In this blog, writer and educator Nicole Luongo outlines the pitfalls of the “Complex Care housing” model that is widely-touted by provincial and municipal governments in BC. This piece is informed by Nicole’s expertise in Mad and critical drug studies, and she highlights the pitfalls of institutionalization as a singular solution to the intersecting oppressions that push people to a breaking point.

This year, The Tyee published a series of articles exposing the living and working conditions in Vancouver single room occupancy (SRO) hotels. It explored their structural disrepair, pest infestations, and other egregious health hazards, as well as systemic exploitation of the buildings’ front-line staff. These concerns are nothing new: the SRO stock was built at the turn of the 20th century. Once intended for seasonal workers in resource industries, most do not meet bare minimum standards of health, safety, or privacy. Today, they are considered the “last stop” before homelessness. Yet for some, homelessness is better. Many SRO tenants, when faced with staying or squatting elsewhere, opt to do the latter. They are maligned for this, and their presence in parks, alleyways, and staircases rankles home and business owners. Tensions between those who want respectable homes and those who already have them seem impossible to resolve. Now, though, Attorney General and ​​Minister Responsible for Housing, David Eby, says things are set to change.

In a 2005 report, “Cracks in the Foundation,” Eby detailed “substandard living conditions” in SROs. He has known that SROs are unlivable for nearly 20 years, Now, he wants to phase them out. This is an ambitious goal, and whether it comes to fruition is yet to be determined.

An emerging proposal, that of replacing SROs with “complex care facilities” for the “hard to house,” is new, and its implications are alarming.

In the interim, a recurring theme espoused by provincial and civic leaders is that the “seriously mentally ill” and addicted are being overlooked. This claim, also not new, may seem innocuous. However, an emerging proposal, that of replacing SROs with “complex care facilities” for the “hard to house,” is new, and its implications are alarming.

"The mayor of Nanaimo, B.C., wants the province to institutionalize severely mentally ill people who are homeless and often addicted to alcohol and illegal substances."

― From December 2019, Mayor wants B.C. to institutionalize severely mentally ill people who are homeless

Complex Care: Widely Touted, Rarely Appropriate

We don’t yet know what is meant by “complex care facilities.” The few public documents available are vague about admission criteria, programming and staffing requirements, and the ramifications of housing people deemed unfit to make decisions. Despite these glaring ambiguities, Premier John Horgan has tasked the Minister of Mental Health and Addictions (MMHA) with leading the development of Complex Care housing, referenced in both the MMHA’s mandate letter and its 2021/22-2023/24 Service Plan. 

Legal uncertainties aside, questions about consent - or lack thereof - are complicated by how readily the vulnerable are already violated. Specifically, severe mental illness and substance use disorder (SUD) designations are prevalent among those deprived of basic autonomy.  The provincial government emphasizes that there are members of our community who “need more intensive care than is available in supportive housing.” These labels and assessments are subjective, and far from diagnosing immutabile, intrinsic personality traits, they reflect the strain of being backed into a corner. For some, especially those living in SROs, lack of choice is omnipresent. It shapes every thought, feeling, and act. 

When organizations such as the Union of BC Municipalities (UBCM) say the unhoused are “falling through the cracks,” this is not entirely accurate: rather, they are slowly - or quickly - pushed through them. Inevitably, people break.

Those who are most free by way of power and resources tend to be most stable. Similarly, treating instability entails expanding freedoms for the oppressed, not constraining them even more.

For the most marginalized, “breaking” can indeed look like severe disturbance. Some conduct is aberrant, and because mental illness and addiction are viewed as brain disorders, we assume that the best treatments are medication, therapy, and, in extreme cases, specialized environments. Yet biology-based theories of mental illness are empirically unsound. For instance, the “chemical imbalance hypothesis,” an oft-cited explanation of aggression, was debunked long ago. No-one has “imbalanced chemicals,” nor does medication correct this - rather, chemical messengers (e.g. neurotransmitters) create memory maps of experience, and it is these maps that guide subsequent reactions to stimuli. Practically, this means that abuse, neglect, and deprivation are encoded in the body. Those who only know traumatic inputs perceive them everywhere, from everyone, so while medication can dull stress response acuity, it does not diminish stress. Related, “serious mental illness” presents less often in those with housing, income, and secure network connections. Cognition is thus political; it varies consistently across class, race, ability, and gender, and the story this data tells is one of freedom and stability: Those who are most free by way of power and resources tend to be most stable. Similarly, treating instability entails expanding freedoms for the oppressed, not constraining them even more.

