Human Rights and Mental Health
- Alberto Vasquez (Chair)
- Julie Hannah (University of Essex)
- Ana Lucia Arellano (International Disability Alliance)
- Michael Njenga (Africa Disability Forum, Users and Survivors of Psychiatry in Kenya)
In recent years, but especially since the pandemic, the issue of mental health has occupied an important place on the global agenda. However critical voices, particularly in the disability and human rights movements, insist that efforts may be futile if mental health systems do not fully incorporate human rights, and that the lack of attention on human rights may risk scaling up the problem rather than finding the solution.
Let's move to our first question. Julie, from your experience supporting the mandate of the UNSR Health and the work you are leading at the International Centre on Human Rights and Drug Policy, what would you consider to be the critical human rights priorities today in relation to mental health?
It’s hard to say what the number one priority is. The issue around the right to mental health is not new but is becoming a new and welcome focus in the global community. Disrupting the dominant narratives that reinforce the current mental health paradigm is a priority, and human rights is a helpful tool for disruption when applied correctly.
There are many important public discussions where mental health is implemented or highlighted, from COVID to racial justice, to conversations around shifting resources from law enforcement to public health responses. Human rights must be foregrounded in these conversations. This means moving beyond access to treatment. Human rights can help guide us to structural causes of distress, that violate and dehumanise individuals. They can help identify the need to act, and the needs of those left behind by harmful systems.
Much more is needed to be done to help frame what a rights based approach to mental health looks practically. There is no one size fits all approach. Every individual is different, and responses must incorporate complex circumstances. This can’t happen without empowered, free, open civic space to explore what that means.
We must look at underpinning principles and practices that support community inclusion, that are anti-coercion. We should scrutinise what’s wrong and diagnose the system, but also harness it to enhance something new.
The International Disability Alliance (IDA) and other organisations have produced a disability rights report in relation to the COVID pandemic, what were the main findings in relation to people with intellectual and psychosocial disabilities?
Ana Lucia Arellano
This survey was based on an initial collection of data on how persons with disabilities were living under the COVID19 pandemic. After receiving a large number of responses, it demonstrated that individuals with multiple and intersecting forms of disability have been disproportionately impacted by the pandemic, including high rates of institutionalisation and other rights violations in contradiction of the UN Convention on the Rights of Persons with Disabilities (UNCRPD). There was also an increased risk of sexual assault, and a sharp rise in institutionalisation, including abandonment of those with intellectual and psychosocial disabilities.
There were concerns about whether health professionals were adequately trained to treat those with intellectual and psychosocial disabilities, and that rules imposed by states did have significant impacts on mental health. We have also launched a global survey on adapting to the global pandemic, and we hope to collect data to launch another report on this experience of the pandemic.
In countries from the Global South, like Kenya, where mental health services are rather scarce, where do you think more efforts should be put?
We must review existing policies to make them compliant with the rights of persons with disabilities and other international human rights frameworks. There are things that can be addressed by the law, and things that need to be addressed beyond the law. We must think about how we strengthen existing health systems, for example how to build the capacity of medical professionals (doctors, social workers, community health workers). Most medical professionals might not understand the kinds of changes that need to be brought, but this is critical.
Universal Health Coverage is also key. We must consider what kinds of support needs to be integrated into UHC to ensure people can access services that are grounded in fundamental human rights. Mental health cannot be seen as isolated. We must reframe the debate, from not just having a conversation around mental health, but the full and effective participation of those with psychosocial disabilities.
Everyone talks about the need to invest in mental health, but often forget the determinants of poor mental health. We need to see how this affects delivery of mental health services from a rights-based approach too.
We also have to look at the role of national human rights institutions. For example in Kenya, you’re talking about an underrepresented group, and as a civil society organisation we must think about how we think about international human rights standards in the context of this.
What opportunities exist at the UN level to advocate for rights based mental health services, including deinstitutionalisation?
Beyond just the convention [CRPD], which is an important piece of ammunition in disrupting this narrative, is the question of how we ensure that the CRPD and the principles of a rights based approach and an understanding of human rights really percolate through the international machinery. We must think about education of the wider community towards an understanding of rights and community inclusion. Enhancing the work of the UN human rights community is important - they are making recommendations that are not necessarily politically binding, but significant. The conversation is sometimes too narrow, focusing on access to mental health services which are highly biomedical, rather than the quality of the services themselves. It’s about making sure there is a percolation within the whole UN human rights machinery, across human rights mechanisms, as there is still so much more that can be done.
Beyond UN human rights mechanisms we must build better conceptual links to the broader UN family, UN Women, UNFPA, for example. Some of this work is happening, but more needs to be done. Mental health and human rights are connected to priorities across the UN. Quality rights work that’s being done is a great start. The voices of those most directly affected need to be included in that process.
