Conceptual and analytic framework

Equity-oriented care refers to approaches that explicitly aim to reduce the impacts of structural inequities on health by addressing power imbalances, historical and ongoing forms of oppression, and differential access to resources within the healthcare systems. In mental health contexts, equity-oriented care integrates trauma- and violence-informed practice, cultural safety, harm reduction, and anti-racist approaches as interconnected rather than discrete components (25, 26). Guided by this framework, this study recognizes that experiences of health, illness, and healthcare are shaped by intersecting structural inequities, including colonialism, racism, poverty, gendered and sexual marginalization, and criminalization. From this perspective, involuntary psychiatric admission and treatment are understood not solely as clinical or legal interventions, but as practices that operate within broader institutional, social, and policy contexts. Experiences of consent, safety, and autonomy are therefore shaped not only by individual mental states, but also by organizational constraints, risk management logics, and the availability of voluntary and preventive services. This analytic lens allows for examination of how coercive practices may emerge even in settings where clinicians and organizations are committed to providing compassionate and ethical care. These conceptual commitments informed the study design, including the use of participatory methods, the leadership of people with lived experience in data collection, and the analytic focus on how structural conditions shape both patient and provider experiences of involuntary treatment.

Reflexivity and rigour

This study was conducted by a multidisciplinary team that included academic researchers, clinicians, and people with lived experience of involuntary psychiatric admission and treatment. Consistent with the participatory orientation of the study, focus groups with people who had received involuntary psychiatric treatment were facilitated by individuals with lived experience rather than by academic researchers. This approach was intended to reduce hierarchical dynamics, support participant safety, and centre experiential knowledge as a legitimate and valued form of expertise. Academic researchers were present during focus groups but did not lead discussions.

Analytic rigour was supported through iterative coding, regular analytic meetings, and collaborative discussion of emerging interpretations. Preliminary themes were reviewed with the Advisory Committee, and areas of divergence or uncertainty were discussed with attention to how positionality, professional roles, and lived experience shaped meaning-making. These strategies were used to enhance the credibility, reflexivity, and trustworthiness of the analysis.

Qualitative data were collected via interviews and focus groups with people who have (1) received treatment under the MH Act at the two health organizations’ facilities, (2) provided treatment under the MH Act, or (3) provided legal or peer support to those who have received such treatment. Methods such as in-depth interviews and focus groups allow for rich, detailed assessment of people’s everyday experiences, providing context that is essential for crafting strategies that truly meet the needs of these populations [27,28]. Qualitative methods were prioritized for the ability to identify, from the perspective of individuals, how lived experiences are intertwined with systemic issues that contribute to health disparities, such as implicit bias in care delivery, cultural barriers to accessing services, and other factors that influence how different individuals and population groups interact with the healthcare system [29–32]. Furthermore, qualitative research fosters a deeper understanding of cultural contexts, which is essential when working with a diverse range of populations. It allows researchers to examine how factors such as personal or cultural beliefs, health-related practices, and individual and collective values influence health behaviours and perceptions of care [33–35]. These insights are critical for developing interventions and policies that address the root causes of health inequities [36,37]. This is particularly important for policymaking which aims to ensure that healthcare services are anti-racist, culturally safe, destigmatizing, trauma- and violence-informed, and responsive to the needs of all communities [26,38–41].

Study setting

The study was conducted within two large regional health organizations in a publicly funded provincial health system. Both organizations provide integrated mental health and substance use services across urban centres and surrounding rural communities. Their service delivery spans a continuum of care that includes emergency departments, designated inpatient psychiatric facilities operating under provincial mental health legislation, and community-based mental health programs. This breadth of service provision across acute and community settings provides a contextual basis for interpreting findings and may enhance their relevance to other similarly structured health systems.

Data collection

Interviews.

Advisory Committee members from health professions recommended that semi-structured interviews with those who provide treatment or support to individuals who have received admission and treatment under the MH Act be conducted individually. Participants were recruited between February 1 and April 30, 2023, through purposive sampling of individuals who provide services to people admitted for involuntary psychiatric treatment under the MH Act. Participants were purposively sampled based on their professional roles and locations of work to ensure diverse representation. Interview participants provided informed written consent.

