On May 14 and 15, the UN Office of the High Commissioner for Human Rights (OHCHR) held a meeting on human rights in mental health, responding to Resolution 36/13 of the Human Rights Council. The meeting was webcast and archived videos are available in three parts: day 1 morning, day 1 afternoon, and day 2, following this agenda; the main page also has links to written presentations and speaker bios.
The event represented tensions in the United Nations between the promotion of mental health and the promotion and realization of the human rights of people with psychosocial disabilities under the Convention on the Rights of Persons with Disabilities (CRPD). Development-focused agencies and member states have emphasized mental health promotion, which has of course always included force and coercion and legislation to restrict our rights and regulate the restrictions. Before the CRPD, human rights in mental health meant the regulation of rights restrictions, and providing access to tribunals to challenge the restrictions. CRPD brought in an entirely different regime that calls for an absolute prohibition of deprivation of liberty in mental health services and absolute prohibition of forced treatment; this is underpinned by recognition of legal capacity as a universal right to make decisions that, at least with respect to adults, cannot be restricted.
Speakers at the recent meeting were mixed as to where they fell. Those who are people with psychosocial disabilities or users and/or survivors of psychiatry uniformly came with the message that our human rights do not belong inside the context of mental health — we have a right to autonomy and full inclusion in our societies, and the laws allowing for restriction of our rights need to be repealed; coercion cannot be reformed, it must be abolished. YeniRosa Damayanti spoke from civil society in the opening panel, Bhargavi Davar in a panel on ‘mental health as a human rights issue’, Olga Runciman (speaking as a psychologist and acknowledging her lived experience) and Michael Njenga spoke in a panel on human rights based services and supports. Jolijn Santegoeds, Mette Elingsdalen and Kristijan Grdan spoke from the floor, also Erich Kopfmel from the autistic community. Their messages were strong and clear, but were at odds with the general framing of the day, which felt to me, listening to the webcast, like a debate that was primarily about us without truly listening to us or allowing our leadership to set the agenda.
Some, like Nils Melzer who is currently the Special Rapporteur on Torture, proclaimed outdated pre-CRPD standards such as the legitimacy of deprivation of liberty in mental health contexts to protect public safety or the person’s own safety. This approach is directly in opposition to CRPD Article 14, which prohibits all deprivation of liberty based on disability and not only that based ‘solely’ on disability as Melzer said. Similarly, Roberto Mezzina from Trieste, Italy, put forward Italy as an example of good practice, since they abolished large psychiatric institutions and have involuntary treatment as a last resort based on health and not danger. It is interesting to note that those two speakers had diametrically opposite justifications for the continuation of acts of medical violence on the bodies of people with psychosocial disabilities — and it does not matter to us which justification is used because the violence is the same. (Mezzina might have tried to suggest moving towards full abolition of coercion at one point, but it was not very clear.) A UK government delegate spoke from the floor and promoted their mental health act review, suggesting a narrow focus on challenging detention, and detailed Scotland’s mental health act which he thinks is fantastic for its great procedural safeguards.
Many in the mental health sphere focused on what they could do that they believe to be pragmatically useful. Michelle Funk from WHO spoke about training materials and processes that she says are having a real impact in changing practices. Vincent Girard, a French psychiatrist, spoke well about a Housing First program that doesn’t require medication compliance, respects autonomy and provides support services (I hope the person can choose to refuse any services they don’t want). Dganit Tal-Slor from New York’s Community Access spoke well criticizing the dominant medicalization and force in our law and practice in NY, including forced outpatient treatment, and also supported Housing First. Sashi Sashidharan from Scotland, while he wanted to focus on ‘easy’ changes, made one really excellent point from work he did with Human Rights Watch in Indonesia. There is a practice of restraint in community called pusung; one mother was persuaded to take her son to a new psychiatric hospital and she was horrified, because they were doing pusung in the hospital too and he was also starved, beaten and abused. Sashidharan explicitly called out psychiatry for doing the same practices and said it is equally bad. (However, I realize he didn’t say anything about forced drugging, which might be considered a harder issue.)
