds) and live-in treatment (i.e. rehabilitation programs).

These programs can be effective for addressing addictions to substances, but people often need multiple attempts in recovery programs before they are able to achieve stability. Long-term relapse rates can vary   between 20-80%. [7]

Treatment from addiction is considered a lifelong process and is most successful when the patient chooses to enter a treatment or recovery program autonomously, with the support of loved ones and their care team.

 
[7] Rates and predictors of relapse after natural and treated remission from alcohol use disorders – PMC (nih.gov)

There is no single definition of recovery. Rather, it is a life-long journey, defined by a person’s unique values, priorities, and circumstances. Many people who seek treatment for addictions define recovery as including abstinence, improved health, social connections and functioning, and higher quality of life. [8] For others, recovery might mean achieving specific social and health-related goals by changing their relationship with certain substances, even though they might not necessarily be abstinent.

[8] Moving Toward a Recovery-Oriented System of Care: A Resource for Service Providers and Decision Makers (ccsa.ca)

There is no evidence that involuntary treatment is effective or more effective than voluntary treatment in producing positive social and health outcomes; rather, evidence indicates that it can create further harm, including increasing the risk of potentially fatal overdose. [9]

Effectiveness in improving health outcomes

• The body of evidence is too weak and inconsistent to draw any empirical conclusions. In a 2023 review, only one study demonstrated a reduction in substance use, albeit in the short run. [10]
• Voluntary treatment consistently outperforms involuntary treatment in health outcomes. [11]
• Findings from the British Columbia Mental Health Act review noted limited evidence supporting the long-term effectiveness of involuntary care for substance use disorders in BC, despite some short-term improvements in stress and drug use patterns. [12]
• Focus groups of people with lived/living experience, family members, caregivers, and Indigenous stakeholders emphasized the need to invest and increase access to pharmacotherapy, psychosocial supports, harm reduction, voluntary treatment, and the need to address social determinants of health. [13]
• A 2016 systematic review of involuntary treatment found no evidence of benefit and a suggestion of potential harm—specifically increased risk of overdose for people being discharged from involuntary treatment. The authors conclude that “non-compulsory treatment modalities should be prioritized by policymakers seeking to reduce drug-related harms. [14]
• In cases where involuntary treatment has been beneficial for people, it is utilized for the least amount of time possible, under specific circumstances (e.g., alcohol withdrawal), and is associated with evidence-based care (e.g., pharmacotherapy, psychosocial services) and follow-up support. [15]

Mortality and Morbidity After Discharge

• Data from Massachusetts, where there is a legal mandate for involuntary treatment of adults with substance use and alcohol disorders, found that the risk of fatal overdose was twice as likely after involuntary treatment compared to voluntary treatment. [16]
• In another Massachusetts study, patients who participated in involuntary substance use treatment had all resumed drug use within one year, had at least one emergency department visit, nearly 80% had been hospitalized, and most experienced “significant medical morbidity”. [17]
• A study of Mexican involuntary drug treatment programs found that 32% of discharged participants reported a non-fatal overdose. Most of the people in the sample were not prepared to stop using drugs when they were taken involuntarily to drug treatment. This, in addition to the reduced tolerance during abstinence in drug treatment programs, puts individuals at a higher risk of overdose. [18]
• Data from Sweden shows that the risk of dying during the first two weeks after discharge from compulsory drug treatment programs was higher than during the remaining follow-up period. [19]

Retention in Treatment Programs

• Two reviews noted higher retention rates in involuntary treatment settings but emphasized that this is not a meaningful proxy for the desired health and social outcomes. [20][21]
• A 2021 review from Australia echoed these findings, highlighting that retention might not reflect genuine engagement or progress. These results are unsurprising—much of the positive change in treatment ‘retention’ is because people are forced to be there. [22]

Recidivism and Criminal Justice Outcomes

• Some studies show a reduction in criminal recidivism for those involuntarily committed to treatment, while others find negative or neutral outcomes. [23]
• Other evidence shows that voluntary treatment leads to better long-term engagement, indirectly impacting recidivism. [24]