Two researchers with qualitative interview experience (AS and MES) conducted interviews with 21 individuals. Table 1 shows participants’ roles. Interviews lasted approximately 1 hour each, were conducted virtually, audio recorded, and transcribed verbatim. The interview guide is available in S1 Data Collection Tools.

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Table 1. Categories of participants who provide clinical care and non-clinical support.

https://doi.org/10.1371/journal.pone.0329049.t001

Ethical considerations

Research focused on involuntary psychiatric treatment presents heightened ethical considerations due to the potential for re-traumatization and the context under study. Informed consent was approached as an ongoing, relational process rather than a single event. Participants were reminded of their right to pause or withdraw at any time without consequence.

To support participant well-being, focus groups were designed using trauma- and violence-informed research principles. Sessions were held in community locations rather than healthcare settings where possible. Breakout rooms were available during both in-person and virtual focus groups, allowing participants to step away or speak privately with a research team member if they experienced distress or required a break. These supports were offered proactively and without requirement to disclose reasons.

Peer facilitators were supported by research team members with qualitative research experience, and post-session check-ins were available as needed. All identifying details were removed from transcripts, and findings are presented in aggregate to protect confidentiality.

Data analysis

Data were analyzed using a thematic analytic approach using NVivo (version 14) guided by an equity-oriented care framework [26] to organize the data and track the analysis. The framework’s components of safety, stigma, trauma- and violence-informed, cultural safety, harm reduction-orientation, anti-racism, and gender affirmation served as sensitizing concepts that informed our interpretation of themes. Analysis of qualitative data from individual interviews and focus groups followed the steps articulated by Braun and Clarke [42,43] for conducting reflexive thematic analysis:

1. Familiarization. Multiple research team members, including those who conducted interviews and those who had not participated in the data collection process, thoroughly read and re-read the data, and then began identifying initial concepts or patterns generated in the narrative accounts.
2. Coding. Two members independently reviewed transcripts and reflexive notes generated in the familiarization stage to generate concise, descriptive, inductive codes for segments relevant to the study aims. To centre the voice of PWLLE, the focus group transcripts were coded first, followed by coding the interview transcripts. Codes captured discrete elements of participants’ experiences, including life-saving treatment, peer support, desire for autonomy, resource constraints, and perceived threat. Iterative meetings were held to discuss interpretive differences, refine codes and develop a shared analytic understanding. Final codes reflected repeated elements across the dataset while preserving the nuances of diverse perspectives. For example, PWLLE and clinicians described involuntary treatment as stressful or uncomfortable, but their interpretations diverged: clinicians emphasized safety, legality, and resource constraints, whereas PWLLE highlighted loss of autonomy and emotional distress.
3. Generating Themes. Codes with conceptual similarity were grouped into subthemes, which were then clustered into overarching themes representing broader patterns across the dataset. Themes represent inductive interpretations of participant accounts, while the equity-oriented care framework was used at the interpretive level to situate findings within the broader and systems-level implications. Theme development was guided by the equity-oriented care framework [26], which served as an interpretive lens at this stage of the analysis. Examining the codes through this lens revealed the presence or absence of safety, stigma, trauma- and violence-informed care, cultural safety, harm reduction orientation, anti-racism, and gender affirmation, which allowed themes to reflect the significance of the themes in relation to equity-oriented care during times of psychiatric crisis. Analytic decisions prioritized both prevalence and conceptual significance, ensuring that aligned and divergent experiences across participants groups were retained.
4. Reviewing Themes. Generated themes were presented to the Advisory Committee along with illustrative examples from the coding process. Committee members reviewed the themes to confirm that they accurately reflected the material present in the data set. Areas of divergence or uncertainty were discussed collaboratively, considering the influence of researcher positionality on interpretation.

To demonstrate transparency and traceability, Table 2 presents illustrative excerpts alongside their corresponding codes, subthemes, and themes, including examples from PWLLE, clinicians, and non-clinical service providers. This table highlights the pathway from raw data to higher-order interpretation, showing how aligned and divergent perspectives were preserved while capturing the complexity of involuntary psychiatric treatment experiences.

