How brain injuries, addiction and mental health require a new model of care
Experts say there is a need for better screening for brain injuries — and the ability to mandate treatment when necessary
By Alexandra Keeler | 7-minute read
Julius Jarvie-Clark, now 28, was born a healthy fraternal twin in 1996.
In 2011, when he was 14, he fell down a spiral staircase and struck a ceramic tile floor, suffering a catastrophic brain injury that left him in a coma.
“That was the last I saw my son as he was,” said his mother Suzanne Jarvie. “It’s like the meat cleaver of the universe just comes down and splits your life in two.”
Julius underwent a massive craniotomy at Toronto’s SickKids Hospital, which doctors did not expect him to survive.
But he did.
Julius now lives with severe brain damage, schizophrenia and a substance use disorder he lacks the capacity to manage. Julius’ combination of conditions has made it nearly impossible to secure stable housing or get him the help he needs.
Julius’ situation may be unique, but the challenges his family has faced getting him help are not. Experts say brain injuries are widespread among people experiencing homelessness — and often overlooked. A critical first step, they say, is identifying who has a brain injury and improving the ability to mandate treatment when necessary.
“These people would look normal,” said Dr. Peter Selby, a senior scientist and medical consultant at the Centre for Addiction and Mental Health (CAMH) in Toronto.
“But they wouldn’t do well in treatment, and we would diagnose this as a lack of motivation or a personality disorder or something like that, not understanding it for what it actually was, which is a head injury.”
Bumpy recovery
Julius’ recovery was initially considered miraculous. Physically, he looked completely normal.
Soon, though, mental health and substance use issues started to emerge. By age 16, he suffered a psychotic break, triggered by heavy cannabis use. “[Cannabis] just scrambled his brain all to bits,” said Jarvie.
In his early twenties, he was diagnosed with schizophrenia.
His brain injury also damaged his impulse control, making sobriety nearly impossible. He spiraled into a cycle of psychosis, hospitalization, criminal charges and homelessness.
While Julius’ brain injury was a known part of his medical history, for many individuals, it is not.
“I think it should be a standard for every mental health and addiction service to screen for [brain injury] and every emergency department to screen for it,” said Selby.
“Those would be where … one in four would have something that needs some sort of modification or understanding of … why they’re not responding to treatment or why they may be sub-optimally responding to care.”
When brain injuries go undetected, it can lead to misdiagnoses and poor outcomes, says Selby.
Selby advocates for proactive brain injury screening in emergency rooms, addiction services and mental health care settings. “If we understand it, then we can be much more compassionate,” he said.
Currently in Canada, brain injury screening is not widespread.
Some specialized health-care settings, such as Vancouver’s Cognitive Assessment and Rehabilitation for Substance Use Program, offers brain injury screening for substance use disorder. But this is the exception, not the norm.
Neuropsychologist Carolyn Lemsky agrees that health-care providers need to be better equipped to identify clients living with undiagnosed brain injuries. Lemsky is clinical director at Community Head Injury Resource Services, a Toronto not-for-profit that runs a brain rehabilitation program and provides housing for people with brain injuries.
“Cognition and brain injury are not even addressed in the strategy document related to substance use in Canada,” said Lemsky, referring to Ottawa’s strategy for addressing substance-related harms and the opioid crisis.
In 2021, Lemsky authored a guide for health-care providers, educators and health and human service administrators on addressing the co-occurrence of brain injury and substance use disorder. It recommends using the Ohio State University Traumatic Brain Injury Identification Method, a structured interview to screen for traumatic brain injury.
Unhousable
Despite having a middle class income, Jarvie’s attempts to care for Julius at home became unbearable due to his personality changes and behaviour.
“It was incredibly difficult to have him at home,” she said. “The whole family is just permanently traumatized. All three of [my] kids live with so much pain and grief, especially his twin.”
Jarvie and her husband tried various housing solutions, but none were sustainable. In 2018, they bought a condo for Julius to live in, but Julius and some drug dealers damaged it.
He then entered the shelter system, which exacerbated his mental health problems and exposed him to crack cocaine and meth.
Subsequent placements, including in a private bachelor unit in a supportive housing building, ended in destruction and eviction.
“I just can’t believe how badly he sabotaged that,” said Jarvie. “At one point, he was just pulling off all the casings off the window and the silicone because he thought he was being gassed, because he has intense paranoid schizophrenia.”
After being evicted from a public housing unit in Toronto’s Annex neighbourhood, Community Head Injury Resource Services of Toronto denied Julius a placement in their housing. The organization said Julius appeared too high functioning, Jarvie says.
As a result, Julius spent 2023 and 2024 living on the streets or in shelters, before being admitted to CAMH in early 2025.
“He [was] living in conditions that are way below the conditions of animals,” said Jarvie. “Animals don’t live the way homeless, catastrophically mentally ill people live.”
Lemsky says she is used to seeing this cycle of eviction and trauma. She points to a lack of adequate housing and community supports for people with complex needs.
“When housing is provided it tends to be in public housing settings or board and care where there is very limited support,” she said. “[This] perpetuates behaviour that may be self-defeating, such as substance use.”
“Evictions occur and the cycle repeats.”
A 2019 Lancet study out of Australia that pooled data from 22 studies found more than half of people who experience homelessness have a brain injury. The study highlights a bi-directional link — brain injuries can lead to homelessness, and homelessness increases the risk of further brain injuries.
