I worked in forensic psychiatry as a psychiatric nurse for over twenty-eight years, primarily in institutional settings where patients were removed from the community and placed in a secure, locked facility.
Our primary focus with our inpatients was to implement care plans so that the patient ceased to be a danger to themselves or others. We generally started treatment with vigorous antipsychotic pharmaceutical intervention. Once that process started to gain traction, we took an extensive multi-disciplinary inventory and established a baseline towards community reintegration. With very few exceptions, most patients were reintegrated into the community.
Although it is not fashionable to say so, I am a big fan of mental health institutions. We did good work and alleviated a lot of suffering for both patients and their families. As a society, we sometimes overlook the anodyne truth that very few families have the fiscal and emotional capacities to handle severe mental traumas in a family member. Mental health institutions provide a necessary sanctuary for both patients and their loved ones.
Yet the overriding peril with hospitalization and institutionalization is the accompanying loss of autonomy and agency. Personal resourcefulness atrophies in institutions. People lose their capacity to act, and over time become afraid to leave. Moreover, from a fiscal perspective, long term hospitalization is prohibitively expensive because it ties up limited health care resources. I am not a fan of unnecessary long-term incarceration.
However, in recent years, I’ve witnessed a worrying trend, namely, the expansion of the role of increasingly dangerous street drugs in triggering mental health crises. Our service was always well resourced. However, relative to the scale of the current addicted homeless situation, it was extremely limited in its scope and capacity.
In British Columbia, our government has largely eliminated long term care mental-health institutions and has instead taken the approach of housing people in the community while addressing their conditions. To address the addicted homeless situation, they are currently building modular residences in the middle of residential neighbourhoods, many of which are near to schools and elder care facilities. These modules are deemed “low barrier,” which means that drug use, including iv opiates, will be tolerated in and around the premises. The objections of the local citizenry have been overruled.
I have a good appreciation of the complexities of this situation. Many homeless are products of appalling and heart-rending life circumstances. They are frequently from broken homes and acutely abusive environments. All too often, they spent their formative years in emotional and nutritionally deficient conditions. In too many cases, they were born with or have incurred intellectual, emotional, psychiatric, and general health deficiencies.
But what isn’t clear, or at least hasn’t been made clear by the provincial government, are their strategies for addressing the criminal component of procuring hard drugs. This activity is inherent in the very designation of “low barrier.” Articulating such strategies would go a long way to reducing anxieties in the surrounding community. Failure to address this concern has the appearance of both contempt for the concerns of the community if not outright incompetence.
I find the government approach confusing in other areas as well. For example, I’m not clear as to their intended outcomes or even their perception of the core issues. Our neighbourhoods have a standard of propriety that we consider reasonable. To introduce a population that is exempt from such standards is problematic. And to add insult to injury, the government has disproportionately burdened some communities with these difficult individuals.
If you were to design an approach that maximally exacerbates antagonisms while perpetuating the problem, you could not have come up with a better model. In short, this a model which appears to be inspired by expediency rather than thoughtfulness. It appears that the current provincial government hasn’t a clue how to address the deepening crisis of homelessness and addiction. As a society, we seem to be caught between the Charybdis of assuring personal dignity and autonomy, and the Scylla of employing our limited health care dollars prudently. What, ultimately, are the issues?
For me, the overriding concern with government policies surrounding the homeless — and government policy trends in general — is that behaviours which can only be considered toxic, dangerous and anti-social are severed from their consequences. Moreover, under the auspices of unconditional compassion, such policies inculcate fragility and enfeeblement, thus perpetrating the ultimate cruelty of diminishing and eroding agency.
Government policy subordinates personal merit (or the lack thereof) to the politics of equality of outcome. To those of us in the mental health professions who see this daily, the governmental ideology and mindset are glaringly obvious. The government has exempted the addicted homeless from personal responsibility for their condition. For example, their free housing comes without any rudimentary compliance expectations, such as reporting visitors or refraining from smoking in their rooms, never mind the hard drug issues that contributed to their current predicament.
I call this the policy of “minimal expectations” or ME. If ME was transitional and simply a strategy for engaging a profoundly estranged population, then it might be acceptable. However, what is required and what the government has so far failed to articulate, is a vision beyond simply supplying free housing. In the specific case of the addicted homeless, the government needs to elaborate policies which speak to the kinds of behavioural expectations which lead to greater personal accountability and social responsibility.