Program Design

• Well-designed treatment programs, which incorporate individualized care and therapeutic support, may enhance outcomes, but without these components, benefits are limited. [25]
• Perceived coercion negatively affects patient motivation, which can undermine the efficacy of involuntary treatment. A patient’s sense of autonomy and readiness for change play crucial roles in treatment success. Treatment can be counterproductive if patients feel forced into it without addressing their individual needs or providing adequate support. [26] [27]
• Many people who use drugs (PWUD), healthcare providers, and health policy experts suggest that improving the voluntary treatment system, rather than expanding involuntary detention in the absence of adequate services, would lead to better outcomes. [28]

[9] Relapse to opioid use in opioid-dependent individuals released from compulsory drug detention centres compared with those from voluntary methadone treatment centres in Malaysia

[10] Effectiveness of Involuntary Treatment for Individuals With Substance Use Disorders: A Systematic Review

[11] Involuntary Treatment for Adult Nonoffenders With Substance Use Disorders

[12] Exploring Care Options for Individuals with Severe Substance Use Disorders in BC

[13]Exploring care options for individuals with severe substance use disorders in BC

[14] The Effectiveness of Compulsory Drug Treatment: A Systematic Review

[15] Involuntary Hospital Admission in the Treatment of People With Severe Substance Use Disorder

[16] An Assessment of Opioid-Related Deaths in Massachusetts (2013 – 2014)

[17] Outcomes for Patients Discharged to Involuntary Commitment for Substance Use Disorder Directly from the Hospital

[18]Increased non-fatal overdose risk associated with Involuntary Drug Treatment

[19] Increased risk of death immediately after discharge from compulsory care for substance abuse

[20] Effectiveness of Involuntary Treatment for Individuals With Substance Use Disorders: A Systematic Review

[21] Involuntary Treatment for Adult Nonoffenders With Substance Use Disorders

[22] Mandatory treatment for methamphetamine use in Australia

[23] Effectiveness of Involuntary Treatment for Individuals With Substance Use Disorders: A Systematic Review

[24] Involuntary Treatment for Adult Nonoffenders With Substance Use Disorders

[25] Does Coerced Treatment of Substance‐Using Offenders Lead to Improvements in Substance Use and Recidivism

[26] The Use of Legal Coercion in the Treatment of Substance Abusers: An Overview and Critical Analysis of Thirty Years of Research

[27] Compulsory substance abuse treatment: an overview of recent findings and issues

[28] The perspectives of people who use drugs regarding short term involuntary substance use care for severe substance use disorders

Mental health and substance use services are under provincial jurisdiction so there is no provision for involuntary treatment at the federal level in Canada. In Ontario, involuntary admission to hospital is governed by the Mental Health Act [29], and decisions about treatment are governed by the Health Care Consent Act. [30]

Under the Mental Health Act, if an individual is apparently suffering from a mental disorder and meets other criteria (poses a risk of serious bodily harm to self or others, poses a risk of serious physical impairment, or suffers from recurrent mental disorder that has responded to treatment in the past) they can be apprehended and taken to a psychiatric hospital, where they can be detained for up to 72 hours for the purpose of a psychiatric assessment by a physician. [31]

The legal mechanisms for getting a person to hospital in these circumstances are as follows:

• The police: if police have reasonable and probable grounds to believe a person is apparently suffering from a mental disorder and meets other criteria, they may take the person to a psychiatric facility for examination.
• A physician: upon examination of the individual, a physician who has reasonable cause to believe that a person meets the criteria above may fill out a Form 1, which authorizes the police to take the person to a facility for psychiatric assessment. [32]
• A justice of the peace: if adequate evidence is brought to them, they may complete a Form 2, which authorizes the police to take the person to a facility for psychiatric examination. [33]

Once at the hospital, the person must either be discharged, or admitted on a voluntary, informal (admitted with consent of another person), or involuntary basis by the end of the 72-hour assessment period.

The legal mechanism for detaining a person involuntarily is a Form 3 (Certificate of Involuntary Admission). [34]

• A Form 3 must be signed by a different physician than the Form 1, and authorizes the patient’s involuntary admission for up to two weeks (so long as the criteria continue to be met).
• The Certificate of Involuntary Admission may be renewed by completing a Form 4 (Certificate of Renewal), provided that the patient still meets the criteria for involuntary admission at the time of renewal. [35]
• The first time a Form 4 is filled out, it is valid for up to one month. The second time it is filled out, it is valid for up to two months, and each time after that, it is valid for up to three months.