What do you see as the most important actions that need to take place now to end institutionalization - at a global and a national level?
Ana lucia Arellano
We need more support from states. Disability should in no case justify a deprivation of liberty. The views of the UNCRPD have not yet been affirmed by the international community in political declarations or UN resolutions. We need to start the process of deinstitutionalisation. Principles of equality, non-discrimination, inclusion, should all be the basis of law, policy and practice. At a regional level we have been deeply troubled by the Council of Europe’s draft addition protocol to Oviedo Convention, contravening CRPD and reaffirming the right of states to institutionalise those with psychosocial disabilities. We hope that this will not be adopted.
At a domestic level, [governments] must abolish any policies that deprive individuals of their liberty. Social support for those with psychosocial disabilities must be made available, including income support, support with housing and social networks, and access to education, particularly during the COVID-19 pandemic. We must end a system of deprivation of liberty, inhumane treatment, discrimination. Without this we will never have human rights based healthcare systems. A paradigm shift is necessary to avoid leaving any person with psychosocial disabilities behind.
From your experience working at national level promoting rights-based mental health services, what have been the key factors for success?
In Kenya we have a “loose network” of organisations of persons with disabilities, and we are trying to create a vibrant community of persons with psychosocial disabilities. We are doing a lot of capacity building, training on CRPD and SDGs, so our network across Kenya can understand what a rights based approach means.
Another important thing is working with our National Human Rights Institution. That has been very helpful, and we also have a reference working group on mental health. This means we have a coalition that can engage with the government, are helpful in giving greater leverage. Policy makers sometimes ask how to tackle or address specific issues, so research is also very important in being able to generate evidence and translate advocacy into practical action that can transform people’s lives.
Tapping into the social capital within communities is also important. For example in the African context families are key, and going to speak with families is crucial as most support comes from within families. How can they contribute to supporting our work and making sure it’s compliant with the CRPD.
The use of courts in Kenya is also key. For example, being able to challenge people being detained is an important tool for ensuring the inclusion of persons with psychosocial disabilities. Where we feel that there is a violation of rights, using the court to fight this is important.
Additionally, working at national level with the WHO on the Quality Rights Initiative has been very helpful. Working with the WHO and the Ministry of Health (MOH) has been helpful to articulate the changes we want to see.
People with lived experience, researchers, etc. might be skeptical about the role of the UN system in achieving change. Why is it important to engage with the system?
It is not the silver bullet for achieving change, I am sceptical myself of that approach. But with any project for transformation, understanding various political opportunities along the way is important. It is important that there continues to be global as well as regional conversations that sustain a progressive direction of travel, and shift in the right direction around our conversation on mental health, on a national level too. The pending resolution on the Oviedo Convention is really important. You can’t ignore that avenue as a pathway to change. It creates the political space for that conversation to happen at a national level.
A final question for all our panellists - what immediate measures should be taken to ensure rights-based mental health services?
Ana Lucia Arellano
We have to insist on what the CRPD brought. It came into force in 2008, and is assisting in two of the most important areas - that everyone has the right to live independently in the community, and disability should in no case justify the deprivation of liberty. We must insist that all decisions take into account the person with disabilities themselves. We must ensure participation on an equal basis by those living with a psychosocial disability.
Rights, human rights are a non-negotiable issue for persons with psychosocial disabilities. Everything that has to do with their lives should be with the agreement and informed consent for all with psychosocial disabilities.
Strengthening organisations of persons with psychosocial disabilities is key, so that they can participate in all activities affecting them. Empowering those persons and organisations is critical, and this is something that we should be able to do immediately. Properly addressing the power imbalance is also crucial. Substantially addressing issues that could be affecting those with psychosocial disabilities is difficult when that power imbalance exists. The law allows people with psychosocial disabilities to be taken to the hospital by police, by law enforcement. We need plans and policies that follow the CRPD. Awareness creation and capacity building is also possible and important, especially within our communities. Engaging with social capital within our communities is essential to ensure the quality of psychosocial services.
A key takeaway is thinking about the fact that when you coerce, you criminalise and dehumanise people.
It’s interesting to see how the CRPD is really changing how we view and assess mental health. So much has changed in recent years. What was previously accepted under regular medical practice is today recognised under international human rights law as a human rights violation. The topics discussed today - institutionalization, coercive practice, biomedical approaches, lack of community support, and other problematic practices - need to be addressed. It’s not enough to just talk about access to care. We cannot advance the conversation around mental health without addressing the issue of human rights.
The next #MHForAll webinar will continue to explore the link between mental health and human rights, and you can register your place here.