In their 2022 position paper, the World Psychiatric Association (WPA) called for international support to find, implement, and safeguard alternatives to psychiatric coercion and ensure the protection of human rights in mental healthcare. This statement reflects recent advances in international human rights law, particularly the United Nations Convention on the Rights of Persons with Disabilities (CRPD), which provides a framework for mental healthcare that protects and promotes human rights.
Following the WPA’s position paper, authors Bernadette McSherry, Piers Gooding, and Yvette Maker conducted a scoping review to examine the recent literature published on human rights, mental healthcare, and the CRPD to gauge international efforts to safeguard human rights and curb coercion.
Published in BMJ Open, the article “Human rights promotion and the ‘Geneva impasse’ in mental healthcare: a scoping review” pays special attention to the “Geneva impasse.” The Geneva Impasse points to the seemingly irreconcilable conflict between those who believe that compulsory care/involuntary commitment can never comply with human rights law and those who argue that compulsory care/involuntary commitment can comply, given the right conditions.
“Breaking through the so-called ‘Geneva impasse’ might seem difficult at first glance. However, although dis- agreements about the legitimacy of compulsory treatment and coercive practices persist, there is optimism that these practices can be reduced, and attention is turning to how best to achieve this,” the authors write. “The importance of implementing a rights-based approach to mental healthcare is not only the subject of commentary on the CRPD but has also been recognized in legislation.”
The United Nations Human Rights Council resolutions on mental health and human rights highlight the need for states to integrate a human rights perspective into mental health and community services, promoting full inclusion and effective participation in society. The CRPD combines civil and political rights, such as the right to liberty and equality, with economic, social, and cultural rights, stressing the interconnectedness of these rights rather than dividing them into categories. Fundamental rights include the right to life, equal recognition before the law, liberty and security, respect for physical and mental integrity, living in the community, education, and the enjoyment of the highest attainable standard of health without discrimination.
The debate has emerged over the interpretation of the CRPD regarding compulsory treatment and substituted decision-making in mental healthcare. Some argue that legislation enabling treatment without consent should be abolished, while others believe it is permissible in exceptional circumstances. However, the focus of recent literature has shifted towards promoting human rights in mental healthcare through practical measures such as psychiatric advance directives, supported decision-making models, and human rights training for service providers, patients, families, and carers.
The scoping review utilized a doctrinal approach to identify the most recent legal understandings and policy precedents concerning curbing coercion and defending human rights in mental healthcare across different countries and cultures. The authors identified multiple treaties and commentaries through the United Nations Treaty Collection, allowing for a streamlined literature review of edited collections, books, articles, reports, working papers, and government documents. All searches were restricted to English-language results published over ten years (2012–2022). One hundred-one (101) individual study-specific results were left after excluding studies that did not fit the project’s scope.
The scoping review results reveal that most literature touches on and talks about the Geneva impasse, indicating that the WPA’s call for protecting human rights and reducing coercion in mental healthcare can be taken seriously and is already being discussed universally.
“International treaties establish that human rights are inherent to all human beings, regardless of status. There has been a persistent view in the literature that there are two categories of rights…What is significant about the CRPD is that it combines both sets of rights into one treaty and challenges the notion that rights can be divided into categories, instead stressing their interconnectedness.”
Utilizing the CRPD, the authors see a potential to move beyond the Geneva impasse and implement meaningful rights-based changes across countries and continents. Perhaps one of the most promising conclusions of their study is that discussions bridging the Geneva impasse are already being discussed on the policy level in Australia and Europe.
Organizations like the Council of Europe and European Cooperation in Science and Technology (COST) are working on initiatives to promote voluntary care and implement a rights-based approach to mental healthcare. For example, the Mental Health and Wellbeing Act 2022 in Victoria, Australia, emphasizes the importance of providing mental health services that protect and promote the human rights and dignity of people with psychosocial disabilities.
Unfortunately, a significant limitation of this scoping review is that it was only conducted in English, leaving out major swaths of the world that are leaders in rights-based approaches to mental healthcare, particularly Latin America. Moreover, although the CRPD is catalyzing meaningful change globally, the US has not ratified the CRPD leaving us with a disjointed inability to bridge the Geneva impasse.
The consensus among experts is that coercion in mental healthcare should be reduced and the range of voluntary options for support expanded. This shift towards a human rights-based approach to mental healthcare emphasizes the importance of offering services rather than imposing them, promoting the rights of persons with disabilities, and encouraging their full inclusion and participation in society.
McSherry, B., Gooding, P., & Maker, Y. (2023). Human rights promotion and the ‘Geneva impasse’ in mental healthcare: scoping review. BJPsych Open, 9(3), e58. (Link)
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