Visions Journal

Kiffer G. Card, PhD

Reprinted from the Involuntary Treatment: Tensions and choices issue of Visions Journal, 2025, 21 (2), pp. 37-38

Involuntary psychiatric and substance use care is increasingly framed as a necessary response to urgent public health crises.¹ I would argue that, in some cases, it can be lifesaving, especially when individuals no longer have the decision-making capacity to act in their own best interest. Many people even say involuntary care helped them.² So it's reasonable to believe there are situations where involuntary care is ethically justifiable.³

Still, we must consider the lack of strong evidence for involuntary care's benefit⁴ alongside the recent rise in its use.⁵ This is especially true in the current political context, where trends toward authoritarianism pose an increasing threat to all our liberty.

Rather than passing judgment on the ethics or effectiveness of involuntary care, I think we need to focus on what involuntary care represents: not a solution, but a symptom of problems facing our health systems. We need to understand why involuntary care has evolved from a rarely used tool to a central policy response to overdose deaths, homelessness and public disorder.

I argue that the rising use of involuntary care is driven and sustained by four interrelated forces:

1. A framework too focused on individual-level problems and solutions

First, at the heart of this issue is a pathologizing framework that narrowly frames problems at the individual level. This framework casts human distress as an individual failing, which obscures the systemic conditions that generate personal and collective crises. I believe most of us cling to the myth that the mind is separate from the body, and that individuals are separable from their social environments. We operate as though mental illness and substance use are the result of chemical imbalances. Instead, they are functional responses to our environment.⁶

Mental health problems are best understood in the context of:

• lack of safety

• absence of belonging

• patterns of living that deny our purposes and needs

Indeed, scientific studies show distress is the normal response when we live in environments that go against our basic human needs and interests.⁷ Yet, this reality is essentially ignored. In its place, a biomedical, individualistic system presents a distorted view of the problem.

2. Metrics-driven bureaucracy

Second, our system focuses on small, countable successes rather than measuring real change. Government reports tout more treatment beds and overdose reversals as markers of success. These numbers mask the absence of adequate, sustained care in communities of mutual support. For example, a bed in a facility means little if the provider is underfunded and understaffed. Politicians and bureaucrats are rewarded not for fixing the problem, but for managing its visibility.

3. Political incentives for easy, immediate wins

Third, governments choose what's expedient rather than engaging in serious discussions about equity, justice and well-being. The result is simplistic, data-driven decisionmaking that manages harm rather than preventing it. Distress becomes a compliance issue, rather than a collective concern.

I conducted an experiment among Canadian residents. Even when programs offered greater population health benefits, the public tended to reject prevention-oriented interventions in favour of treatment-oriented ones. They prefer mental health programs in favour of ones targeting physical health, and they opt to allocate resources to interventions that support the general population at the expense of those supporting marginalized people.⁸

These preferences matter because they shape what is politically feasible. Governments often respond to the will of the majority, rather than to the actual needs of people who are struggling with substance use and mental health challenges.

4. Fear of change

Finally, we are biased to justify systems. People tend to favour the status quo by rationalizing the way things are as inevitable or even preferable, even when the status quo poses very real problems.⁹ Instead of change, we (and our policy-makers) favour incremental actions that have little potential to actually solve the problem.

Involuntary care is one such favoured approach. It already exists as a policy response, its use matches our stigmas and biases, and if there isn't enough support for people who are involuntarily treated, it will hardly be of public concern (except to those unfortunate enough to be exposed to it either professionally or as a patient). As a "solution" it seems effective: demonstrating its success is as easy as listing the number of care beds alongside the other countable metrics used to define care in our health system.

A better way forward

These four forces act to reinforce one another, contributing to a complex system in which involuntary care is held up as an acceptable practice. However, our research among mental health experts suggests there is an alternative path. We must overcome our fear and imagine a care system that strengthens the social fabric of society. This would involve:

• building a system of communitybased social supports

• expanding timely access to voluntary and culturally safe care

• supporting pathways for people to re-enter their communities

• resourcing other well-supported evidence-based practices

Admittedly, these strategies are expensive and politically risky. They shift responsibility away from people with little political power and onto governments and the populations they represent. In other words, the interventions we need are transformative, and transformation is hard. So, if we want a better system, we need to stop acting as if distress is only an individual problem and start responding to it. That means acknowledging what our systems are doing and failing to do, and not relying on hollow metrics to create this understanding.

We need to be honest about tradeoffs and have the courage to take transformative action. Without this, involuntary care will remain not a solution, but a symptom of a system disengaged from the project of human flourishing.