Patients placed under a Form 3 or 4 hold must be connected with a rights adviser, who explain the patient’s rights to them and can support them in making an application to the Consent and Capacity Board to review whether the criteria for issuing the Form is met.

While the Mental Health Act authorizes an individual to be brought to a psychiatric facility for up to 72 hours to be assessed, and may authorize a subsequent admission (either as a voluntary, involuntary, or informal patient), it does not authorize physicians to provide treatment without the individual’s consent. [36] The provision of treatment is governed by the Health Care Consent Act, which provides that treatment can only be provided if the patient provides consent (or, if the physician finds the patient “incapable” of making decisions about treatment, with the consent of the patient’s substitute decision-maker).

Community Treatment Orders

In addition to involuntary admissions to psychiatric facilities, under the Mental Health Act, a physician can issue a Community Treatment Order (CTO), which requires a person to receive supervised treatment and care in the community. [37]

• A CTO can be issued or renewed for people who have a serious mental disorder, have been a patient in a psychiatric facility two or more times or for a total of 30 days or more during the prior 3-year period, and who experience a pattern of stabilizing in hospital followed by deterioration as a result of stopping treatment once discharged, requiring readmission.
• CTOs require the development of a Community Treatment Plan, developed with the input of the individual or their substitute decision maker (SDM), their physician, and other care providers involved with the individual.

[29] Mental Health Act, R.S.O. 1990, c. M.7 (ontario.ca)

[30] Health Care Consent Act, 1996, S.O. 1996, c. 2, Sched. A (ontario.ca)

[31] Mental Health Act, R.S.O. 1990, c. M.7 (ontario.ca)

[32] Form 1 – Application by Physician for Psychiatric Assessment

[33] Form 2 – Order for Examination under Section 16

[34] Form 3 – Certificate of Involuntary Admission

[35] Form 4 – Request for Assessment of Capacity under Section 16

[36] unless emergency psychiatric treatment is needed in the event of significant morbidity or mortality.

[37] MOH Information Guide CTOs**

As each province is governed by their own health care legislation, the laws vary around involuntary treatment across Canada. In the last year, multiple provinces have indicated an interest in expanding the use of involuntary treatment for people with substance use issues or addictions. Below are brief descriptions of similar legislation in select other provinces.

British Columbia

• British Columbia’s Mental Health Act [38] allows for involuntary apprehension, assessment, and treatment for mental health and substance use. [39]
• BC’s mental health legislation also provides “deemed consent” for individuals who have involuntary status.
• An individual can be detained for up to 48 hours. For longer periods, a second provider must complete a second medical certificate to detain individuals for up to one month. These certificates can be renewed again for three months, and then six months.
• There are 30,000 Mental Health Act apprehensions each year in BC, which is the highest rate of all provinces in Canada. [40]
• On September 15, 2024, the BC government announced that it would expand involuntary care for people with concurrent substance use, mental illness and acquired brain injuries, by modernizing 280 existing hospital-based beds, adding 140 new beds, and building two secure care facilities. [41][42]

Alberta

• Similar to Ontario, under Alberta’s Mental Health Act, involuntary detainment can be issued for individuals at high risk of harming themselves or others, or if there is a high chance of “substantial mental or physical deterioration or serious physical impairment.” [43]
• People designated under the Act who are using substances have the right to refuse treatment if they have the capacity to understand the risks of drug use. Like Ontario, Alberta also has CTOs, for community-based treatment. [44]
• Alberta also has legislation for youth, The Protection of Children Abusing Drugs Act [45], which allows for a legal guardian to ask for a Protection Order for a child under the age of 18 whose use of alcohol or drugs will likely cause significant psychological or physical harm to themselves or others. This Protection Order means that the child will be taken involuntarily to a Protective Safe House for up to 15 days for detoxification, stabilization, and assessment.
• In April 2023, the government of Alberta committed to introducing compassionate intervention legislation, to enable police and family members or legal guardians to refer adults and youth into involuntary treatment if they pose a risk to themselves or others due to drug use. [46]

New Brunswick

• Under New Brunswick’s current Mental Health Act, there is a provision that permits the involuntary hospitalization of individuals considered a threat to themselves or others, posing “imminent physical or psychological harm.” However, this requires a psychiatric evaluation and tribunal approval, and the hospitalization period is limited to 72 hours.
• The government of New Brunswick has announced the plan to also introduce compassionate intervention legislation for the province. [47] The new legislation will include a medical evaluation process for individuals with severe substance use challenges into involuntary treatment.