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Table 2. Illustrative excerpts with corresponding codes, subthemes, and themes.

https://doi.org/10.1371/journal.pone.0329049.t002

Theme 1: Lack of voluntary, community-based mental healthcare within the context of the social determinants of health leads to involuntary psychiatric admissions and complicates discharges

Among the most salient themes found in both the interview and focus group data was the view that voluntary treatment, both in community to prevent people from reaching a state of mental health crisis and in hospital for those requiring acute care, is extremely limited and inaccessible to many. PWLLE and clinicians emphasized that community-based mental health supports are insufficient to meet demand, with programs often unavailable and unaffordable, and long wait lists and strict entry requirements making it hard to qualify for services.

We shouldn’t have to prove, actively prove in front of them, that the situation is bad enough to actually get treatment. – PWLLE

We don’t have enough acute psychiatric resources in the system, and we also don’t have enough at the other end. We don’t have enough places for people that have serious mental health dual diagnosis issues who don’t need to be in hospital but don’t have a place to go. – Clinician

The perspective of PWLLE and clinicians was that available mental health supports provided in community are insufficient to meet needs of people in this geographic region. This contributes to circumstances in which people reach a state of mental health crisis and perpetuates reliance on acute care. Both groups of participants assessed that, from a pragmatic perspective, the only meaningful way for many people to receive timely access to mental healthcare is to be admitted involuntarily to hospital. Interview participants reported that most people who receive psychiatric treatment in hospital are admitted involuntarily (with the exception of people receiving treatment for eating disorders, who participants observed tend to be predominantly treated voluntarily).

People are uncomfortable with voluntary patients in an acute care setting … it almost feels like a luxury to be admitted voluntarily in an acute care setting. – Clinician

Even where preventative services are available, the stigma and ableism associated with “mental illness,” and the consequences of seeking help for such readily stigmatized conditions, were mentioned as barriers to accessing services. This in turn was reported to have negative implications for other determinants of health, such as employment.

My employer has no idea that I have a mental illness. I cannot divulge. I would get degraded in my work, if not even let go – kind of pushed under the carpet – and one day I’m gone… So there needs a lot more done to also support people that are like me, living and hiding and have nowhere to run. - PWLLE

The role of social determinants of health — including housing, transportation, income, social support, food, spirituality, and culture — on mental wellness was also emphasized by PWLLE, clinicians, and other service providers. PWLLE reported their conditions are exacerbated by unmet basic needs, leading to mental health crises and repeat involuntary admissions. Additionally, for those on extended leave, not having access to key social determinants of health can contribute to not being able to meet the conditions of extended leave (e.g., attending appointments), ultimately leading to recall to hospital.

People go back to their lives that were the same as when they came in. – Clinician

Somebody’s required to make an appointment and to show up on a day, or they’re getting recalled and going to the hospital. If that person is sleeping on the side of [the road], doesn’t have a clock, doesn’t know what day it is, doesn’t have the support to get there, and they missed their appointment with their mental health team. [Then] it’s negative documentation about their not following through, they’re not doing ABC and D. They’re getting recalled back to the hospital and they get put in same cycle again. – Clinician

Some clinicians noted that, in some cases, involuntary psychiatric admission and treatment was the only avenue for patients to access (or continue to access) resources to meet their basic needs. Clinicians frequently remarked that they felt “backed into a corner” to certify patients under the MH Act due to a lack of system-level support for voluntary care and community-based service coordination to address social determinants of health.

I feel like that we get a little bit more backed into a corner to do involuntary treatment. Because I think we know that without it, sometimes this person might lose all these resources that they have, and it will be very hard to get them back. If our system was different, and people could get housing, and they could try again somewhere else, I think we would maybe feel less, or at least I would feel less, kind of stuck in the need for involuntary treatment in this context. – Clinician

Furthermore, clinicians described the challenges of working within an acute care setting focused on getting patients out of hospital quickly, with limited capacity to promote care continuity. The acute care system was seen by these participants as not being conducive to delivering quality care and supporting people post-discharge with access to supports promoting mental well-being. They also described the distress it caused them when they must discharge patients knowing there are few to no low-barrier, accessible resources to which to refer them.

Usually, they give you a little slip of paper that says (sometimes not always), sometimes a slip of paper that says you can do this, that and the other thing. But you’re kind of left [on your own]. Sometimes it will say that you have a follow-up appointment but that only happened to me once. Otherwise, it’s just goodbye, good luck. And it’s terrifying going from the secure environment of a hospital back into the real world… especially if you live alone. It’s very scary. – PWLLE

They just get discharged when they are good enough, you know, but they’re not. They’re just good enough to go home and not be taking up a $1,600 a day hospital bed. – Clinician

Clinicians described how a lack of resources in community even for those on extended leave can be a barrier to discharging a patient from hospital and can lead to patients having repeated episodes of involuntary psychiatric admission and treatment.

