Forced into treatment

Lauren Davis met her best friend when she was 18 years old.

It was 2004, and Ricky Garcia was a fellow teacher at the preschool where she worked. She recalls a magnetism about him.

Ricky would light up the room. He was extremely funny. He had a beautiful smile, Davis said.

But behind the smile lurked something that, years later, would ultimately change both of their lives: Rickys addiction to alcohol and opioids.

Rickys drug of choice was, Yes please.

Between 2010 and 2012, he logged more than 75 trips to emergency rooms in the Seattle area and had three stints in ICU due to his addictions, she said. He would refuse treatment when he was using.

Garcias story eventually became the catalyst for Washington state to bring in Rickys Law in 2018, which gives the state the power to force someone with addictions into involuntary treatment.

I dont think involuntarily committing somebody is the best avenue. I think involuntarily committing somebody is the worst avenue. But sometimes its the only avenue, said Davis, now a Democratic state representative.

While the approach is now common in the U.S. with 37 states and the District of Columbia having involuntary treatment for substance use disorder, alcoholism, or both, according to the Betty Ford Foundation the idea is novel in Canada.

Today, its merits are being debated from B.C.  to Alberta to Ontario, as politicians look for some fix to a drug crisis that is now more visible than before.

CBC News went inside an involuntary treatment facility near Seattle to see first-hand how Rickys Law works and spoke with proponents, providers and lawmakers about what lessons Canada could learn.

The issue of involuntary treatment is thorny and ultimately forces society to answer a complicated question: What options are there when someone with addictions is a danger to themselves or others, but doesnt want to or cant do anything about it?
 

For Davis, now 38, Garcias experience altered the course of her life.

At the time of Rickys hospitalizations, from 2010 to 2012, Washington state had an involuntary treatment act for mental health, not for addictions.

During those two years, Davis admits to using whats known as a mental health hold to civilly commit Garcia, and she said it was in those moments of clarity that he chose treatment voluntarily.

Davis was struck that there was no comparable law when it came to substance use.

After Ricky went into recovery in late 2012, both he and Davis lobbied for the law that would eventually be passed in 2016 and named after him.

Active addiction is a miserable existence. It didnt matter to me how much I was using or drinking because I didnt care anymore if I woke up or not, Ricky said while testifying at a 2015 Senate human services, mental health and housing committee meeting.

This is why involuntary treatment is necessary in certain cases. Sometimes you need someone to say no for you when you cant say no for yourself.

Washington has four facilities across the state where people can be involuntarily detained for substance use disorders.

Patients are initially held for 120 hours, or five days, and a court can decide to hold them for another 14 days, then potentially an additional 90 days. 

The hope is, once they are discharged, that they will voluntarily choose treatment.

CBC News was invited inside one of those facilities in Kent, Wash., about 30 km south of Seattle.

When a person is in crisis, they really need someone to step in and get them help that they need when theyre not able to, said director Teri Hardy, who herself has been in recovery for 22 years.

Patients arrive at Recovery Place Kent by ambulance and are taken to an intake room, where staff check their skin for scabies or lice, test for COVID and assess any wounds or cuts.

There are 16 beds set aside for Rickys Law patients, who are cared for by doctors, therapists and psychiatric providers, and patients share a space with people being held under the states mental health involuntary treatment act.

Each room has two single beds with their own night tables all bolted to the floor.

While at the facility, patients meet with a discharge planner, participate in group sessions about triggers, relapse prevention and coping skills, and take part in activities.

Security is also top of mind; every entry point in the building is locked and requires a badge to swipe in.

Hardy said seclusion rooms and restraints are used as a last resort if staff feel the patient is a danger to themselves or others.

She disputes the idea that the building feels like a jail.

I dont look at it like that because we look at it as treatment. I think the amazing approach that we have to patient care overshadows the stigma that we often deal with with involuntary commitment. This is not jail, she said.

In March, Kristov Burgos, who long struggled with alcohol, woke up in hospital.

I was practically dead when I went to the hospital and the doctors were like, dude, if you keep drinking, you're going to die. And your nostrils are inflamed from all the cocaine and your liver or your kidneys are failing because of the pills, he said. 

When he learned that he had been civilly committed for substance use and was being sent to Recovery Place Kent, Burgos was upset.

He called family members to see if they could help him get out but quickly realized that was not possible.

Burgos said he spent the first week in his room, angry that he was there and going through withdrawal. By the second week, he started to participate in sessions and by his fourth week, Burgos said he began thinking about working there.

When asked if he would have come to a point where he voluntarily sought treatment, Burgos said he doesnt think so, and he is clear that involuntary treatment saved his life.

I was trying to kill myself, he said. I think I would have died somewhere.

Burgos ultimately spent 30 days at the facility and is now sober.

People are typically referred to Rickys Law by family members, first responders or other caregivers. There is a crisis line to trigger an assessment, and there is a deadline of six to 12 hours from referral to placement. 

But before a patient can be detained, they are first assessed by trained mental health professionals known as designated crisis responders, also known as DCRs, who ultimately make the decision about whether they should be civilly committed.

Using interviews and medical records, a DCR evaluates the individual to see if they are a harm to themselves, a harm to others or if they are unable to take care of their health and safety.

What is going on thats putting them or others in danger? said Dawn Macready-Santos, co-president of the Washington Association of Designated Crisis Responders.

We really want to make sure that theres a sort of long term pattern of substance use thats impacting this individuals life. 

Now 23 years old, Isaiah Fillmore started using fentanyl and methamphetamine when he was 18.