Abolish the Psych Ward

presented by the Disability Justice Network of Ontario

Challenging Institutionalization

To better understand why calls for institutionalisation are troubling, we can also assess its historic functions. The closure of Riverview Hospital, or so goes the party line, was the catalyst for our predicament (which in Vancouver includes an open-air drug market and ongoing complaints of acquisitive and other petty crime as well as class antagonism). Many subscribe to the idea that from the 1960s to the 1990s, patients, all of whom depended on constant, intensive support, were discharged into community programs that failed to meet demand. Funds were mismanaged, services never materialized, and the newly unhoused flocked to the Downtown Eastside - a space of abjection whose lawlessness echoed their own - where they succumbed to the pimps and predators. Now, decades later, they and their descendents roam the streets. They are helpless and sinister; victims and vultures; crazed; irrational; scary. Re-institutionalization must be swift.

It’s a convenient narrative, one that, like all enduring myths, isn’t wholly wrong: Riverview was handled poorly. Some ex-patients did deteriorate after. But this narrative is also a red herring, and focusing on the small group involved, most hospitalized because their families could not afford alternatives, obscures what it represents. That is, we like the idea of Riverview because it enables us to fantasize about a past that never was - one where streets were “safe” and deviance disappeared. Of course, this past is stuff of lore. Canada was built on violence. Sustaining it takes the same. In Vancouver, colonialism, austerity, price speculation, and tax breaks for investors have caused the housing crisis. Staggering rates of accidental overdose and death are endpoints of prohibition. These are predictable policy outcomes, but now, their impact too big to ignore, our refusal to admit defeat is equally predictable. This is where complex care facilities come in. Like Riverview, these monolithic institutions symbolize the illusion of public order. If we can just reform the wayward - or, barring that, forget they exist at all - we can deny that our relationships with place, capital, and each-other have also become dis-ordered. It’s colonial logic, and it shows we haven’t learned a thing.

With institutionalization will come paternalism, cynicism, and the steady, relentless erosion of what it means to be a person.

In this milieu, “complex care facilities” are like bandaging a wound. They conceal structural inequalities, but only superficially. Moreover, the term itself is meaningless: All humans are complex. All humans need care. But we suspect that some are such enigmas - are so un-knowable, even to themselves - that keeping them in line requires in-humanity. This was not the answer with Riverview, as patient advocacy groups noted from its inception if 1913, and it is not the answer now. With institutionalization will come paternalism, cynicism, and the steady, relentless erosion of what it means to be a person. Further, by pathologizing rational responses to suffering, we create permanent patients. 

"Deviant behaviors that were once defined as immoral, sinful, or criminal have been given medical meanings. Some say that rehabilitation has replaced punishment, but in many cases medical treatments have become a new form of punishment and social control.”

― Peter Conrad, Deviance and Medicalization: From Badness to Sickness

Meaningful Change: Beyond Carceral Logics 

Returning to “freedom,” in this context it is achieved through systems change. It is not enough to warehouse people in psychiatric prisons, nor can we rely on “soft policing” to contain social unrest. While the latter may seem progressive, assertive community treatment (ACT) programs and related initiatives do not allay material disadvantage - they are just kinder, gentler expressions of surveillance and control. Instead, we must strengthen the rights of tenants under existing tools, such as the Residential Tenancy Act, prioritize welfare and disability-rate housing, and increase benefit recipients’ allotments for shelter and recreation. We must also repeal laws that criminalize being poor. This means granting the unhoused access to public space, ending discriminatory ticketing practices, and eliminating “street sweeps.” Money saved from defunding the police could be directed to health and social services. Additionally, the possession, consumption, and distribution of all currently illegal drugs must be legalized and regulated. Prohibition is catastrophic. It begets stigma, shame, and secrecy, and implementing comprehensive safe supply would do more than just save lives - it would reduce chaotic use. 

In this vein, let’s stop calling people “hard to house” when we mean easy to discard.

Collectively, our approach to those we cannot or will not empathize must be led by these very people. In this vein, let’s stop calling people “hard to house” when we mean easy to discard. Re-framed, these are groups we justify excluding to evade complicity in their pain: Do we hoard wealth? Are we purposefully ignorant? Whose land are we on? To treat mental health and addiction, we must address crises at their source.

Nicole Luongo has spent a decade working in solidarity with those most impacted by the intersections of drug prohibition, housing-deprivation, and disability (in)justice, including as a member of the Vancouver Area Network of Drug Users (VANDU). Nicole is the author of The Becoming: A memoir (2021), and her academic background is in medical sociology, primarily conducting research in the fields of Mad and critical drug studies. She currently works at the Canadian Drug Policy Coalition as the Systems Change Coordinator.