A Rights-Based Approach to Mental Health Crisis Response

A new article describes nine critical elements to a human rights-based approach to mental health crisis response.

Ana Florence, PhD
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A new article, published in the Health and Human Rights Journal, describes, for the first time, the critical elements to a rights-based approach to mental health crisis response. The authors identify the normative framework of a rights-based approach, specify the key principles and values, and enumerate the elements in crisis response practices that embody a human rights framework.

The fundamental principles that guided the authors’ rights-based approach are participation and empowerment, equality and non-discrimination, quality and diversity of care, social inclusion, autonomy, and dignity. The researchers, led by Peter Stastny, a psychiatrist and founding member of the International Network Towards Alternatives and Recovery, write:

“The key principles that guide the identification of the critical elements for rights-based mental health care are selected here because they can eliminate substitute decision-making and promote self-determination for individuals within crisis response and systems of mental health support. Without these assurances, crisis situations, whether gradually or rapidly evolving, are likely to result in the immediate and sustained infringement of human rights.”
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Human rights abuses in the context of mental health service provision have been systematically described and documented by several organizations, including the United Nations. The need for a rights-based approach to mental health is particularly urgent, given that a person experiencing an emotional crisis is often vulnerable to abuses of power, coercive practices, violent interventions, and loss of basic rights, such as the right to freedom.

While the United Nations Convention on the Rights of Persons with Disabilities provides the normative standards for a rights-based approach, it does not operationalize this framework into practice.

Practices around the world are indicative of the potential for a rights-based approach to mental health crises. In Brazil and Italy, deinstitutionalization processes were accompanied by innovative and creative ways to reconceptualize “mental illness” and shift practices to focus on the right to be supported in the community.

Soteria houses, developed in the 1970s by Loren Mosher, provided care to persons experiencing psychosis for the first time in homes staffed by non-professionals as an alternative to hospitalization. Peer respites in Germany, India, and the United States provide support delivered by persons with lived experience with mental health challenges in safe environments.

More recently, the Open Dialogue approach, developed in Finland in the late 1980s as a form of family therapy and a way to organize mental health systems, completely shifted the locus of care from the hospital to the community by providing services at people’s houses with a relational focus and a social network perspective.

Such alternatives to coercive and often dehumanizing practices have often shown superior outcomes compared to traditional treatments. However, alternative models are frequently criticized for not being evidence-based. The authors argue that the mainstream research methods employed by psychiatry are not adequate to assess issues related to violence, coercion, and rights violations and have historically failed to include that framework, which in turn has led to the widespread abuse and rights violations pervasive in mental health care to this day.

Using an experience-based phenomenological approach, researchers conceptualized nine critical elements to a rights-based approach to mental health crises that are sensitive to social, cultural, and individual differences and that stem from the subjective experiences of persons in crises rather than objective behavioral response. The critical elements are communication and dialogue, being with, flexible location, safe spaces of respite, continuity, meaningful peer involvement, harm reduction, judicious use of medication, and response to basic needs.

The importance of being heard is paramount to successfully deconstruct the crisis by building a trusting relationship with professionals and peer workers. In the authors’ words:

“Connection to a trusted professional, friend, or ‘person with experience’ can help resolve the immediate situation and avoid coercive consequences.”

Along with communication and dialogue, being with persons in crisis without an agenda is a powerful way to connect and provide non-coercive supports. Many programs rely on simply being present, either at scheduled times or spontaneously:

“The mere fact of sharing space with someone in extreme distress communicates trust and has been shown to have a sustained calming effect,” the authors explain.

Flexibility respects the person’s autonomy and avoids settings that can be stigmatizing or uncomfortable by meeting them in their own territory and accommodating to individual needs. If needed, respite spaces can provide a safe environment with 24/7 assistance and support and successfully avoid traumatic hospitalizations and involuntary interventions. The authors argue that peer involvement in respite settings is crucial.

“Such spaces meet key rights principles of empowerment, equality and non-discrimination, social inclusion, and autonomy and dignity, as long as decisions to use them are made by the person in crisis or collaboratively.”