Some of the more intensive mental health resources require that people have tried and failed different things. So, sometimes we know we’re setting someone out on extended leave, probably to a mental health service that’s not gonna meet their needs, and that it’s probably not gonna be successful and it’s going to lead to them being recalled, brought in by the police. – Clinician

These accounts indicate that involuntary psychiatric admission frequently operates as a downstream response to gaps in voluntary and preventive services, with structural constraints shaping both crisis trajectories and post-crisis care pathways.

Theme 2: Involuntary psychiatric admission and treatment is a stressful experience for both people receiving and providing treatment and can lead to harm, trauma, and distrust in the healthcare system

PWLLE described a spectrum of experiences with involuntary psychiatric treatment. Some indicated that, due to their mental state while in crisis, they would not have sought or accepted care voluntarily, and, looking back, were grateful to have received treatment.

For me, at the onset of my illness, only outside intervention and getting me into hospital seems to work. I don’t think I would have actually survived, if I would have continued roaming on the street and not eating. – PWLLE

However, it was unclear whether the benefit was ascribed to the involuntary circumstances under which treatment was delivered, or if a similar outcome would have been achieved if some or all aspects of their care were voluntary.

I am thankful that I did have involuntary treatment… I just wish there was a different process for going through it all like we’re sharing now, with options and stuff. – PWLLE

Some described a range of negative experiences during involuntary psychiatric admission.

Participants repeatedly stated the use of coercive measures, including the understanding they were being “stripped of their rights” or being treated “like a criminal” when in hospital under the MH Act, led to fear and overwhelm, feeling stigmatized and traumatized. Some participants described feeling disempowered and being made to feel “like a child”.

But if somebody like me gets stripped of all their rights and put into seclusion rooms — and close the door and injected and have no idea what’s going on — that’s a pretty brutal assault to one’s human dignity, to one’s human rights, to one’s perception of who we are in the community, how we are appreciated and included in a greater community. – PWLLE

And I feel we are treated and under the law, we are [treated like a] criminal because our rights are taken away. We’re not criminals. We’re in a medical facility but we’re treated as a criminal that has done something wrong. – PWLLE

You begin to feel like you’re being treated like a child when you’re actually an adult with a mental illness, which is very different than being a child. – PWLLE

PWLLE discussed how these negative experiences of involuntary psychiatric admission and treatment impacted them, including creating lasting trauma and lowered self-esteem. Some felt fearful of reliving the traumatic experience, which, in turn, discouraged them from seeking healthcare or fully disclosing their concerns to clinicians in the future. Health professionals corroborated this, noting they have witnessed ways that trauma associated with involuntary psychiatric admission and treatment can deter people from seeking care, both for mental and physical health concerns.

Now for future, if I need to go back, I know I can’t be honest. I have to filter what I say or I’m going to be in a very scary situation that is going to, that is traumatic. And yeah, it’s taught me not to be honest when I seek mental healthcare. – PWLLE

It also impacts access to healthcare because a lot of my clients will not bring themselves to the hospital or to a clinic if they’re having a health issue, because they’re afraid of being re-certified again. – Service Provider

Another consequence of involuntary psychiatric admission and treatment is that it can become a system barrier for patients to receive other forms of care and support, including accessing onsite programming at hospitals while admitted. For example, if a patient is in seclusion, they are unable to access other programs or services during that period.

The involvement of police in apprehending people under the MH Act was highlighted by PWLLE as a significant source of trauma, and by clinicians as compromising the therapeutic relationship. Experiencing, witnessing, or being aware of circumstances in which people experiencing mental health crises were “tasered”, “attacked”, handcuffed, or “dragged” by police while being detained and transported for involuntary treatment complicated and constrained participants’ willingness to engage with health services. For those participants, this created additional barriers to access. For some clinicians, police involvement created unnecessary complexities for healthcare delivery, creating additional strain on their ability to assess and care for patients in emergency settings.

