Michelle Funk is the Unit Head of the Policy, Law, and Human Rights at the Department of Mental Health and Substance Use at the World Health Organization. She has created and leads the WHO Quality Rights Initiative that aims to assess and improve human rights standards in existing services and advance the full implementation of the UN Convention on the Rights of Persons with Disabilities (CRPD).
In this interview, we discuss the launch of the new “Guidance on Community Mental Health Services: Promoting Person-Centred and Rights-Based Approaches.” The document is grounded on the principles of recovery and rights-based approaches. It presents successful examples of best practices in mental health service provision respecting dignity, moving to zero coercion, and eliminating neglect and abuse. Among the best practices showcased in the document are Open Dialogue as practiced in Tornio, Finland, Soteria Berne in Switzerland, Afiya House in Western Massachusetts, Basal Exposure Therapy in Norway, and Hearing Voices Support Groups.
The Guidance builds on the momentum created by the critical voice of Dainius Pūras, former UN Special Rapporteur on the Right to Health. Puras criticized the dominance of the biomedical model in the Mental Health field and highlighted the harms associated with ignoring the social determinants of health that impact a person’s mental health, such as violence, poverty, lack of proper nutrition, housing instability, lack of universal health coverage, discrimination and others.
In our conversation, Michelle Funk described the process of engaging stakeholders and persons with lived experience throughout the design and development of the document, the challenges of ensuring geographical representation given the global inequalities, and the hopes for the future.
The transcript below has been edited for length and clarity. Listen to the audio of the interview here.
Ana Florence: I wanted to start by talking a little bit about your career. How did you decide to work in public health and global health?
Michelle Funk: My education throughout university was in psychology and public health. My Master’s, in fact, was a specialized degree in Clinical Psychology, and my doctorate thesis was on Cardiovascular Disease Risk Prevention Strategies. So very much a focus on public health and global health.
Then, following my university studies, I led a large WHO multi-country research study on Early Intervention for Hazardous Alcohol Consumption, which was really what brought me in contact with the World Health Organization. In fact, it was through this study that I was invited to join the WHO and also to expand this work to mental health.
Florence: What does a day in Michelle Funk’s life look like?
Funk: In my work, I have global responsibility for supporting countries to develop their policies and laws on mental health, and this requires several steps. So closely reviewing what is being done today, and what is having good results, as well as what is not having good results in countries.
It also involves ensuring that the guidance is in line with international human rights standards. It means closely consulting with a full range of stakeholders, including organizations or persons with disabilities, individuals with lived experience, mental health professionals, civil society organizations, policymakers, and many others.
Then the huge task then is really to pull all this information together in easily understandable, digestible guidance that’s really sensitive to the diverse socioeconomic context that countries face, and of course, the different levels of development of countries’ health systems.
Florence: What are the things you’re most interested in, and what are the things you’re proud of doing during your career?
Funk: In my position, I have seen just how many people are living through so many bad, difficult and disempowering situations in mental health services. To help change this situation has been very important to me, and the fact that I think that this is now happening makes me proud.
Basically, I think I’m most proud of contributing to a new direction for mental health, which is a rights-based approach that puts people using services, people with mental health conditions and psychosocial disabilities, first in the whole mental health story. Here, what is important is that people’s preferences need to be respected—that their views count and are primary.
When people know their voice is being heard and their voice counts within the World Health Organization, it really empowers people who are so often not listened to or heard concerning the issues that affect them the most. That has been extremely important in the work that I do to make all of that happen.
I am also proud that over the years, through the work that we have developed, I have been able to bring many stakeholders to the table to get behind this work, many of who were previously reluctant. This is really encouraging and brings a lot of optimism about change being possible and change already happening.
Florence: I wonder if we could move on to the new Guidance document that was published on June 10th.
Funk: First of all, let me explain just a little bit about that WHO Guidance. It’s the World Health Organization’s new guidance for countries on how to put in place person-centered and rights-based community mental health services. Within this Guidance, we highlight good practice services from around the world that align with key human rights criteria, grounded in the convention on the rights of persons with disabilities (CRPD), including respect for legal capacity, non-coercive practices, participation, and community inclusion.
This Guidance is also providing detailed information on how each of the services explicitly implements these CRPD criteria in the setup and running of the service. I’d like to say that this Guidance is the first of its kind, so it’s going to be extremely important, and it has been many years in the making as well.
