Since the last few months, the world has been witnessing increasingly challenging times on various fronts, triggered in part by the COVID-19 pandemic. There have been, and continue to be, numerous instances of violence and injustice against the vulnerable and the marginalised. It is also important to add here that most of this violence has been an everyday reality for scores of people around the world since even before the pandemic. However, the mishandling of the pandemic by various governments has only added to those instances manyfold.
In these times of crises, it has become even more imperative to foreground conversations and measures focused on the promotion and protection of all human rights. In this light, we are delighted to see that the latest report by the UN Special Rapporteur (SR), Dr Dainius Pūras, adopted in the 44th session of the Human Rights Council of the United Nations is distinctive in declaring that, “There is no mental health without human rights”. In this new report, he calls for worldwide measures to ensure the “right of everyone to the enjoyment of the highest attainable standard of physical and mental health.”
Dr Pūras has previously appealed for the need to “abandon the predominant medical model that seeks to cure individuals by targeting ‘disorders.'” In this new report, he presses upon the importance of the “promotion and protection of all human rights, civil, political, economic, social and cultural rights, including the right to development”. This report is also perhaps the document most strongly endorsing the UNCRPD.
He urges us to look at how the Movement for Global Mental Health (previously known as Global Mental Health) is framed and delivered because it will have a huge impact on whether human rights are upheld or not. The Movement for Global Mental Health (MGMH) aims to scale up access to mental health services, and to a wider field of advocacy, activism and research, including critical perspectives. The fact that the SR is referring to a better framing ensuring human rights tells us that there are areas for concern in the way the MGMH is currently being delivered and needs thought and change. In addition, he speaks about the need to critically assess which policies may work in certain areas and contexts and that we can’t simply ‘export’ advocacy strategies and other literature from the Global North to the South.
He stresses the importance of moving away from standardisation for global mental health, “while standardization is important for global work, it also overlooks understanding and practices that resist standardization owing to complexity or locality.”
As user-survivors from the Asia Pacific region, it is of utmost significance for us that global guidelines are not universally applied to our context, without due consideration given to our social realities. The SR suggests:
A rights-based pathway to achieving more local relevance in global mental health might be to move away from evidence-based practice to practice-based evidence, which takes as its starting point local realities, possibilities and understanding of care. Research shows that mental health system reform in fragile and conflict-affected areas emerges through creative practices, experimentation, adaptation and the application of knowledge, as people deal with uncertainty and complexity in contexts where fundamental resources are sometimes lacking.
This is exciting for us because it puts rights at the forefront of all action while asking us to move from evidence-based (read medical) to practice-based (read community-led, local) evidence.
The SR quotes TCI Asia Pacific’s Bali Declaration of 2018 that “affirmed the need for a paradigm shift in mental health towards inclusion and away from a focus dominated by the medical model” and was similar to the approach shared by other organisations such as Mental Health Europe. Several organisations share this advocacy approach about moving towards non-medical alternatives and these voices add to the global conversation asking for a shift from more medical services to other culturally relevant, community-focused, and trauma-informed means of enhancing what health may mean to individuals.
The SR’s report firmly states that human rights violations, perpetuating coercion, stigma and discrimination against persons with disabilities, are all still happening due to practices existing within the field of mental health and that it is imperative to work towards changing these oppressive structures.
Mental health systems worldwide are dominated by a reductionist biomedical model that uses medicalization to justify coercion as a systemic practice and qualifies the diverse human responses to harmful underlying and social determinants (such as inequalities, discrimination and violence) as “disorders” that need treatment. In such a context, the main principles of the Convention on the Rights of Persons with Disabilities are actively undermined and neglected. This approach ignores evidence that effective investments should target populations, relationships and other determinants, rather than individuals and their brains.
It is commendable that the report engages with the power imbalance entrenched in the mental health space and the importance of “the participation of persons with mental health conditions, including persons with disabilities, in the planning, monitoring and evaluation of services, in system strengthening and in research.”
The combination of a dominant biomedical model, power asymmetries and the wide use of coercive practices together keep not only people with mental health conditions, but also the entire field of mental health, hostage to outdated and ineffective systems. States and other stakeholders, specifically the professional group of psychiatry, should critically reflect on this situation and join forces already on the way towards abandoning the legacy of systems based on discrimination, exclusion and coercion.
The SR cautions against “over-medicalisation” while reflecting on the labels that are assigned based on “enforced boundaries around normal or acceptable behaviours and experiences.” He affirms that medicalised responses to social exclusion and discrimination “can often disproportionately affect individuals who face social, economic or racial marginalisation.”
Medicalization can mask the ability to locate one’s self and experiences within a social context, fuelling misrecognition of legitimate sources of distress (health determinants, collective trauma) and producing alienation. In practice, when experiences and problems are seen as medical rather than social, political or existential, responses are centred around individual-level interventions that aim to return an individual to a level of functioning within a social system rather than addressing the legacies of suffering and the change required to counter that suffering at the social level. Moreover, medicalization risks legitimizing coercive practices that violate human rights and may further entrench discrimination against groups already in a marginalized situation throughout their lifetimes and across generations.
He, thus, appeals to move away from “individual-level interventions” by critically reflecting on the exclusionary and discriminatory social structures that cause distress. This is an important point, one that urges us to stop looking at individuals through an illness lens, from a what is wrong with you lens, to a societal lens – what may have happened to make this individual feel or react this way? This is exciting to us at Mad in Asia Pacific where we work to bring awareness to this social justice model.
In order to prevent mass medicalization, it is essential to embed a human rights framework in the conceptualization of, and policies for, mental health. The importance of critical thinking (for example, learning about the strengths and weaknesses of a biomedical model) and knowledge of the importance of a human rights-based approach and the determinants of health must be a central part of medical education.
The SR acknowledges that mental health-care systems and institutions are failing and that there are other approaches to look at the right to health. He looks towards innovative community projects that focus on building strength and resilience in the communities, allowing for diversity, and acceptance of varying versions of ‘normal’. Several sections of the report also emphasise the importance of engaging with persons with lived experience and ask for the acceptance of diverse communities with a variety of experiences.
Action that focuses only on strengthening failing mental health-care systems and institutions is not compliant with the right to health. The locus of the action must be recalibrated to strengthen communities and expand evidence-based practice that reflects a diversity of experiences.
He demands an “immediate scaling-up of rights-based, non-coercive alternatives” that are “occurring in neighbourhoods and communities worldwide” operating with a “deep commitment to human rights, dignity and non-coercive practices, all of which remain an elusive challenge in traditional mental health systems too heavily reliant on a biomedical paradigm.”
The SR also urges for critical and sustained engagement with factors like climate change, digital surveillance and the current COVID-19 pandemic situation and their effects on global mental health. He writes that the “emotional and existential realization of the magnitude of the climate problem” is increasingly being experienced particularly by children and young people. Additionally, he talks about the curtailment of people’s rights and the significant harm that “non-transparent surveillance” of people by State or non-State actors can bring to people’s mental health.
Finally, the SR concludes the report with a set of important conclusions and recommendations, firmly declaring that “There is no health without mental health and there is no good mental health and well-being without embracing a human rights-based approach”.
The report’s holistic and interdisciplinary engagement with mental health fills us with immense hope about a more just and equitable world and we at Mad in Asia Pacific fully endorse it.
You can download the Word and PDF versions of the full report in English and several other languages here.
Drafted with inputs from Jhilmil Breckenridge.