Since I was having an episode, so I decided to run instead of being safe and being like, to stand here. So, [the officer] attacked me, put me in cuffs. – PWLLE

Separation between healthcare and police is super important… I don’t think police are trained or suited to make those [mental health] assessments. And in my experience, they’re the ones escalating the situation. – Clinician

A lot of the times, the police will bring somebody, and they’ll say “look, we’re just told to bring them in. I have no idea why, like literally none.” I have to deal with it right? I’m responsible so those stress me out quite a bit. There’s no information whatsoever. The patient looks perfectly normal. There’s no supporting documentation why certain decisions got made. – Clinician

The majority of clinicians expressed a range of negative feelings related to involuntarily admitting and treating patients, including feeling burned out, traumatized, and inadequate due to working in a system that limits their ability to meet their patients’ needs. For instance, emergency department clinicians described the environment as unconducive to providing care to people experiencing a mental health crisis. The chaotic environment, lack of privacy, and lack of time to interact with patients limited their ability to deliver quality care.

I think it is environment too. When you think about patients in Emergency on a stretcher being assessed and then involuntarily certified, you would just never want that for someone you care about. – Clinician

I have to interview people in the parking lot, because every single care space is full, like literally. Everything is full. So, we have to go on the freezing parking lot. – Clinician

Clinicians felt hindered by not knowing a patient’s history and having limited time to observe a patient or establish a relationship. This was stated to increase the likelihood of activating “triggers” for PWLLE that may exacerbate mental health crises and determining a course of action that might not be of maximum benefit to the person they were treating.

One of the things for example is the observation period. If the patient [within] two hours is completely rational, that’s an alteration period as well, where I’m going to be a lot less likely to do something. But if given only the five-second observation period to make decision, I’ll probably err on the side of certifying somebody. – Clinician

Some participants described adversarial feelings between clinicians and patients, between different clinicians, and between lawyers representing patients and clinicians, which can introduce additional risks and harms to all involved. For example, one participant commented:

There are some [clinicians] that are great and have no problem with their patients, clients, whatever, applying for Review Panels. Others take that quite personally – that their judgment is being questioned – that makes it difficult. – Service Provider

Risks and fears discussed by clinicians included the conflicting fears that if they do not involuntarily detain someone, they will be responsible if “something bad happens”, and fears that if they do involuntarily detain someone, they could be held liable or sued. Clinicians also mentioned the risk of harm to staff by patients when attempting to deliver treatment against their patient’s will. Many participants talked about involuntary psychiatric admission and treatment being traumatic for patients, introducing additional emotional harms.

These findings show that involuntary care is experienced as both a clinical and relational intervention, with significant emotional and institutional consequences that can erode trust in healthcare systems for both patients and providers.

Theme 3: Peer support improves experience of care

Many PWLLE felt having a peer to help them navigate the system while being admitted and treated would have been of tremendous benefit in allaying their fears and improving their experience.

Another thing that would really, really help is peer support. Having [someone] there that could reassure me that, “OK this is what’s going to happen, you’re going to meet with the psychiatrist” or whatever the process is. And then if I’m admitted into the ward, or in this case certified, to explain what that means. – PWLLE

Clinicians agreed that peer support roles were valuable; however, they noted peer support workers are often treated as though they are not part of the care team with negative consequences for people in these roles.

[Peers] had a really significant role in building relationships and helping people to access care. But the peers had a hell of a hard time, and we went through so many of them because they were stepping into an environment where there was fierce hierarchy. They didn’t even have letters after their names; they weren’t going to be taken seriously, and your self-esteem can only handle so much. – Clinician

Moreover, both PWLLE and interview participants felt including patient advisors with lived and living experience in planning services would provide valuable expertise for developing more holistic programs and services.

Another source of support identified by PWLLE was engagement and inclusion of family and friends. However, PWLLE had varied views regarding if and to what extent they would have liked their families to be informed about or involved in their involuntary psychiatric admission and treatment. Some participants felt family members could use more education on how to support their loved ones who are experiencing mental health crises. Others identified that family members, including chosen family and others providing support from within their communities, could serve as a valuable source of information to clinicians as they deliver care to people in crisis.

Peer support appears to play a stabilizing relational role in involuntary care by providing continuity, reassurance, and system navigation, although its impact is constrained when insufficiently integrated into clinical teams.

