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In December of 2019, Nanaimo Mayor Leonard Krog courted national controversy when he suggested that some of Nanaimo’s homeless who also suffer from severe mental health and addictions issues might find better help in a smaller, community-based institutional setting than on the streets.
Today, he says he feels even more strongly about this, given the level of street disorder he sees in Nanaimo. A range of services are needed, he says, from homeless shelters to low-barrier housing to simple rent subsidies. But he’s concerned about those with high needs who don’t meet the criteria of various facilities and then end up in encampments like the one in Nanaimo’s downtown on Wesley Street.
“If you’re screening people into some facilities, what are you saying to those you won’t let in? What are you doing with them?” says Krog. “Because my sense is that the answer we give right now, either expressly or implied, is ‘we’re going to let you die.’ And I’m sorry but in the 21st century, in a wealthy liberal democracy, that is not an answer.”
According to the Everyone Counts: 2020 Point-in-Time Count, 60 per cent of the respondents in Nanaimo have reported ongoing mental health issues, and almost a quarter say they have sustained a brain injury at some point in their life. Though 433 people were recorded as being currently homeless in Nanaimo, those working on the count have estimated the real number is close to 600.
Some, like Krog, believe small-scale institutionalization is one way to support those struggling with severe mental health issues. Others like Andrew Thornton, the co-coordinator of the homeless count with the Nanaimo Region John Howard Society, wonder what exactly that would mean, as “institutions” can come in many forms.
“That’s a hugely complicated legal, moral and practical issue – of apprehending people and institutionalizing them against their will,” says Thornton. “I know a lot of the front-line people are dead set against it, and rightly so. We know the history of institutionalization, broadly speaking. It’s been largely negative for people. There’s no doubt about that.”
Impact of Riverview Hospital
The name of Coquitlam’s Riverview Hospital comes up frequently in discussions around the intersection of mental health, addiction, and homelessness. At its peak, Riverview housed more than 4,000 residential patients. But by the 1960s, a trend towards deinstitutionalization and integration of patients within community support systems emerged.
Places like Riverview came to be viewed as emblematic of all that was wrong with prolonged institutional psychiatric treatment, which some experts believe can lead to a debilitating condition called “institutional neurosis.” Through the following decades Riverview began to transfer patients out of its care, despite an estimate that only 10 per cent of patients could feasibly be discharged into the community.
The transition wasn’t exactly smooth. By the late 1990s, it seemed that the hundreds of millions of dollars saved in closing down Riverview and other institutions was not re-invested in community supports — in fact, according to numbers published in the Canadian Journal of Psychiatry in 2004, the funding for community-based psychiatric services had dropped.
While community care worked well for some, in the early 90s it was clear that mental health services in some municipalities were becoming overwhelmed and were ill-prepared to handle the complexity of some patients’ psychiatric needs, according to a 1992 report from the Greater Vancouver Regional Health District.
As a result, various studies found that some of those released from Riverview and other institutions simply fell through the cracks or ended up in the criminal justice system. In some cases, those suffering from severe mental health issues were not given adequate shelter or sources of income, and ended up on the streets where they developed addictions.
“We’re getting into the second and third generation of those folks right now,” says Jen McMillan, about the patients who were released from Riverview. “So they had kids and their kids are having kids now.”
McMillan lives in the encampment on Wesley Street and was previously employed as a shelter and a housing support worker in the Downtown Eastside.
“It was a really great, idealistic plan to close down Riverview and let them out, but there was nothing in place for them and most of them had been institutionalized since they were children. So of course if you ask a child if they want to be free, it sounds like a great plan,” she adds. “It really wasn’t though. It was really sad. Scary. It’s one of the reasons the Downtown Eastside is such a shit show.”
It is this population, sometimes referred to as those with SAMI — severe addictions and/or mental health illness — that often don’t receive the help they need from community support systems; either the services don’t exist in an official capacity, or are chronically underfunded, or in the words of Downtown Eastside psychiatrist Dr. Bill MacEwan, the people themselves are viewed as “too difficult” or “too unsavoury” to deal with.
“We’re leaving the people who would need the most help, and saying ‘Sorry, good bye, good luck, have fun and please stay safe.’ And that’s just unreasonable. It’s untenable,” he says.
Though a strong believer in community support teams, harm reduction, ensuring a safe, secure drug supply and overdose prevention sites, MacEwan believes those approaches are just not doing enough to address the problem of extreme cases.
In the majority of cases and wherever possible, intervention and assistance should be on a voluntary basis. However he would like to see the most extreme cases targeted and helped, even if that means some form of involuntary institutionalization.
