Mental health and human rights in the 21st century
Authors: Dainius Puras, Piers Gooding
Journal: World Psychiatry (2019)

Mental health is emerging from the shadows. Human rights are on the agenda, and advocates are increasingly calling for parity with general health funding and a reduction of the treatment gap for people in crisis, particularly in low- and middle-income countries. There is high-level agreement on key components of good mental health policy, from promotion to prevention, treatment and rehabilitation. However, important disagreements remain about how to invest resources. An impasse has emerged, and it risks hardening into a dispute. The controversy relates to complex connections between mental health and human rights, and coalesces around a single question: do involuntary psychiatric interventions violate international human rights law? Coercion in psychiatry and broader mental health services is rising worldwide. This fact demands not merely discussion but action. The Convention on the Rights of Persons with Disabilities (CRPD) offers a chance for all stakeholders to rethink conventional wisdoms, address long-standing power imbalances and implement innovative practices. Anxieties about the change must not obstruct dialog or political action. The CRPD provides a unique opportunity to liberate not just users of mental health services but the entire field of mental health from a legacy of stigma, hopelessness and discrimination. The directive of the CRPD to embrace a social or "human rights" model of disability and move away from a "medical model" of disability has strategic advantages, including shining a light on the many social, political and economic factors that create grave disparities for people with mental health conditions or psychosocial disability. It may be tempting to focus on the most exceptional cases, which seem unmanageable without coercion. More important, however, is the need to substantially reduce coercion by implementing alternative, human rights compliant ways of providing support. Psychiatry can and must be among the leaders in this direction, not just among those resisting change. Human rights violations in the mental health context remain significant throughout the world, including in high-, middle- and low-income countries. The prevalence of rights abuse cannot be explained by a mere lack of resources. In the relatively wealthy European region, for example, funds continue to be invested in the renovation and expansion of large scale residential and psychiatric institutions1, 2. These sites perpetuate a vicious cycle of exclusion and despair. The rise elsewhere of involuntary psychiatric intervention in hospitals and homes also suggests that something is wrong. We recognize the serious arguments of professionals who warn against a prohibition of forced treatment. They insist on retaining legal permission to treat individuals with serious mental health conditions involuntarily in exceptional circumstances in ways that preserve dignity and autonomy, even the right to life. Those against argue that the non-consensual imposition of mind- and body-altering drugs based on narrow conceptions of impairment, poorly evidenced claims about "risk" and "necessity" , and a limited range of alternatives, is incompatible with dignity and autonomy. Scholars in diverse fields, including philosophy, neuroscience, psychology and economics, are increasingly challenging the grounds for the "exceptions" that legitimize coercion in mental health care. The CRPD has elevated this challenge to the level of international human rights law. Indeed, the CRPD challenges centuries of legally sanctioned prejudice. However, "exceptions" remain at the domestic level, in law, policy and practice, and they filter into the norm, fostering power asymmetries, the overuse of biomedical interventions, and the disempowerment of an already marginalized population. Systemic violations follow. This status quo, which can be observed on a global scale, is no longer acceptable. For psychiatrists and all healing professions, a pivot toward human rights would require setting aside "substitute decision-making" and offering support according to a person's "will and preferences" , and where unknown, the "best interpretation" of her/his will, preferences and rights. Szmukler's paper3 makes a substantial contribution to this effort. He elucidates some of the practical and conceptual requirements involved in a move toward a "will and preferences framework" and asks seriously what the CRPD means for the future of psychiatry, and for global health governance more generally. One of his claims, however, raises some concerns: namely, the proposal to assess decision-making inability in the form of functional assessments of mental capacity when a person's will and preferences are unclear or appear to be in conflict. On this point, caution is warranted. Szmukler mentions the many critics of functional assessments of mental capacity, to whom the authors of the World Health Organization's QualityRights Framework4 could be added. Yet, his efforts to assure against discrimination or a replication of long-standing power imbalances will fail to convince many (including ourselves). He is right, however, insofar as emergency responses are needed and the dialog must continue to find grounds for intervening in ways that are just. This Forum in World Psychiatry, and the WHO QualityRights Framework, are exemplary of this ongoing search. Creative responses are needed that foster therapeutic relationships based on trust and empowerment, in ways that avoid the pitfalls of the past. Moving in this direction opens space and creates urgency to develop innovative practices, some of which emerge organically when involuntary interventions are suspended or greatly restricted (as appears to have occurred in Germany, for example)5. Academic psychiatry – as Szmukler's own work makes eminently clear – will be essential to this shift. Clinical researchers can continue this effort by calling for the reinvestment of the vast resources currently spent on narrow biomedical research, shifting funds instead to social, clinical and community studies within a humanistic frame6. Ties between psychiatry, public health and social sciences need to be strengthened. There are no simple solutions. Debates may be uncomfortable, but they could open new opportunities and roles for psychiatry. The shift would diminish the "formal power" currently afforded to psychiatrists. Yet, there could be multiple benefits in shifting the profession from a tutelary to a facilitative role, including unlocking funds currently used for coercion and addressing important issues of image and reputation. It should be in the interests of psychiatry as a medical profession to substantially reduce its reliance on coercion, and to spread such a message to its members worldwide. A rights-based approach can provide a pathway to the future of mental health care we want for all. The CRPD can be used to promote the investment of human and financial resources into a broad spectrum of support to drastically reduce non-consensual measures with a view to their elimination. It offers a framework to achieve social justice, attain the highest standard of health care, and strengthen governance of health and social services.