This past June, he overdosed in a parking lot in Everett, Washington, north of Seattle.

Fillmore was taken to the hospital, where he decided to voluntarily go into treatment for the second time.

Im not getting younger. How long am I going to keep going until I lose all opportunity, chances to live a better life, he said. I cant do that to my family.

Fillmore is now looking for a job and hoping to go back to school.

While he said that Rickys Law could be an opportunity for some people to change their lives, he does not think mandatory treatment would have worked on him, saying it could have had the opposite effect.

Thats what makes people rebel, you know? he said.

It has been six years since the law came into effect, and shortcomings have become visible.

Not many Washingtonians have heard of Rickys Law, according to Davis, the state representative.

It could explain why capacity at the facilities runs between 40 to 65 per cent, according to recent quarterly and annual reports compiled by the state, lower than what Davis would like.

This is what keeps me up at night. The process for civil commitment is very clunky, said Davis, the state representative.

Theres just endless opportunities for things to go wrong.

WATCH | How involuntary treatment works in Washington state:

Other bottlenecks include difficulties in matching patients with facilities and challenges in getting patients to facilities that may be on the other side of the state. 

Even though somebody might meet criteria per our laws and weve detained them, we might not be able to find a facility to actually take them, said Macready-Santos. Some decline clients who have complex health needs, such as using a walker or a CPAP machine, she said.

Having the workforce to execute an involuntary treatment program is also something Canada needs to consider, according to Hardy. 

She said that, in Washington State, there are not enough designated crisis responders to handle demand.

The Tacoma Needle Exchange, founded in 1988, was the first legally sanctioned syringe exchange in the United States, serving 3,500 a year.

Director Paul LaKosky is conflicted over people being civilly committed.

I dont think people should be snatched off the street and thrown into treatment. I do think that people should have other alternatives, he said.

However, LaKosky also understands the other perspective.

If I were the parent of a child who was in that situation, I would feel relieved if they were detained and involuntarily committed. At least I would know that theyre safe from their own actions for now.

But when asked whether he thinks Rickys Law has had a visible impact on the streets, LaKosky said no.

I think that it makes people feel good, he said. 

Philosophically, Id like to say everyone has the right to individual autonomy. They can do whatever they want with their own bodies. But no one has the right to make their problem somebody elses problem.

Dr. Jonathan Buchholz, an addiction psychiatrist, said that there are limitations of Rickys Law.

Buchholz said that there are few treatment centres that provide the level of care required, and there is no guarantee that patients can get into residential treatment after being committed under Rickys Law.

He said involuntary treatment does not work for everyone and time and resources should be spent giving treatment to people who want it.

He also points to how Rickys Law is a short-term solution.

Theres actually inconsistent evidence that forced treatment has good long-term outcomes for people, said Buchholz, who is an assistant professor in the department of psychiatry and behavioural sciences at the University of Washington. 

A June 2023 report done by the Washington State Institute for Substance Abuse found it could not be certain positive outcomes of patients who were involuntarily treated were the direct result of Rickys Law.

Research published in 2023 in the Canadian Journal of Addictions looked at 22 studies comparing involuntary and voluntary treatment for substance use disorders and found 10 reported negative outcomes with involuntary treatment, five reported non-significant findings and seven reported improvements, mostly around treatment retention.

The overall data neither supports nor is against involuntary treatment, and more research needs to be done, the study said.

Hardy, the director of Recovery Place Kent, shrugged off a question from CBC News of why the treatment should be used if the evidence is not definitive.

Maybe the evidence doesnt show it but I know how many lives we have saved.

Hardy said that, at her facility, between 20 to 30 per cent of patients end up being involuntarily detained again but argues that it does not constitute a failure.

Absolutely not a failure. No, we dont believe in failures here. Its a chance to help them again, to work on things, she said.

As for Buchholz, he said that there are constraints in what civil commitment can do to solve social disorder on the streets.

There is a misconception that potentially involuntarily detaining someone is going to fix that problem if they could just get treatment then they would no longer be experiencing homelessness, they would no longer be using substances, they would no longer be experiencing mental health crises.

Thats just the tip of the iceberg of treating someone.

He said that Canadian lawmakers should be careful if crafting similar legislation.

What is the end game to a short-term involuntary treatment? And what are the ethics involved in the detainment of someone for long periods of time? At what point do you determine that someone has the capacity to make a decision for themselves?"

In 2020, after eight years in recovery, Garcia relapsed; he was ultimately detained under his own law two times in 2020 and twice again in 2023.

But Davis said the trauma of detainment was too much for him.

In May 2023, Garcia fled the state to Oregon, to escape his own law.

Ricky himself advocated for Rickys Law. Ricky himself came to this capitol campus and begged lawmakers to save lives like his. He believed in it and it saved his life multiple times, she said.

When he was using, he was terrified of it and I dont blame him.

Rickys mother and two sisters ultimately found him in Oregon and Ricky returned to Washington state, where he voluntarily entered treatment.

Thirty-six hours later, on May 16, 2023, Ricky died inside a treatment centre, said Davis.

His cause of death is under investigation.

When pressed on whether Garcia running away from his own law conveyed a message, Davis stood by the law named for her late friend.

Theres nothing about this disease that is rational and it doesnt respond to logic, she said.

I will never minimize the trauma that Ricky did experience because of his civil commitments. I would do it again. I mean, I got 10 more years with him because of civil commitment and I wouldnt trade that for anything.

Producer: Kory Siegers | Copy editor: Lisa Johnson