There was a lot of talk about stigma, about the burden of mental health, about people suffering from mental health conditions. Some speakers addressed social determinants of mental health, especially in context of gender, and the UNICEF representative highlighted a study that showed that 14-15 year old girls were depressed much more than boys, while there was no sex difference at age 11-12, likely due to pressure to conform to gender roles as they enter adolescence. A Bolivian delegate spoke about indigenous values that need to be incorporated into our thinking, and said that market values go against human dignity.
Dainius Puras, the Special Rapporteur on Health, took an intermediate position and has positioned himself deliberately to promote a way forward based on developing alternative practices “with a view to eliminating coercion.” This is itself contrary to the message expressed by survivors in the meeting — as Mette Elingsdalen said, the harm from coercion does not go away when you encounter a good practice.
Two of the panels had no survivor participants: those on system-wide changes in mental health and, astonishingly, on improving practices to combat discrimination, stigma, violence, coercion and abuse. The latter appeared to be a place to invite speakers from various UN mandates that may or may not link with mental health, in addition to Kriti Sharma from Human Rights Watch. That panel was disheartening and odd to listen to. I can’t help but infer that the organizers would have imagined it too threatening to the delicate structure they had attempted to build, to invite survivors to address this area in which our movement has indisputable expertise.
The concluding panel was composed of the three special rapporteurs: Melzer (torture), Puras (health), and Catalina Devandas, Special Rapporteur on the Rights of Persons with Disabilities, who also spoke earlier and supports the abolition of involuntary treatment and commitment. It was chaired by Kate Gilmore, UN Deputy High Commissioner for Human Rights. Most interesting to me was Gilmore’s sense of being impressed that the current situation is unacceptable, and saying that activists whose rights have been deprived are leaders and her office will proceed that way going forward. Dainius Puras got the last word, criticizing the ‘hierarchy of rights’ idea by which psychiatrists want to ‘fix the disorder’ of the person before respecting their human rights: “To have a monopoly of power is not healthy; it’s in the interest of psychiatry to share power and responsibility with others.”
And that, I think, will remain the bottom line for how the UN will continue to lurch towards what it thinks to be the paradigm shift — but it is not the way forward pointed by survivors. And then the cycle will continue whereby we are silenced and then others in the disability and human rights sector imagine that we are not politically powerful because we lack support; then we will say no, it’s because the state and psychiatry are not willing to give up their power and we need allies to make them give it up. And this will be too hard for most of them who also want to keep their jobs and speaking gigs and relationships, and the cycle continues.
So as not to end on a negative note, the state of development of the survivor/user/people with psychosocial disabilities movement as human rights advocates and practitioners is wonderful, something to celebrate and nurture. We have allies in growing numbers all the time. The Working Group on Arbitrary Detention, a UN human rights mechanism not represented at the meeting, has started to do significant work in cases of psychiatric detention and forced treatment, upholding an abolitionist standard that views these practices as discrimination. The High Commissioner for Human Rights himself, Zeid Ra’ad Al Hussein, spoke in the opening panel and clearly enunciated the CRPD standard of abolition, while also speaking to promotion of mental health. We are always reaching out to people in the human rights system who are open to learning. Portugal, one of the country sponsors of the meeting and the Human Rights Council resolution, has come out publicly in opposition to the Oviedo Protocol, a draft treaty in the Council of Europe that is entirely about authorization of forced interventions in a mental health context. The Council of Europe representative herself spoke against the Protocol in this meeting, but said they were unable to convince the Council of Ministers to abandon it. People like Olga Runciman, Bhargavi Davar, and Michael Njenga will continue to develop good practices and promote them; Peter Stastny from INTAR spoke from the floor and announced a forthcoming meeting or conference in Kenya co-organized with the user/survivor group there. Litigation and law reform, opposition to new legislation that continues authorizing coercive practices and deprivation of legal capacity, calls for reparations, drafting of a model law of inclusion, research and promotion of our paradigm by survivors in scholarly conferences and academia, all will continue and our initiatives will keep on challenging the UN as a whole to keep up with us.
Mad in America hosts blogs by a diverse group of writers. These posts are designed to serve as a public forum for a discussion—broadly speaking—of psychiatry and its treatments. The opinions expressed are the writers’ own.