Theme 4: An “all or nothing” consent approach reduces patient autonomy and restricts rights

PWLLE described a lack of control over all aspects of their treatment, and some reported they were not informed of what was happening — including not being informed of their rights under the MH Act. An “all or nothing” phenomenon seems to occur with the BC MH Act deemed consent approach, where once a person is involuntarily admitted under the MH Act, there is a default that all treatment and related interventions are delivered involuntarily. This approach leaves no room for patients to state their preferences or have those preferences considered in treatment planning.

I think the hardest part about it was I felt like a persona non grata. I felt like nobody discussed anything with me. – PWLLE

Nobody told me what was happening. Nobody told me that I had any rights, they just gave me two shots of Loxapine and I went to sleep. – PWLLE

[I was told] “you’re here for shock treatment” and then they explained what that all meant. They did very good in that respect in explaining what shock treatment was, and even I got to watch a video about it. So that part was good. But no, there was no “Oh! by the way, do you want to get this?” – PWLLE

PWLLE described the importance of connection and compassion. Whenever they experienced empathy and compassion from clinicians or felt listened to and involved as much as possible in their care, this had a positive impact on their well-being and their engagement in care.

Any time I’ve had a doctor or care provider that has included me in the decision-making or at least made it feel that way, I’ve found that the outcomes have been better and I’m more willing to take the medication. – PWLLE

They also noted that clinicians are very busy and burnt out, and it is challenging for staff to have enough time to meaningfully engage with their patients.

Some PWLLE emphasized information should be shared with patients in an easy-to-understand way and when they are more receptive.

But the rights [under the MH Act] are so much, there is a lot of jargon, so it doesn’t really make sense to you, especially if you’re not in the right mindset to listen. – PWLLE

Participants also noted that when a person treated under the MH Act is informed of their rights, there are many process barriers to acting on this knowledge. For example, participants noted a potential for conflict when clinicians providing care are the ones to inform patients of their rights under the MH Act, including the right to a second medical opinion and a review panel. Moreover, they were concerned about the potential for a conflict of interest to arise when seeking second medical opinions, as the second physician consulted often works on the same care team as the first physician. In addition, there was concern there is no requirement for the first physician to change the treatment based on the second opinion. Concern was also expressed that when a person treated under the MH Act challenges their treatment at a review panel hearing, it is often a unit clerk who selects which health record documentation to provide to the lawyer representing the patient. In these circumstances, participants expressed concern that unit clerks may not have sufficient medical and legal knowledge to determine which parts of a patient chart are relevant. Another concern was that clinicians sometimes had to play roles during review panel hearings that impair their relationship with their patients.

[It] creates a very weird dynamic, because they are acting kind of as counsel, they are also the expert witness; and, of course, they’re the client’s treating doctor. So, it can really impair the treatment relationship for it to proceed in that way. – Service Provider

These experiences suggest that the deemed consent model is often enacted in practice as a withdrawal of patient participation, with limited opportunities for meaningful involvement in care decisions during involuntary admission.

Theme 5: Available treatments are limited to a narrow range of options

When reflecting on options available for “treatment” to those being treated under the MH Act, medication, physical restraints, and seclusion were often mentioned. References to non-pharmaceutical treatment options, such as psychotherapy, tended to focus on how it is lacking. Some clinicians raised concerns about over-dependence on the use of physical and chemical restraints, as well as seclusion. A pertinent recommendation from one interview participant was to institute frequent re-assessments of patients in seclusion and hold debriefing sessions after every seclusion event to identify ways things could have been done differently. Clinicians and PWLLE alike expressed desire for meaningful and timely access to a much broader array of options, including counsellors and psychologists; recreation, music, and art therapy; and access to the outdoors.

In emergency, people get thrown in seclusion because the nurses don’t have time, or they feel they don’t have time, or they’re worried that they’re going to abscond, or whatever, and they kind of lock them in there in an unethical way. But I don’t think that the nurses see it that way. They see it as they’re preserving their safety, whereas the patient probably wouldn’t feel that way. – Clinician

There are so many things to do in response to someone yelling and only one of them is putting them in seclusion. – Service Provider

Treatment options during involuntary admission are constrained by institutional capacity and workflow pressures, resulting in reliance on a narrow set of interventions across acute care settings. This theme was most commonly discussed by clinicians and service providers, reflecting how this issue was discussed across participant roles in the dataset.

