WORLD NETWORK OF USERS AND SURVIVORS OF PSYCHIATRY
Secretariat: c/o LAP, Store Glasvej 49, DK-5000 Odense C
International Disability Alliance (IDA)
Disabled Peoples' International, Down Syndrome International, Inclusion International,
International Federation of Hard of Hearing People,
Rehabilitation International, World Blind Union,
World Federation of the Deaf, World Federation of the DeafBlind,
World Network of Users and Survivors of Psychiatry, Arab Organization of Disabled People,
European Disability Forum, Pacific Disability Forum,
Red Latinoamericana de Organizaciones no Gubernamentales de Personas con
Discapacidad y sus familias (RIADIS)
The Elephant in the Room – Involuntary Psychiatric Treatment and the WHO
World Network of Users and Survivors of Psychiatry (WNUSP) and International Disability Alliance (IDA), October 2010
The World Health Organisation (WHO) has recently released Mental health and development: targeting people with mental health conditions as a vulnerable group1. The report is a “call to action to all development stakeholders ... to focus their attention on mental health” and “makes the case that people with mental health conditions are a vulnerable group, and as such, deserve targeted attention in development efforts” (p vii). A central feature of the report is that is at least partly in response to the UN Convention on the Rights of Persons with Disabilities (CRPD):
The human rights-based approach to development recognizes the protection and promotion of human rights as an explicit development objective. This approach, coupled with the United Nations Convention on the Rights of Persons with Disabilities (CRPD), places a duty on countries to ensure that the rights of people with mental health conditions are protected, and that development efforts are inclusive of and accessible to people with disabilities. (p xxv)
Dr Michelle Funk and Dr Benedetto Saraceno from the WHO’s Department of Mental Health and Substance Abuse were responsible for the conceptualisation and overall management of the report. Dr Funk is also one of the principal authors, along with her colleague Ms Natalie Drew and also Professor Melvyn Freeman from the National Department of Health in Pretoria, South Africa.
There is much to be commended in this report, including the recognition of people with psychosocial disabilities as particularly vulnerable to human rights violations, the need for them to be included in development programs, and for these programs to be based on the human rights principles of the CRPD.
A closer reading, however, indicates some serious shortcomings in this report.
Involuntary treatment – the elephant in the room
The only mention of involuntary treatment in the entire document is:
For example, they can encourage the establishment of mechanisms within the justice system to prevent abuses in relation to involuntary admission and treatment in mental health facilities. (p 50)
Given that involuntary treatment is the most serious and urgent human rights issue for people with psychosocial disability, it seems an extraordinary oversight that the report fails to address this issue. But those of us familiar with the Department of Mental Health and Substance Abuse at the WHO (WHO-MHSA) recognise that this is no accidental oversight. On the contrary, their persistent silence on this critical human rights issue is the elephant in the room that is always present but never mentioned.
The WHO-MHSA clearly endorses involuntary psychiatric treatment even when it equally clearly violates the CRPD prohibition against discrimination on the basis of disability. This can be seen in this report through its endorsement of South Africa’s Mental Health Care Act:
Development stakeholders can catalyze human rights reform through encouraging the development and implementation of policies and laws that comprehensively address mental health and human rights (see Box 14 for an example from South Africa). (p 49)
If you look at the South African Act you will see that, like most mental health legislation around the world, it gives legal sanction to the detention and involuntary medical treatment of people with psychosocial disabilities on the basis of “mental illness”, along with the other criteria that are typically found in such laws that the person is deemed to be a potential danger to themselves or others (Section 9 of the Act). Such discrimination on the basis of a medical diagnosis violates the CRPD, which becomes evident when you consider that other people who might be at risk of danger to self or others are not subject to the same limitations of their rights. That is, people with psychosocial disabilities (i.e. labelled as “mentally ill”) are not treated in South African law on an equal basis as others, as required under the CRPD.
It is worth noting that the Preamble of the South African Act refers to the South African Constitution that “prohibits against unfair discrimination of people with mental or other disabilities”, which suggests that it allows for the curious notion of “fair discrimination” when it comes to people with mental or other disabilities.
The implicit acceptance of involuntary treatment in this report without any discussion, along with its endorsement of South Africa’s discriminatory Mental Health Care Act, represents a failure by the WHO to address the most serious and urgent human rights issue for people with psychosocial disability. This is no accidental oversight by the WHO. They are well aware of the global controversy around involuntary psychiatric treatment but choose to remain silent on it – the elephant in the room that is always present but never mentioned.
The WHO is still locked into the medical model of psychosocial disability.
This report is very careful in the language it uses but, once again, a closer reading reveals that the WHO is still very much locked into the medical model of psychosocial disability.
The new, preferred terminology of the WHO is to refer to “mental health condition”. This follows the concept of a “health condition” in the ICF3, which has been criticised because it puts an ICD-10 medical diagnosis at the centre of their definition of disability. It is also notable that the body of this report does not refer to “mental illness” at all – the only use of this term is in some of the quotes used and also some of the Supporting Statements. Similarly, the use of the term “disorder” is only found in conjunction with specific psychiatric labels, such as bipolar disorder etc (e.g. p 40).