In terms of process, it has involved many months of intensive research and many rounds of in-depth consultations with all key stakeholder groups and experts in countries throughout the world.
That includes research and consultations about all the different types of services that are out there and being run in different countries, as well as consultations for reviewing and commenting on drafts and helping with the revisions of the different drafts into what we have today in terms of the final technical guidance.
Florence: It is a fascinating document, and it seems to be something entirely new and one of a kind. One of the very interesting pieces of this new Guidance document is the connection between human rights and recovery. That connection is not obvious in many places, including in the United States. Could you tell us why it is important to combine those two frameworks?
Funk: Yes, I can. It is actually an extremely good question to ask, and it is not so obvious for everyone. It is important to combine the frameworks because the human rights approach and the recovery approach share common values and principles.
Both these approaches promote key rights such as equality, nondiscrimination, legal capacity, informed consent, and community inclusion. The main difference, though, between the human rights and recovery-based approaches is that the human rights approach imposes obligations on countries to promote these rights.
More specifically, why is it important to put these frameworks together, which is the key, is that it is important to show their alignment with each other—to bring a more powerful voice to advocate and implement change.
The Recovery Framework has its own constituency that may not understand the language of human rights and, vice versa, the human rights constituency may not understand the language of recovery. Incorporating both frameworks and showing how they align can bring these important groups or constituencies together on common grounds and for a common purpose.
Florence: I think this will be welcomed by both communities and hopefully create an opportunity to work together. The Special Rapporteur on the right to health, Dainius Pūras, was interviewed by me as well (see this interview here). Can you talk about a paradigm shift that he proposed? How important was that for the development of the Guidance?
Funk: Well, the paradigm shift from a biomedical model to a human rights model is actually the basis of the new WHO Community Mental Health Service Guidance, including the services showcased and the recommendations made.
All of the services are united by several features, and these include the right to legal capacity, in other words, the right to make decisions on all aspects of one’s life.
Secondly, the freedom from coercive practices such as forced treatment, seclusion, and restraint.
Thirdly, participation, meaning that people with lived experience are running services or have a key role in deciding how are services designed and run.
And fourth, community inclusion, which refers to the support that people are given to access social welfare services and benefits, housing, employment, and educational opportunities, will ultimately allow people to live and be included in the community.
This is the new paradigm. This new human rights model and paradigm permeates everything we are promoting in this new Guidance on community mental health services.
Florence: There is another issue that I think is relevant to this document. There has been criticism around the western dominance of the global mental health arena. How did the Guidance deal with that?
Funk: Well, we looked for good practice, rights-based services from around the world in all regions. We also sought inputs from all stakeholders around the world, including the Global South.
But having said that, for sure, there is a limiting factor. That limiting factor was around the fact that we needed to select good practices that had evaluation outcomes. This tended to bias selection in the direction of high-income countries where there are more funds to complete evaluations.
However, at the same time, we really did our best to compensate for this bias to get a geographic representation of the services and representation from low-, middle- and high-income countries.
Florence: The issue of research, evaluation, and funding is so massive in the Global South, and coming from Brazil, I have lived experience with that, I should say. It is much appreciated that the Guidance found ways around that and managed to include several examples of good practices in the Global South. In a sense, I guess the Guidance really seems ahead of its time, especially considering where mainstream psychiatry currently is and the dominance of the biomedical model. With that in mind, what was most challenging about developing this document?
Funk: What was most challenging was to find good practices that truly aligned with the human rights criteria of the CRPD. The additional layer on top of all that was to find those types of services that also had an evaluation.
As you mentioned, most services in the mainstream do not meet these criteria, particularly the CRPD criteria, and there are so few services out there who actually are evaluating what they are doing.
So that was particularly challenging and really points to the need to invest in rights-based services like the ones we describe in the WHO Guidance, evaluate them, and compare costs and outcomes with the mainstream services, which is actually what we do in the Guidance document.
Florence: Hopefully the Guidance will impact the way services are funded and the way research is conducted. I’m already seeing many ways this can help us move forward. I wonder, moving back to a more general idea of your entire work, what do you find most rewarding in what you do?
Funk: What is most rewarding for me is collaborating with people with lived experience, learning from them, and integrating that learning into my work. Seeing, hearing, and reading so many people who are truly appreciative of the work being done, has also been incredibly rewarding.