Theme 6: Stigma and discrimination occur

Those who provide care and support to people who experience involuntary psychiatric admission and treatment noted some instances of discrimination, such as clinicians’ perceptions of risk and behaviour being influenced by racism (e.g., men of colour viewed as more dangerous) and sexism (e.g., women being judged on their appearance and sexual behaviour).

I can tell you that I have unquestionably seen anti-Indigenous racism, sexism, ableism, operating in the attitudes of the people enforcing detention involuntary treatment which has changed the way the experience has played out for my clients. Yes, that’s what I think I could sort of confidently say. – Service Provider

I have been treated like somebody that doesn’t have any life or nothing together, and [later] I had gone through university, had a professional degree and actually have been working as a professional, suddenly I was treated differently. And the doctor, constantly commenting on my university degree and on my education. – PWLLE

There were also mentions of people being certified during pregnancy over concern for the fetus and then decertified once the baby was delivered. In addition, there were discussions of challenges for birthing parents who are involuntarily treated, as there is currently no option for them to have their newborns with them during an involuntary admission in these organizations’ facilities.

There’re people who have been using [substances] and don’t necessarily have mental health challenges that I would assume would warrant certification in the hospital, but because they’re pregnant, that becomes the designated reason as to why they’re certified. – Service Provider

Examples of anti-Indigenous racism and discrimination against transgender people were also provided. For example, an interview participant shared that they had seen a patient chart that described an Indigenous patient who was speaking their language as speaking “gibberish.” As another example, interviewees described situations where a patient’s identification with a gender different than the one assigned to them at birth was viewed as a symptom of mental illness. In these examples, the lack of culturally safe or gender-affirming care is not only discriminatory, but clinicians were using patients’ behaviour in response to this discrimination as “evidence” of a mental health issue.

The person recently is identifying as male and it says right in the report, the doctor’s handwritten notes, “This person likes to go by – the name that this person has chosen is Dave and the pronouns are he/him.” And it’s mentioned in handwritten notes a couple times that, “The client – patient – was upset and didn’t feel heard or understood.” And the physician referred to [the persons as] “her” consistently in handwritten notes, in the case note, and in the entire presentation. That’s not uncommon, that’s just one example I think of medicalizing and, “This person is delusional,” that kind of stuff. – Service Provider

Indigenous people serving in the role of liaisons for Indigenous patients in the health organizations were noted as providing culturally safe care and interview participants expressed a desire for people serving in this type of role. Also mentioned was the added layer of complexity in which Indigenous patients are held without their consent in a place where they have no access to cultural healing and wellness practices, language-speakers, or other tangible aspects of culturally safe care.

There was concern that equity-oriented care and related principles — such as cultural safety, patient-centred care, harm reduction, gender-affirming, and trauma-informed practice — are buzzwords that are not translated into practice. Conscious, conspicuous, and transparent efforts are needed to ensure these principles are applied to practice within the context of involuntary psychiatric admission and treatment. This includes capacity for ongoing monitoring and evaluation focused on understanding how these efforts are experienced by care recipients and care providers, and what the tangible results are over time.

I don’t think you can actually be trauma-informed when the policies and the system itself is just perpetuating that trauma. So, yeah, it feels a bit like an oxymoron. – Service Provider

These accounts highlight how stigma and discrimination are embedded within clinical and institutional practices, shaping both decision-making and interpretations of patient behaviour.

Theme 7: The lack of conclusive evidence for involuntary treatment creates distress for care providers

When considering the above issues together, and in light of their lived experience providing care, participants who have dedicated their careers to supporting people during mental health crises raised many questions and concerns about the lack of evidence for involuntary psychiatric admission and treatment. In so doing, they reflected openly on whether the presumed “benefits” of using the MH Act to intervene with someone experiencing a mental health crisis are substantiated by available evidence, and whether such approaches justify the harms they repeatedly observed occurring for their patients and clients when they are subjected to involuntary and coercive “care”. These participants expressed concern that little is known about the long-term impacts of removing a patient’s rights on their health and well-being, and about the financial impacts of continuing with “a carceral approach” to mental health service delivery at times when health systems are increasingly under pressure economically and related to adequate staffing levels.

For some, the experience of being asked to mandate care of unknown quality with unknown results was inconsistent with their goals to ensure all patients receive high-quality, evidence-based care. These participants advocated strongly for a transformation in how mental health crisis response is delivered, centring preventive, community-based, and voluntary supports that acknowledge and respond to social determinants of health and inequities in service access and treatment outcomes.

