Two decades ago, B.C. closed one of the last large mental institutions in the province. The institution, known as Riverview Hospital in Coquitlam, had at its peak housed nearly 5,000 patients across a sprawling campus.

There, patients with mental illnesses were subjected to a range of inhumane treatments, city records show. These included coma therapy, induced seizures, lobotomies and electroshock therapy.

When the province transferred patients out of institutions like Riverview during the 1990s and early 2000s, it promised them access to community-based mental health care instead. But that system never materialized.

“There was not a sustained commitment to seeing [the deinstitutionalization process] through,” said Julian Somers, a professor at Simon Fraser University who specializes in mental health, addiction and homelessness.

“[B.C.] did not put forward a clear vision of what we were trying to achieve and how we were going to get there. So we languished.”

Today, amid a sharp rise in involuntary hospitalizations, experts say B.C. risks repeating the mistakes of the past. The province is using coercive forms of care to treat individuals with mental health and substance use disorders, while failing to build community supports.

“We’re essentially doing the same thing we did with institutions,” said Somers, who began his clinical career at Riverview Hospital in the 1980s.

“[We’re] creating a system that doesn’t actually help people and may make things worse.”

ECT machines and electrodes from the Riverview Hospital Artifact Collection. | City of Coquitlam

Riverview’s legacy

B.C.’s push for deinstitutionalization was driven by growing evidence that large psychiatric institutions were harmful, and that community-based care was more humane and cost effective.

Nationally, advances in antipsychotic medication, rising civil rights concerns and growing financial pressures were also spurring a shift away from institutional care.

A 2006 Senate report showed community care could match institutional care in both effectiveness and cost — provided it was properly funded.

“There was sufficient evidence demonstrating that people with severe mental illness had better outcomes in community settings,” said Somers.

Somers says people who stay long term in institutions can develop “institutionalization syndrome,” characterized by increased dependency, worse mental health outcomes and greater social decline.

At the time, B.C. was restructuring its health system, promising to replace institutions like Riverview with a regional network of mental health services.

The problem was, that network never fully materialized.

Marina Morrow, a professor at York University’s School of Health Policy and Management who tracked B.C.’s deinstitutionalization process, says the province placed patients in alternative care. But these providers were not always well-equipped to manage psychiatric patients.

“Nobody left Riverview directly to the street,” Morrow said. “But some … might have ended up being homeless over time.”

A 2012 study led by Morrow found that older psychiatric Riverview patients who were relocated to remote regional facilities strained overburdened and ill-equipped staff, leading to poor patient outcomes.

Somers says B.C. abandoned its vision of a robust, community-based system.

“We allowed BC Housing to have responsibility for mental health and addiction housing,” he said. “And no one explained to BC Housing how they ought to best fulfill that responsibility.”

Somers says the province’s reliance on group housing was part of the problem. Group housing isolates residents from broader society, instead of integrating them into a community. A 2013 study by Somers shows people tend to have better outcomes if they get to live in “scattered-site housing,” where tenants live in diverse neighbourhoods while still receiving personalized support.

“All of us … are influenced substantially by where we live, what we do, and who we do things with,” he said.

Somers says a greater investment in community care would have emphasized better housing, nutrition, education, work and social connection. “Those are all way more important than medical care in terms of the health of the population,” he said.

“We closed institutions having no [alternative] functioning model.”

Reinstitutionalization

Despite B.C.’s efforts to deinstitutionalize, the practice of institutionalizing certain patients never truly went away.

“We institutionalize way more people now than we ever did, even at peak Riverview population,” said Laura Johnston, legal director at Health Justice, a B.C. non-profit focused on coercive health laws.

Between 2008 and 2018, involuntary hospitalizations rose nearly 66 per cent, while voluntary admissions remained flat.

In the 2023-24 fiscal year, more than 25,000 individuals were involuntarily hospitalized at acute care facilities, down only slightly from 26,600 the previous year, according to B.C.’s health ministry. These admissions involved about 18,000 unique patients, indicating many individuals were detained more than once.

In September 2024, a string of high-profile attacks in Vancouver by individuals with histories of mental illness reignited public calls to reopen Riverview Hospital.

That month, B.C. Premier David Eby pledged to further expand involuntary care. Currently, B.C. has 75 designated facilities that can hold individuals admitted under the Mental Health Act. The act permits individuals to be involuntarily detained if they have a mental disorder requiring treatment and are significantly impaired. These existing facilities host about 2,000 beds for involuntary patients.

Eby’s pledge was to add another 400 hospital-based mental health beds, and two new secure care facilities within correctional facilities.

Johnston, of Health Justice, says Eby’s announcement merely continues the same flawed approach. It “[ties] access to services with detention and an involuntary care approach, rather than investing in the voluntary, community-based services that we’re so sorely lacking in B.C.”

Kathryn Embacher, provincial executive director of adult mental health and substance use with BC Mental Health & Substance Use Services, says additional resources are needed to support those with complex needs.

“We continue to work with the provincial government to increase the services we are providing,” Embacher said. “Having enough resources to serve the most seriously ill clients is important to provide access to all clients.”

θəqiʔ ɫəwʔənəq leləm’ (the Red Fish Healing Centre for Mental Health and Addiction) is for clients with complex and concurrent mental health and substance use disorders. | BC Mental Health and Substance Use Services website

Inertia

If B.C. wants to avoid repeating the mistakes of its past, it needs to change its approach, sources say.

One concern Johnston has is with Section 32 of the Mental Health Act. Largely unchanged since 1964, it grants broad powers to medical professionals to detain and control patients.

“It grants unchecked authority,” she said.

Data obtained by Health Justice show one in four involuntarily detained patients in B.C. is subjected to seclusion or restraint. And even this figure may understate the problem. B.C. only began reliably tracking its seclusion and restraint practices in 2020, and only collects data on the first three days of detention.

A B.C. health ministry spokesperson told Canadian Affairs that involuntary care is sometimes necessary when individuals in crisis pose a risk to themselves or others.

“It’s in these situations where a patient, who meets very specific criteria, may need to be held involuntarily under the Mental Health Act,” the spokesperson said.

But York University professor Morrow says those “specific criteria” are applied far too broadly. “We have this huge hammer [involuntary care] that sees everything as a nail,” she said. “Involuntary treatment was meant for rare, extreme cases. But that’s not how it’s being used today.”

Morrow advocates for reviving interdisciplinary care that brings psychiatry, psychology and primary care together in community-based settings. She pointed to several promising models, including Toronto’s Gerstein Crisis Centre, which provides community-based crisis services for those with mental health and substance use issues.

Somers sees Alberta’s recovery-oriented model as a potential blueprint. This model prioritizes live-in recovery communities that combine therapeutic support with job training and stable housing, and which permit residents to stay up to one year. Alberta has committed to building 11 such communities across the province.

“They provide people with respite,” Somers said.

“They provide them with the opportunity to practice and gain confidence, waking up each day, going through each day without drugs, seeing other people do it, gaining confidence that they themselves can do it.”

Johnston advocates for safeguards on involuntary treatment.

“There’s nothing in our laws that compels the health system to ensure that they’re offering community-based or voluntary based services wherever possible, and that they are not using involuntary care approaches without exhausting other options,” she said.

“There’s inertia in a system that’s operated this way for so long.”

This article was produced through the Breaking Needles Fellowship Program, which provided a grant to Canadian Affairs, a digital media outlet, to fund journalism exploring addiction and crime in Canada. Articles produced through the Fellowship are co-published by Break The Needle and Canadian Affairs.