There are no easy solutions to these challenges.
In Julius’ case, his brain injury and complex mental health issues made it nearly impossible for him to receive treatment. Despite multiple hospitalizations, he often evaded care and escaped psychiatric units twice.
Jarvie says she wishes Julius could have been forced into treatment sooner through a community treatment order. With a community treatment order, a court mandates that an individual with severe mental health disorders adhere to treatment conditions — such as taking medication — while living in the community, rather than an institution.
In Ontario, community treatment orders can be issued for individuals with mental health disorders, who may also have substance use issues. It cannot be issued for substance use disorders alone.
In contrast, B.C. and Alberta are advancing models for involuntary treatment specifically for substance use.
Selby, of CAMH, says community treatment orders are designed to provide treatment in the least restrictive environment. But they often fail when individuals with complex needs do not receive the support they require for recovery.
“There’s not enough support services to help them, so they’ll end up homeless,” he said.
Nowhere to go
After multiple hospitalizations, a court issued a community treatment order for Julius in 2022. The order removes his right to refuse treatment, requiring him to receive an antipsychotic injection every three weeks. If he misses an appointment, his psychiatrist can issue a form empowering police to apprehend Julius and bring him to hospital for the injection.
As of April 28, Julius is overdue for his shot.
“I’ve tried to get him to meet me at my mother’s, so that he can shower and get changed and attend at the clinic for his shot,” said Jarvie. “Despite saying that he will, the phone call ends, and then there is no rendezvous.”
Since April 28, Julius has also been living on the street, after being evicted from Toronto’s Filmore’s Hotel, a temporary placement approved by the Ontario Office of the Public Guardian and Trustee.
“His physical deterioration is so intense and his mental deterioration is so bad that I feel like anything could happen,” said Jarvie, with palpable anguish. “I just don’t know how long he’s going to live.”
Lemsky says individuals like Julius with complex needs would benefit from earlier intervention under Ontario’s Mental Health Act. Currently, the act requires individuals to be in an advanced state of distress before a community treatment order can be issued.
She also advocates for a different outlook on such patients’ long-term care. Some individuals with brain injuries should not be expected to be rehabilitated or regain independence, she says. Rather, the goal should be to manage symptoms and prioritize comfort.
“We don’t need more institutions, but we do need controlled settings that can support stabilization and address the needs of people,” she said.
Selby believes another necessary reform is making the health-care system less fragmented.
“[W]e have acute care, chronic care, ambulatory care,” he said, referring to outpatient medical services. “And all of these systems [are] separate.”
A lack of coordination between these systems allows people to fall through the cracks. “Everyone’s trained to work in isolation,” he said. “I’m really interested in how we connect them such that the journey is seamless.”
At CAMH, Selby is working on collaborative care models that use technology and relationships — not more funding — to close those gaps. Every six weeks, he meets with care providers from multiple institutions to coordinate treatment for clients navigating several systems. Together, they pool their expertise in mental health, brain injury, addiction and pain management.
“This requires people talking to each other, trusting each other,” he said. “It’s relationship based.”
Selby says he is cautiously optimistic about Canada’s proposed national brain injury strategy — first introduced under the Trudeau government but now stalled in Parliament. He warns it will fall short without better integration across mental health, substance use and housing.
“We need better integration of social care and health care,” he said.
“Provincial and local governments need to collaborate to have settings, such as housing and supportive housing, and staff, both medical and non-medical, that provide coordinated and integrated care.”
Currently, housing is not part of Selby’s coordinated care model. “If we had additional funding, I’d like to bring in housing,” he said.
For Jarvie, the solution must include permanent, stable housing.
“People who are acutely mentally ill, for whom the only other option is the street — they have to be in places where they’re not evictable,” she said.
“The same way we treat an Alzheimer’s patient.”
This article was produced through the Breaking Needles Fellowship Program, which provided a grant to Canadian Affairs, a digital media outlet, to fund journalism exploring addiction and crime in Canada. Articles produced through the Fellowship are co-published by Break The Needle and Canadian Affairs.
This is a great article. Thank you for sharing it. I do outreach work for street entrenched people in rural British Columbia. I wont lie: some of my clients have the capacity to make different, more healthy choices. But a large percentage of them can’t. It’s hard to see people with such limited capacity being sent into the streets with little more than a free tent, a sleeping bag, and “safe supply” drugs to fend for themselves. This is not a compassionate approach. And the limited shelters we have in my region aren’t equipped to deal with people suffering from brain injury. Staff do the best they can facing danger, with limited training and mediocre pay. But shelters aren’t the solution. Mandated mental health care, treatment, and supportive housing are a must.
Unfortunately, this is not an uncommon situation. Being in the Mental Health and Addiction sector for 16 years, I have seen it all. Many think Medical Detox is the answer. In some cases, it is, but in other situations, after medical detox, the mental health issues are unveiled. What is needed is a controlled, supported environment. Mental Health facilities that require permission to leave. Canada used to have many of these, but for some reason most were closed or torn down. Alberta has a center called The Centennial Center for Mental Health and Brain Injury, which also deals with substance use disorder. Dual Diagnosis, if you will. There is also the Claresholm Dual Diagnosis Centre. We need more of these across the country. We are losing our young adults and the next generation.