Some of my concerns about this field, which seems unique to this field, is that the intention to help shuts down any evaluation about what the impact is… I’m not aware of any good evidence on evaluating what the long-term benefits or harms etc. are for involuntary intervention, so that’s something that feels problematic and unique to this area. – Service Provider

When you mandate care that you know is good quality, then it’s one thing. If you mandate care that it’s unclear what the positive effect will be other than in the acute period, that’s very problematic or that brings out the more problematic aspect of mandated care which is terminating of freedom that a person has. – Clinician

I know how expensive a carceral approach is, I know how much the police costs and I know how much having someone locked up in a psych ward cost. So yeah, I’d like to see a world where voluntary services are not only available (which doesn’t exist, so that’s a huge step), and then where the voluntary services are something that’s incentivized and that people feel like they want to go. – Clinician

Clinicians’ reflections reveal how uncertainty regarding the effectiveness and long-term impacts of involuntary treatment contributes to ethical tension and professional distress. These concerns highlight the challenges of delivering mandated care in contexts where evidence is limited and where providers are simultaneously accountable for patient safety, legal compliance, and quality of care. This theme was most commonly discussed by clinicians and service providers, reflecting how this issue was discussed across participant roles in the dataset.

In summary, our findings demonstrate that, overall, participants in this study did not experience involuntary psychiatric admission and treatment under the MH Act in ways that are consistent with the principles of equity-oriented care (i.e., care experienced as safe, destigmatizing, trauma- and violence-informed, culturally-safe, harm reduction-oriented, anti-racist, and gender-affirming) [25,26]. PWLLE, clinicians, and other professionals who support PWLEE highlighted the stressful and often traumatic nature of their experiences with involuntary psychiatric admissions and treatment. PWLLE discussed feeling afraid, overwhelmed, stigmatized, and disempowered. Concerns were also raised about treatment received being limited to primarily medication, restraints, and seclusion, and challenges to accessing their rights to second medical opinions and review panels. Moreover, participants expressed the view that a lack of voluntary, prevention-oriented, community-based mental health services and unmet basic needs exacerbate mental health issues, leading to a reliance on involuntary psychiatric admission and treatment. This lack of community-based services was also reported to be challenging with efforts to provide adequate discharge planning. Practices that were experienced as helpful included peer support, and instances where PWLLE felt listened to and involved as much as possible in their own care.

Strengths and limitations

This study was guided by an Advisory Committee comprised of individuals with lived and living experience of receiving or providing involuntary psychiatric admission and treatment, service providers in community agencies supporting those receiving care under the MH Act, clinicians and leaders working within the health organizations’ mental health and substance use services, and researchers with expertise in equity-oriented mental health policy and practice. We used a trauma-informed approach to the data collection and focus groups for PWLLE were led by PWLLE of involuntary psychiatric admission and treatment.

Following the Committee’s advice, we recruited participants for the focus groups for PWLLE through both social media and through community agencies that work with PWLLE. Interested participants were later screened to exclude those who did not receive involuntary treatment in the specific health organizations in which the study was situated. We did not recruit directly through the health organizations or their services directly. As part of our recruitment process, and to ensure transparency, we disclosed that this study was commissioned by the health organizations, and that results would be communicated directly to it. Consequently, we may have not reached those experiencing the greatest structural vulnerabilities when interacting with health systems, or those whose experiences of trauma during their interactions with health systems would have discouraged them from participating in a study involving those health organizations.

This is a study with a small sample size using qualitative methods, and as is typical with qualitative research of this type, results may not be generalizable to other contexts or representative of all patient or provider experiences or perspectives. While the interview guide and recruitment materials were neutral with respect to the type of experiences sought, the overwhelming majority of participants in both the treatment recipient and the care provider groups (clinician and service providers) spoke of negative, stressful, or concerning experiences. No participants spoke of experiences that were primarily positive. As a result, this study is not able to comment on policies, practices, or contexts which participants associated with positive care experiences. There was a high rate (66%) of people who registered for the in-person focus groups who did not attend the focus group; however, this did not occur in virtual focus groups, in which all who registered attended. In addition, 17 PWLLE participants did not disclose their age, gender, or other demographic information, preventing the opportunity to conduct intersectional analysis of these experiences.