This week, Dainius Pūras, a professor of psychiatry from Lithuania who has been appointed by the United Nations as an independent expert and Special Rapporteur on the right to health, presented a report to the Human Rights Council in Geneva. The report, which can be read in full here, calls for a radical and global “shift in approach” to the treatment of mental health issues.
“The urgent need for a shift in approach should prioritize policy innovation at the population level,” he writes, “targeting social determinants and abandon the predominant medical model that seeks to cure individuals by targeting ‘disorders.’”
The report by Pūras aims to inform global policy makers and healthcare workers of the current challenges facing mental health care and lay out priorities and opportunities for improving existing systems. The report identifies three major obstacles to mental health reform, including the dominance of the biomedical model, power asymmetries, and the biased use of evidence in mental health research.
While he acknowledges that many other organizations have called for improvements to existing services, he expresses concerns that these calls, based on “alarming statistics to indicate the scale and economic burden of ‘mental disorders,’” are too rooted in the biomedical model to “address the grossly unmet need for rights-based mental health services for all.”
“The focus on treating individual conditions inevitably leads to policy arrangements, systems and services that create narrow, ineffective and potentially harmful outcomes,” he writes. “It paves the way for further medicalization of global mental health, distracting policymakers from addressing the main risk and protective factors affecting mental health for everyone.”
Pūras also lays out an alternative framework for mental health care that is founded on a human rights paradigm. Informed consent makes up a key part of the rights-based approach to mental health care and Pūras argues that forced treatment is ineffective and “perpetuates power imbalances in care relationships, causes mistrust, exacerbates stigma and discrimination and has made many turn away, fearful of seeking help within mainstream mental health services.”
In addition, this paradigm shift means that “rights-based strategies” must also target the social determinants of mental health and seek to improve the environments and communities in which people live. Pūras writes:
“The fact that children spend a significant amount of time in schools and most adults at the workplace, means that rights-based action must promote healthy, safe and enabling environments that are free from violence, discrimination and other forms of abuse. Likewise, a person’s mental health affects life within those domains and is integral to shaping the health of communities and populations. Population-based approaches to mental health promotion move health systems beyond individualized responses towards action on a range of structural barriers and inequalities (social determinants) that can negatively affect mental health.”
When more severe forms of mental distress are present, the reports calls for a rapid shift away from “coercion, medicalization, and exclusion” and towards evidence-based recovery services. “People can and do recover from even the most severe mental health conditions and go on to live full and rich lives,” he adds.
Pūras highlights existing recovery-based services including “peer support, when not compromised,” and “recovery colleges, club houses and peer-led crisis houses.” Open Dialogue and the Soteria House project are both given as long-standing examples of rights-based and effective services for mental health crisis.
“Today, there are unique opportunities for mental health. The international recognition of mental health as a global health imperative, including within the 2030 Sustainable Development Agenda, is welcome progress. The right to health framework offers guidance to States on how rights-based policies and investments must be directed to secure dignity and well-being for all. To reach parity between physical and mental health, mental health must be integrated in primary and general health care through the participation of all stakeholders in the development of public policies that address the underlying determinants. Effective psychosocial interventions in the community should be scaled up and the culture of coercion, isolation and excessive medicalization abandoned.”
Finally, Pūras offers several policy recommendations for confronting global mental health challenges from a rights-based perspective. Among others, his suggestions include:
- States take immediate measures to establish inclusive and meaningful participatory frameworks in the design of and decision-making around public policy, to include, inter alia, psychologists, social workers, nurses, users of services, civil society and those living in poverty and in the most vulnerable situations;
- States and other relevant stakeholders, including academic institutions, recalibrate mental health research priorities to promote independent, qualitative and participatory social science research and research platforms, exploring alternative service models that are non-coercive;
- End all financial support for segregated residential mental health institutions, large psychiatric hospitals and other segregated facilities and service;
- Ensure that users are involved in the design, implementation, delivery and evaluation of mental health services, systems and policies;
- Invest in psychosocial services, that are integrated into primary care and community services to empower users and respect their autonomy.
Read the UN press release here: http://www.ohchr.org/EN/NewsEvents/Pages/DisplayNews.aspx?NewsID=21689&LangID=E
Read the full report here: https://documents-dds-ny.un.org/doc/UNDOC/GEN/G17/076/04/PDF/G1707604.pdf?OpenElement