Another critical element to a rights-based approach to a mental health crisis is continuity of care, a rare feature in mental health systems. Developing a trusting relationship with professionals and peer workers is key to recovery, and referrals to several different services and providers can be detrimental to care.

Strong connections are essential as “the offer of an ongoing relationship provides a powerful tool for persons in crisis to reconstitute their lives, even in the face of fractured connections.”

Peer involvement in a non-tokenistic way can preserve dignity, empower the person in crisis in a non-discriminating way, and promote social inclusion. Harm reduction strategies are described by the authors as critical to avoid violence and coercion by tolerating engagement in risky behavior, reducing shame, and improving engagement:

“Responses to mental health crises that incorporate harm reduction principles may be more acceptable to distressed persons because they destigmatize harmful acts and reduce shame.”

Finally, the authors describe the judicious use of psychotropic medication or its complete avoidance, and the importance of meeting basic needs such as nutrition, housing, and financial needs. Research has shown that long term use of psychotropic medications does not always lead to better outcomes and is associated with a wide range of physical and subjective harms.

The involuntary use of medications is still a common practice that should be thoroughly avoided and, when needed, the medication should be negotiated collaboratively and kept to a minimum. Additionally, authors stress that crises can emerge out of precarious livelihoods such as housing instability, financial difficulties, and food insecurity. Such material needs must be met.

The nine critical elements described by the authors are supported by the five key principles and values that characterize a rights-based approach to mental health crisis: participation and empowerment, equality and non-discrimination, quality and diversity of care, social inclusion, autonomy, and dignity. In addition, researchers note that accountability is necessary to build a rights-based culture in mental health systems and ensure that the rights of individuals are respected, and quality of care is preserved.

In the wake of recent violent episodes involving police responding to mental health crises, a rights-based approach seems timely and urgent. Peter Stastny and colleagues provide a concrete framework to operationalize crisis support describing the critical elements policymakers, clinicians, peers and advocates should be looking for to create a system where no rights are violated, and dignity is preserved.

The scientific and clinical community now has a clear set of strategies to employ moving forward. Violence, coercion, and rights violations should be eliminated from mental health care, and this article provides the necessary tools to do so.

 

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Stastny, P., Lovell, A., Hannah, J., Goulart, D., Vasquez, A., O’callaghan, S., & Pūras, D. (2020). Crisis response as a human rights flashpoint: critical elements of community support for individuals experiencing significant emotional distress. Health and human rights journal22(1), 105-119. (Link)

12 COMMENTS

  1. I wonder if “rights” include not having bogus “illnesses” “diagnosed”. After all, it is IN the “diagnonsense” that the persecutions begin. If there was no “diagnonsense” there would be no need to talk about pretend words like “stigma”

  2. I don’t mean to be rude, but I do prefer the video of the cat chasing it’s tail on youtube.

    There’s just no nice way of violating human rights. they have tried all sorts of ways to make it sound nice. Instead of the vans going around doing orbital lobotomy, they use the ‘chemical ice pick’ these days. Sure they ‘sedate’ before ECT these days, but the damage is the same. Your not going to find easy ways to do that, sitting down with the people you want to damage and singing Kumbayah just isn’t going to work.

    Do it the way it was done to me. Put on your Jack Boots and kick your way into their homes, drag them out and beat them into submission. Anything else is a waste of time, and tax payers dollars. Stop spreading lies about human rights, you don’t mean it. In 9 years I haven’t found what authority I should provide the proof of me being tortured to, because there is no point having an authority, because anyone who complains gets ‘unintentionally negatively outcomed’. We have rights on paper, but no mechanism for remedy. The people who torture you, are the people who take the evidence/proof and then ‘fuking destroy’ you. Deny you right to legal representation (a human right we also don’t have, though it is supposed to be one) And we take our seat at the UN as good global citizens.

    Cut the crap, mental health IS a euphemism for human rights abuses, and there is no amount of spin doctoring going to conceal that from it’s victims.