We have had many people reaching out to us, for example, to thank the World Health Organization for this work. We have heard people say that the work has completely changed their perspective and changed their practices. Before receiving the training through the QualityRights Initiative, they did not know the harm that they had caused people, nor that they could do things differently.
So hearing so many comments like that every day has made the work and the struggles to complete it really worthwhile and rewarding, to know that what we set out to do we are achieving, and we’re getting that feedback to say that yeah, it’s happening.
Florence: What was most surprising, or what continues to surprise you in your day-to-day?
Funk: It was surprising to see just how many people, groups, and organizations there are out there who want this change to happen.
In the last couple of years or so, I sense there has been a shift—a groundswell of people from all areas and disciplines and movements, increasingly calling for significant change in mental health and calling for full alignment of policies, laws, and services with the Convention on the Rights of Persons with Disabilities, and for an end to the coercion that we see in mental health.
I think this movement is growing in confidence and gaining momentum and resulting in an increasing number of countries exploring in earnest how they can create better and more responsive human rights-oriented services and systems.
When you’re working in sort of a little bit of your own environment with your own stakeholder groups around you, you sometimes forget that there is a whole other world out there in countries, on the ground, in the community who are just desperate for this change to happen. It is nice to see that.
Florence: If folks did not know what the WHO is, now they certainly do. It has been on the media daily, and the COVID pandemic really brought the importance of this work to the front. There has also been talk about how COVID-19 affects people’s mental health, and a lot of the talk has been around the potential epidemic of mental illness following the COVID-19 pandemic. How can we ensure a focus on human rights and social determinants in this time, especially with this type of attention to mental health that COVID has brought?
Funk: I mean, it might be interesting to look at the types of problems and the mental health issues related to COVID to understand better how we can best address mental health in this context.
Obviously, COVID-19 has raised some important issues around mental health and how it can be negatively affected. I want to run through some of the key issues. There is fear, worry, and stress of infection and dying, losing family members, and the loss of income and livelihoods, which has been hugely significant in increasing distress, anxiety, and other mental health issues.
We also have some important impacts on people who have had pre-existing mental health conditions. Sometimes, the stress has amplified their distress and mental health condition. We’ve seen how stigma and discrimination create isolation for people who have mental health-related conditions and disabilities. This is amplified during the COVID lockdown when they’re being cut off from normal routines and activities and having the effect of becoming even more isolated and distressed.
We have also seen how lockdown has cut many people off from critical services and the support they received before the pandemic. We have seen some horrific impacts in institutional settings, such as psychiatric hospitals and social care homes, where people have been really disproportionately affected by COVID. Many people dying.
Also, many people, particularly older people residing in the homes, have really been cut off from their families, their loved ones, which has resulted in a huge emotional toll.
It’s important to highlight all those aspects, the mental health aspects of COVID-19 because it really reinforces the critical role of social determinants of health and the need for a human rights-based approach that focuses on these social aspects rather than conceptualizing mental health issues as an illness.
So mental health services, supports, and interventions need to engage with these important life issues to truly address mental health issues. The social determinants of health and their role have really come to the forefront during the COVID-19 pandemic, but they were always there. It’s just now that it’s more in people’s awareness and attention, and we need to seize that opportunity to make sure that these are the critical issues addressed in mental health services and mental health systems going forward.
Florence: I guess the issues were already there, but now they’re really so obvious it’s becoming very hard to ignore. With that in mind, the fact that these things are so obvious right now, are you optimistic about some change coming and it going in the right direction?
Funk: Definitely. You may have picked that up already from my previous responses. Absolutely, I am optimistic about change coming. I think it has actually started. I think it is going to continue. Many groups now are demanding a sea change, a real transformation of the mental health agenda.
Florence: What is next for you after the Guidance document?
Funk: Yeah, a lot is coming. We have not finished our work.
We’ve already started work on new guidance around mental health-related laws and policies that comply with the human rights standards—the CRPD or the convention that I’ve already mentioned. There has been a lot of demand for this from countries, so that is really good news.
We’re really keen to develop this Guidance, finalize it, and make that available to countries so they can develop new policy and legal frameworks to complement the rights-based services guidance that we’ve just launched, as well as our earlier work with the QualityRights training materials to promote attitudinal and practice change, in line with the human rights-based approach.
MIA Reports are supported, in part, by a grant from the Open Society Foundations