In contrast, the term “psychosocial disability” does not appear at all in the report even though this is the preferred terminology of people with psychosocial disabilities, which has now been generally accepted elsewhere throughout the UN. This preferred terminology reflects one of the key principles of the social model of disability that underpins the CRPD, which is that a medical diagnosis becomes a disability when you experience discrimination because of that diagnosis. Once again the WHO is well aware of this preferred terminology but chooses not to use it.
There is an attempt in this report to de-medicalise psychosocial disability, but it only goes part of the way. Phrases such as “diagnosable mental health condition” (p 30) and the frequent mention of symptoms and treatment, including “treatment gap” (pp 16, 24, 35), indicate the medical bias behind the report. Similarly, statements such as “Children with sub- clinical mental health conditions (mental health problems not meeting criteria for psychiatric diagnoses)” (p 20) establish psychiatric diagnosis as the gold standard for what constitutes a mental health condition, and therefore of psychosocial disability.
Of particular concern are statements like “The treatment of mental health conditions is as cost effective as retroviral treatment for HIV/AIDS, secondary prevention of hypertension, and glycaemia control for diabetes” (Box 4, p 36), which sounds perilously close to the now discredited “chemical imbalance of the brain” hypothesis of mental illness4. It is also a concern that the report claims that “Patients must have access to essential psychotropic medications” (Box 5, p 37) without any discussion of the hazards of these medications – especially when they are forced on people without their consent.
If you look at the other literature out of the Department of Mental Health and Substance Abuse at the WHO then it is clear that psychosocial disability is still seen very much in terms of modern, western psychiatry – i.e. mental illness, psychiatric disorder, diagnosable symptoms, medical treatments, and so on. This report is a step towards understanding psychosocial disability through the lens of the social model of disability and the CRPD. But it is only a small step and much more is required, especially when you consider that the medical label of “mental illness” is so often the basis for discriminatory legislation against people with psychosocial disability.
The medical colonisation of psychosocial disability
In many western countries, the excessive medicalisation of psychosocial disability is a major controversy that is hotly debated, especially (but not only) when it occurs in partnership with involuntary psychiatric treatment. Once again, the WHO is well aware of this controversy but, once again, chooses to remain silent on it.
This excessive medicalisation is sometimes described as the medical colonisation of psychosocial disability, which is of particular concern – and apt terminology – when this very medical, very western model of psychosocial disability is being so heavily promoted in developing countries. The WHO, through this report but also many of its other activities, is at the forefront of these efforts.
There is a colonialist attitude in this report, an attitude that western, medical concepts of psychosocial disability are superior to other local, traditional and indigenous ways of understanding extreme psychosocial distress. On page 9, the report gives some examples from Afghanistan, Oman, Thailand and Turkey of stigmatising superstitions and prejudices against psychosocial disabilities. It is difficult to read these examples without thinking they show the ignorance of non-medical (and non-western) ways of understanding madness. The report fails to balance this with any examples of non-medical and non-western ways of understanding psychosocial distress that many people find useful, helpful and healing. One notable example of this is in New Zealand where traditional Maori values and ways of understanding psychosocial distress are respected and integrated into New Zealand’s mental health system.
The colonialist attitude can also be seen in the lack of any critical analysis by the WHO of the stigmatising prejudices that can be found in the western, medical model that they endorse. Modern (western) psychiatry is under serious attack in many western countries for its flawed diagnostic system, its frequently hazardous treatments, and also its participation in human rights violations. The challenge to modern psychiatry is being led by users and survivors of psychiatry but also includes many other experts from a broad range of disciplines, such as psychology, social workers, mental health practitioners, and also a growing number of dissenting voices within psychiatry itself5. Once again, the WHO is well aware of these criticisms but, yet again, chooses to defend the status quo of modern psychiatry by remaining silent.
This is of particular concern in the context of this report that claims to be advocating a human rights approach to targeting psychosocial disability in development programs. People in developing countries that do not currently have mental health legislation are asking whether they need to introduce such laws. Sometimes this is being asked in the context of the CRPD and whether these laws are necessary to help protect the rights of people with psychosocial disabilities. But the reality is that in those countries that do have mental health legislation, these laws are used not to protect the rights of people with psychosocial disabilities but, as in South Africa, to give legal sanction to depriving them of their rights. And as noted above, these laws use the western, medical concept of “mental illness” as the basis for limiting these rights.
The WHO-MHSA report correctly highlights stigma as a key issue – though it should be called by its correct name, discrimination, to highlight that it is community attitudes rather than any attribute of the stigmatised individual that is responsible for stigma. It also highlights some examples of the ignorance, prejudices and fears that lie behind this discrimination. It fails, however, to mention that the primary source of stigma in those countries that have mental health legislation is this same legislation that makes second class citizens of people with psychosocial disabilities. It also fails to examine the central role of the (contested) concept of “mental illness” in these laws. Again the WHO is aware of this and chooses to remain silent.