Saskatchewan

• The Youth Drug Detoxification and Stabilization Act [48] in Saskatchewan allows for a parent, person with close personal relationship, or youth worker to apply to a judge to place a youth (ages 12 to 17) with severe drug or alcohol use that puts them at risk of further harm to themselves or someone else in an involuntary treatment program.

[38] Mental Health Act (gov.bc.ca)

[39] BC Mental Health Act (BCMHSUS)

[40] Forced Mental Health Treatment Spikes in BC (thetyee.ca)

[41] Experts speak out on B.C.’s involuntary care proposal (Healthy Debate)

[42] Province launches secure care for people with brain injury, mental illness, severe addiction (news.gov.bc.ca)

[43] Guide to Alberta’s Mental Health Act (AHS)

[44] Involuntary drug treatment: ‘Compassionate intervention’ or policy dead end?

[45] SA 2005, c P-27.5 | Protection of Children Abusing Drugs Act | CanLII

[46] Alberta’s involuntary addictions treatment law violates Charter rights, expert says

[47] Bill on forced addiction treatment will include evaluation process, minister says | CBC News

[48] The Youth Drug Detoxification and Stabilization Act, SS 2005, c Y-1.1

Many families and caregivers of People Who Use Drugs (PWUD), especially youth and young adults who use drugs, support involuntary treatment. A common perspective is that untreated substance use leads to deepening addictions challenges, homelessness, criminal justice system involvement, overdoses, and death. [49] It is understandable that many loved ones, parents, and friends support the concept of involuntary treatment from a place of compassion, love, and, very often, desperation.

Some municipalities struggling with surging rates of homelessness and drug toxicity deaths are also calling on the provincial government to take action. Ontario’s Big City Mayors passed a motion in October 2024 calling on the government to “urgently review, consult on, and update the Mental Health Act and the Health Care Consent Act” [50] and expand the scope and reach of Drug Treatment Courts (voluntary program for individuals facing charges from non-violent criminal activities related to substance use to access treatment and case management). [51] [52]

[49] Involuntary treatment (FAR Canada)

[50] Motion on Homelessless, Mental Health and Addictions Crisis – October 18, 2024 – FINAL.docx (ontariobigcitymayors.ca)

[51] Ontario’s Big City Mayors are Calling on the Provincial and Federal Governments to Take Action on Homelessness, Mental Health, Safety and Addictions (OBCM)

[52] Windsor wants to be part of a pilot for forced mental health, addictions treatment| CBC News

Harm reduction advocates, many PWUD, many substance use service providers, and public health bodies have called for comprehensive investment in voluntary care and treatment systems instead, focusing on capacity needs that are already unmet These groups also call for investment and increased access to supportive and affordable housing, so people have safe, sustained and supported spaces to pursue wellness. [53] [54] [55]

One reason for this is that if a person is unhoused and put into treatment, without being provided housing and supports when they leave, they will not be able to successfully reintegrate into the community and maintain their recovery.

Instead of expanding the number and scope of involuntary programs, some groups think the government needs to decrease barriers to accessing health and social services, including housing and voluntary mental health, substance use treatment and harm reduction services.

In a 2020 joint statement, multiple United Nations and World Health Organization entities called on Member States to “close compulsory drug detention and rehabilitation centres and implement voluntary, evidence-informed and rights-based health and social services in the community.” [56]

[53] Brampton mulls forced treatment for addictions, mental health | CBC News

[54] CCLA Urges Big City Mayors To Vote Against Resolution That Overrides Rights Of Vulnerable People In Ontario

[55] Ontario Big City Mayors: Involuntary apprehension + bypassing Charter of Rights and Freedoms | Drug Strategy Network of Ontario

[56] Compulsory drug detention and rehabilitation centres | WHO

Involuntary treatment is a very intricate legal issue, and anyone seeking advice or legal direction should consult a lawyer who specializes in mental health law.

For general information about involuntary treatment as it relates to mental health and addictions please contact:   

• Addictions and Mental Health Ontario: info@amho.ca

• Canadian Mental Health Association – Ontario: info@ontario.cmha.ca