On 1 July 2016, the UN Human Rights Council adopted a Resolution on Mental Health and Human Rights, highlighting that “persons with mental health conditions or psychosocial disabilities, in particular persons using mental health services, may be subject to, inter alia, widespread discrimination, stigma, prejudice, violence, social exclusion and segregation, unlawful or arbitrary institutionalization, over-medicalization and treatment practices that fail to respect their autonomy, will and preferences”.
Therefore “the need for States to take active steps to fully integrate a human rights perspective into mental health and community services, particularly with a view to eliminating all forms of violence and discrimination within that context, and to promote the right of everyone to full inclusion and effective participation in society”.
There are millions of people in psychiatric hospitals – or chained or caged – in low to high income countries. They need more opportunities to improve their human rights, mental health and wellbeing whilst they are in these hospitals and should have the prospect of returning to their communities. In many countries the development of a comprehensive community mental health system, including supportive community-based residential alternatives, is still a patchy and slow process. This is due to many factors, economic, political, environmental, social, educational and ideological.
The CRPD is the first high level international legally-binding standard which aims to promote, protect and ensure the full and equal enjoyment of all human rights and fundamental freedoms by all persons with disabilities, including those with mental health conditions, and to promote respect for their inherent dignity.
This is an important balancing standard between the right to adequate care and the right to all fundamental human rights.
Recently, the UN Special Rapporteur on the right of everyone to the enjoyment of the highest attainable standard of physical and mental health has declared:
“The crisis in mental health should be managed not as a crisis of individual conditions, but as a crisis of social obstacles which hinders individual rights …The urgent need for a shift in approach should prioritize policy innovation at the population level, targeting social determinants and abandon the predominant medical model that seeks to cure individuals by targeting “disorders”.
Therefore he has recommended to “develop a basic package of appropriate, acceptable (including culturally) and high-quality psychosocial interventions as a core component of universal health coverage; take targeted, concrete measures to radically reduce medical coercion and facilitate the move towards an end to all forced psychiatric treatment and confinement”.
Even, if there are guidelines, protocols, recommendations, monitoring systems in order to control forced treatments and restrictive practices, we should move toward a no-restraint general framework, e.g. an open door policy at all levels of the system, recognizing dignity and rights of individuals, not treated as an “object of the institution”, as Franco Basaglia wrote in 1967. The contradictions of power end up being played out in confined places, without any possibility of opening up towards the external world, in a different frame of space and time and without a project that pertains to real life. If I (as doctor, nurse, in any case guardian) have the key, or keys, I decide for you without any possibility of negotiation. Instead, I have to convince you, persuade you to agree, I must enter into dialogue with you in order to negotiate a solution.
Italy is still a laboratory, where de-institutionalization has been completed by pursuing it until the complete closure of all Psychiatric Hospitals over two decades (1978-1999). The Legislation of 1978 was based on rights (free communication, right to appeal, no prolonged involuntary treatments, no detention during those treatments) and fostered the lowest rate of involuntary treatment in Europe (17/100.000) and the shortest average duration (10 days), avoiding institutional “careers”. The forensic hospital sector has been included recently in a further de-institutionalization, with the closure of all remaining (6) Forensic hospitals, replaced by small (less than 20 beds) regional units linked to MH Departments. There was a reduction of cases detained from 1.500 long term patients to less than 600 usually for a much shorter time. The legal prospect is the right to be found guilty of a crime and the right to trial, and expectation of other developments in Penal Codes will be consistent with HR’s.
Other countries including the UK have closed the institutions and developed a community mental health system. However more needs to be developed to ensure a better quality of life, no restriction on liberty and better social outcomes for users.
Deinstitutionalization was therefore a starting point, and even now it is a necessary step, that means substituting community for hospital care and voluntary for involuntary care wherever possible. This could break the traditional nexus between custodial psychiatry and denial of human rights & social exclusion, or marginalization in institutional facilities and generally in mental healthcare.
To this end, the WHO has launched the “The Quality Rights Programme” which aims to improve both quality and human rights conditions in inpatient and outpatient mental health and social care facilities and empower organizations to advocate for the rights of people with mental and psychosocial disabilities. The WHO QRs Programme specifically helps to promote human rights, recovery, and independent living in the community; to support improvements on the ground and at policy level; and to promote participation of people with mental health conditions.
We explore particularly the issue of liberty and freedom in care processes, as opposed to a vision of restraint and denial of subjectivity. We should focus on:
- The possibility of not using detention and compulsion – the legislation
- The absence of locked units
- The lack of a clear open-door policy
- The lack of low-threshold, easy and friendly access to services
- The lack of rights e.g social rights
- The lack of a discourse based on negotiation within trusting therapeutic relationships
“Liberty is therapeutic” was in the 70s the motto in the Trieste experience, which is still preserving that legacy.
‘Freedom first’ the new slogan of the international movement for better care in a rights-based and person-centered approach, emphasizes this is not outcome but a pre-condition for care.
So, which practices can promote freedom? Can be described and operationalised? Which are related indicators? What connects key-words such as open door, open dialogue, free access, community engagement, co-production with stakeholders, recovery (also of the whole system)? This is required while contrasting restraint, coercion in care, special forensic psychiatry institutions.
On October 2016, the THINK-TANK Conference – CROSSROADS OF CHANGE – The leading experiences in a Whole Life, Whole Systems, Whole Community Approach to Mental Health, organized in Trieste by our WHOCC and the IMHCN in the framework of the International School Franca and Franco Basaglia gathered some of the most innovative practices, programs and services from all over the world. This has been used to compile a compendium of our best practices and leading experiences, then submitted to WHO for the development of a WHO QualityRights guidance on community based and recovery oriented services that respect and promote human rights as part of the overall WHO QualityRights initiative, which works to improve quality and rights in mental health around the world.
Organizations should be driven by Whole Person principles and values and embrace a Human Rights approach, only then their practice will prove to be “inherently” healing.
The new frontier is about not only fighting against asylums for better community services (and changing legislations accordingly) on one hand, and on the other hand advocating individual, subjective rights, but a convergence of both is essential. But how this can be translated into actual effective strategies and concrete plans?
A further necessity is to focus on inclusion in society, acting on social determinants of health like home, work, education, social supports and networks, relationships, participation and many other aspects. A political and social action must be combined with a change of institutional practice and new thinking in mental health and social care.
The right to have a life means all of this. It requires adequate opportunities and the prospect of a whole life based on the needs of the individual. A person with a mental health problem has the same basic human needs as all of us. Recognizing the whole person is the way to develop and lead a life that is full of purpose, interest, recognition, contribution, value and reward. People with a mental health problem are seeking a whole life comprising of these needs and aspirations despite additional stresses such as migration, displacement, social withdrawal, social exclusion, cultural clashes. Enabling people to have a whole life opportunity and assisting them in their recovery and wellbeing requires full access to health, educational opportunities, vocational training schemes, work, volunteering, social networks, sport and leisure, art and culture and faith and religion. This should be usually guaranteed as part of citizenship, but in case of refugees or migrants without recognized access to social integration, this remains the most significant key for their health and social inclusion.
We need here to widen the chances of communication, exchange experiences and successes, find new ways and strategies by collaborating, networking and continued learning.
This will be the scope of our meeting, that will encompass stakeholders, leaders, organizations, international bodies, brought together to a common discourse and dialogue.