    My government is now in a position where making a complaint about being tortured is proof that you need to be tortured. Disagreeing with those in power proof that you have a mental illness and are in need of ‘treatment’. A Chief Psychiatrist whio has, in writing, confirmed arbitrary detentions for Community Nurses (and anyone above that rank), while we warn people not to travel to China as a result of the possibility of arbitrary detentions.

    Not unlike the Community Nurse who arranged to have me thrown into a police van in front of my In Laws and neighbours writing on his fraudulent statutory declaration that I had “potential for damage to reputation and meaningful relationships”. I agree that this is every person on the planet, and if that’s enough for police to be dispatched to drag someone from their home, so be it. I had “potential”, he did ACTUAL damage. They claim concern for my welfare? And that requires the total destruction of a persons life to ensure they don’t harm themselves.

  3. Equality DOES NOT exist when only one person is paying or unpaid. You either need to drop the word “equality” or divide your funding equally making the “person of concern” a full fledged team member. This solution would empower, motivate engagement, and reduce shame while helping to ensure that material needs are met.

    Participation and empowerment, equality and non-discrimination, quality and diversity of care, social inclusion, autonomy, and dignity would all be met by balancing power in a measurable way. In crisis it would start as a temp position, but with the possibility of advancement.

    I can see this working. Being a paid colleague is huge motivation to be better. Plus the pride alone. 🙂

    What you have laid out doesn’t end the issue of being stuck in the patient/client/crisis/broken/sick role.

    • It’s just a pay cut for the greater good. No one is expecting professionals to volunteer, or go into debt to cover crisis support, or pay a therapist out of the wifi/cell phone/grocery/contact lens/make up/car or other such luxuries budget. Yet we ask clients to make such sacrifices all the time.

      Radical Alternatives left me further away from true freedom than psychiatry did because money is kind of important for thriving. How many get to PROUDLY thrive off my want before I break? I wouldn’t wish psychiatry on anyone, but one way they are ahead of “alternatives” is that they do, at least in Canada, help secure a small regular income, affordable housing, and practical support. When I escaped psychiatry, I did so by hiring my own team by cutting out all non-essentials like wifi, cell phone and groceries. JUST for a chance at living, but honestly… when I weigh the pros and cons. There are serious side effects to private alternatives. Including this idea that you aren’t enough as you are. That you are the one that is broken. Plus if you spend everything on therapy and end up homeless it doesn’t matter. Crazy happens when life is just IMPOSSIBLE. If I had to do it again, I would have spent the money on credentials, like those I hired had, because that’s how the game is played. You can use the term human rights as catch phrase or a marketing slogan, but it’s just more tokenism if you aren’t willing to meet me human to human. Inside the office and out.

  4. Jordan B. Peterson psychologist talks about withdrawal akathisia both himself (a MH professional) and daughter made terrible terrible mistakes in his treatment:

    https://www.youtube.com/watch?v=HLWgVpmo1e0&feature=youtu.be&t=1020

    He stopped the benzodiazepine to take Katamine at the advice of a psychiatrist – disaster.

    There are no treatments for akathisia other than very slow taper, the extreme strength of character needed to hold off the suicide urge to get out of the horror, and staying the hell away from psychiatrists. He doesn’t fully realise it but he is still in trouble. Most of the other class of psych drugs cause akathisia for those who are new to this. So watch all of this and you will realise just how dangerous psychiatry is.

    • I did watch this. POWERFUL! J Peterson is a perfect example of how difficult and dangerous withdrawal can be, even with money and support.

      Gives me new respect for those who have come off benzos and other meds alone and without such luxuries. How amazing it is that any of us survive! I spent times of withdrawal treating myself with meanness and anger, as if I was weak or “Making it all up” as my first kid shrink accused me. I went through cold turkey benzo withdrawal at 17. I wouldn’t understand until years later what exactly it was. A Nightmare.

      WE ARE WARRIORS! We don’t celebrate how huge SURVIVAL is after psychiatry enough! ROCK ON!!!!

  5. But there is in many cases. It’s the dietary use of manganese salts along with your taper. A Richard Kunin, MD, has been using manganese salts for dyskinesias since the 1980’s, as have some of the orthomolecular guys. He had a website naming the conditions he treated, tardive dyskinesia being one of them. I don’t know if he’s still around- he must be close to fossilization if he is.