“We have to be attending to this group. What we do and how we do it, I think that’s the part which is the rub. My only criteria is we don’t stop doing something with them. That’s the key feature here,” he says.
In 2019, the provincial ombudsperson published a report on protecting the rights of involuntary patients under the Mental Health Act calling for increased oversight and accountability from government and health authorities to ensure they uphold obligations under the Mental Health Act and safeguard patients’ rights.
Searching for solutions
According to the Nanaimo RCMP, calls for service that have a mental health component make up just 5.5 per cent of their files, but in the Wesley Street area that number jumps to approximately 20 per cent.
Kevan Griffith, who coordinates the Nanaimo Unitarian’s emergency shelter and helps run a free shower program at a downtown sports park, says he thinks the most pressing need at present is to open a government-funded treatment facility in Nanaimo or on Vancouver Island.
“There’s people who should be in the psychiatric unit that are wandering around in the streets because it’s full,” he says “The sad part is, the ones usually who are most in need don’t get housing because they’re too hard to deal with.”
Griffith adds that there needs to be better, more streamlined access to detox beds so that if someone wants to get off drugs they can get in as soon as possible.
“I have advocated for [a] 40, 50 bed facility, in-community, where people literally have the opportunity to have contact with their family and loved ones,” says Krog. “Generally tied in with some form of activity, work production, social enterprise, where once you’re through the detox and all those other stages you have the opportunity for skills and improvement and regularity and routine.”
He wants to hear the premier and prime minister acknowledge that it is a nationwide issue and that beyond just an opioid or a drug crisis, it is also a mental health crisis. In 2013, the City of Vancouver made headlines when the mayor and police chief declared the crisis on their streets as such.
The most severely mentally ill “don’t get any resources at all,” says McMillan. When the temporary modular supportive housing was set up to house people evicted from 2018’s Discontent City, she says the more extreme cases “didn’t even get interviewed.”
She agrees that something needs to be done for them, but when it comes to institutionalization, she warns that it could have a negative impact.
“I’m not willing to go there. In the worst case — the scenario where people are an immediate danger to themselves or others — that’s fine,” she says. “It’s too slippery of a slope for everyone else though. With freedoms comes a price, right? Unfortunately.”
When it comes to solutions, McMillan says, “ask people for what they need.”
“We often largely have a deficit model, even with people in government. It’s like, ‘What can we do to sort out the problems with the homeless?’ It’s not the homeless that are the problem, it’s the systems that serve them,” says Thornton. “We don’t look at people and say, ‘Hmm how can we fix them?’ No. We look at the systems that don’t work for them and try to fix them.”
What’s happening now
On Sept. 20, the province announced six new Assertive Community Treatment (ACT) teams aimed at people struggling with severe mental health challenges and substance use disorders— one of which will be in Nanaimo.
“We’ve heard from vulnerable people and from communities that they need more specialized care for those living with really severe mental health challenges,” said Judy Darcy, Minister of Mental Health and Addictions, in a statement.
The support will be flexible and individualized, and seeks to target those with complicated and persistent mental health challenges who don’t always respond well to traditional outpatient services and have trouble managing day-to-day activities.
Though it does not yet have a location, the city has recently partnered with Island Health and the provincial government to develop a $4.5 million 60-bed navigation centre expected to be opened in the spring of 2021.
A first for Vancouver Island, the centre will target those experiencing long-term homelessness and the “navigation” portion of the facility will include wraparound services such as clinical health supports, individualized care, and case planning to help people better organize their lives.
The first centre was announced in August and will be located in Vancouver.
The Nanaimo Affordable Housing Strategy, adopted by council last year, also set a target to develop hundreds of new housing units to address a variety of needs from affordable to supportive housing by 2028.
This goal was boosted when a proposal for more than 300 new homes located in sites around the city was announced in July. Three sites will offer roughly 125 units of affordable low and moderate income rental housing, and four supportive housing developments with around 190 units will be for people who are currently homeless or at risk of experiencing it.
Though promising, Nanaimo will have to contend with its difficult history around choosing the location of new low-barrier and supportive housing developments.
Two years ago, just prior to the large tent city occupation downtown, city council rejected the location of a potential $7 million supportive housing development in the south end after residents in the area mounted an opposition due to the proximity of schools in the area.
Prior to this, other various low-barrier supported housing projects also experienced fierce opposition, including one in the north end that opened in 2015 and a 36-unit development on Bowen Road that was put on hold and eventually re-designated as a housing site for Indigenous students attending Vancouver Island University.