One of the most frightening aspects of the addiction dynamic is that the perspective of the addict narrows as their addiction progresses. Their scope of considerations profoundly contracts throughout their addiction. Consideration for others – the most minimal or moral considerations — diminishes almost to the vanishing point. Marc Lewis, a recovered addict and a practicing neuroscientist, gives an excellent account of his own experiences in his book Memoirs of an Addicted Brain: A Neuroscientist Examines his Former Life On Drugs. Lewis had a good recovery, but in many ways he was exceptional: he was educated, he had an extensive support system, and he was never homeless. He was also well socialized before his addiction and didn’t suffer from a major mental illness or obvious disability.
However, for most addicts, their addiction puts the socially responsible perspective out of reach, and they take on deeply anti-social behaviours. They developmentally regress as their addictions deepen. Unethical and immoral behaviours become normalized. In an opportunistic sense, they become more resourceful, but at the high cost of “cashing out” relationships and extinguishing future opportunities. Like children, they often appear indifferent to the consequences of their actions. Unlike children, however, they are often acutely aware of the consequences of their actions but simply no longer care. Their intelligence, imagination and agency are reduced to animal cunning.
The consequences of their behaviours consume vast quantities of social resources. Their lifestyles leave them vulnerable to diseases that often go untreated, placing all of us at greater risk for pandemics.
A big portion of their recovery is surmounting a vast wall of shame. Yet if addicts are to recover, they first and foremost need to take personal responsibility for their recovery. Government policies need to foster and encourage this.
Yet governments typically exhibit a distinctly Orwellian flavour of double-speak and disingenuousness. Categories become perilously blurred. For example, in the case of addiction, we fail to make the rudimentary distinction between treatment and enabling. We resuscitate overdosed addicts repeatedly without addressing their obvious loss of control. And resuscitating overdosed addicts is not a casual undertaking. Even when the intervention is timely, the individual will still incur some brain damage. This damage is cumulative, and beyond a certain point, the user will require long term, expensive institutional care with little chance of significant recovery. The earlier the intervention in the addiction process, the better.
Yet our policymakers continuously console themselves with empty clichés such as “they have to want help before they’re ready for help.” These policymakers remain willfully blind to the inability of addicts to shape intentions beyond their insatiable appetites. Involuntary treatment is considered a violation of charter rights unless you are deemed a danger to yourself and others. Addicts are indeed a danger to themselves and others. However, they are left in the community because we don’t have facilities, nor do we have the will to enforce treatment when necessary.
We need to be realistic. But we need to have expectations for addicts, and work towards establishing basic standards of civility and personal responsibility.
It’s also important that we recognize individuals who are either willfully or constitutionally unable to rise above their anti-social proclivities even after detox and other treatments. These refractory individuals will require a different treatment regime involving closer monitoring at the very least.
Most importantly, government policies must protect the general public. This is common sense. Governments should not alienate the ones who pay the bills, by simply overruling the objections of the local citizens in establishing housing for the homeless. Unfortunately, the B.C. government seems intent on disparaging the legitimate indignation of citizens whose communities and neighbourhoods have suffered at the hands of policies which are both poorly designed and poorly executed.
In my view, the addiction issue is not so much about mental disease per se, as it is a cultural and moral failure. Quite simply, our cultural sense of consequence is blunted. A certain number of people drift into addiction under the auspices of “personal growth” or “expanding their horizons” or peer pressure.
I am concerned about the issue of personal responsibility and keeping a tight focus on distinguishing between compassion and enabling behaviours. Bad choices must not be trivialized. Succumbing to addiction is a devastating and potentially lethal choice. At best, addiction is life-shortening and life-limiting. Moreover, although the homeless epidemic can’t be exclusively ascribed to the addiction epidemic, it is nonetheless a powerfully exacerbating factor. It needs to be front and center in any plan for dealing with homelessness on a long-term basis.
Currently, the government appears to place addiction treatment very low on its list of priorities. Yet we don’t have forever to get this right. Public forbearance is not unlimited. Costly boondoggles that end up exacerbating the problem can easily lead to the politics of rage – something that is not in anybody’s best interest.
However, If we handle this situation thoughtfully, we can alleviate human suffering, successfully reduce the harm done to our communities by ill-conceived policies, and maintain our faith in our authorities and public wisdom in general. I would prefer not to contemplate the alternative.
James Percy lives in Maple Ridge, B.C. Since retiring from Psychiatric Nursing in 2010 after a career of 28 years, he and his wife have travelled extensively, mainly in Europe.