  6. “Human rights abuses in the context of mental health service provision have been systematically described and documented by several organizations, including the United Nations.”

    Now why would that be? Why would some shrinks talk about abuse within the system they work for? And it will continue to be just talk, but talk means there is evidence.
    It was not enough that clients complained, must be a few kind shrinks out there that care enough to “talk” about it. We need them to stand up and be counted.

    Leave a legacy for Pete’s sake. What have you left behind when you ruin people and families? And within that, you believe you are sane? It is insanity to practice abuse every single day. It’s even worse if you pretend that you “treat” people. For what? What do you feed them poisons for? Why label them ill?
    That is a very disordered person.

  7. There will never be a truly human rights based approach to “mental health care,” until “forced treatment” is abolished.

    Although I agree with Sam. The lies about the “invalidity” of the DSM disorders need to end. The lies about the “chemical imbalance” theories need to end.

    How can you have a mutually respectful, human rights based approach to “mental health care,” when the so called “mental health professionals” do nothing but lie to people, or are too misinformed about the reality of the drugs they’re pushing, to give informed consent?

    The psychologists allowed the psychiatrists to run amok, and you people need stand up and speak out about the psychiatric industry’s staggering in scale societal crimes, if you ever hope to regain credibility.

    In case you don’t know, the psychiatric industry is murdering “8 million people” every year, based upon their “bullshit” DSM disorders, and with their neurotoxic drugs.

    https://www.nimh.nih.gov/about/directors/thomas-insel/blog/2015/mortality-and-mental-disorders.shtml

    Psychologists have been complicit – and aiding and abetting – in this modern day psychiatric holocaust. And you all have malpractice insurance for a reason.

    • “The critical elements are communication and dialogue, being with, flexible location, safe spaces of respite, continuity, meaningful peer involvement, harm reduction, judicious use of medication, and response to basic needs.”

      Just an FYI, this is largely the opposite of what mainstream psychiatry today does, and encourages. But doing the opposite of what is helpful to their patients is very profitable for them.

  8. “The fundamental principles that guided the authors’ rights-based approach are participation and empowerment, equality and non-discrimination, quality and diversity of care, social inclusion, autonomy, and dignity. ”
    I find most of these principles worthy of recognition, but I do have concerns about autonomy. No one is an island, and the demand for autonomy is just more of excessive western independence rearing its ugly head. It’s almost ironic that they put social inclusion right before autonomy: you can’t have it both ways in my opinion and even less in the intimate relationships of family and SO’s/spouses where a rights-based approach truly needs to be hashed out and everyone must learn and/or be taught how to honor each one’s dignity and agency in the context of relationships…which can’t only be one way…but flow in all directions.

    I find it a little telling that the article this was based upon mentioned Open Dialogue and then spent NO time dealing with the issue of family/SO’s. ‘Peers’ are well and good, but it is family that can either be the best or worst partners on a healing journey. We are the only ones who are truly set up to give long-term 24/7 coverage and who are probably willing to make the necessary sacrifices to do so like our son and I did for my wife. I doubt any ‘peer’ would give 13 years of his/her life to commit to walk the healing journey, and despite the bad rap family often gets on this website, I bet many family members/SO’s would be willing to do so if only they were taught and given the tools to help rather than abdicate what ONLY they can do to the ‘experts’ at the urging of NAMI.
    Sam

  9. Excellent article, and our retraining of professionals, families and community members at arge with Emotional CPR carried out these principles. Our C is for connecting in a respectful manner with our hearts. P is for emPowering by regarding the person as an equal human being with equal rights. As some comments point out, a crucial way to protect rights is to enhance the power and status of the person labeled with a MH condition. The micro and macro aggressions of the mental health system start with the concept that these conditions are due to chemical imbalances in the brain of the individual. Replacing the DSM 5 with the Power,Threat,Response framework would be much more in line with human rights.
    I would also insist that being treated for emotional distress did not diminish our rights under the Bill of Rights.

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