The practice of freedom: Human rights and the global mental health Agenda

Abstract

In the long history of human rights advocacy in psychiatry, the Convention on the Rights of Persons with Disabilities (CRPD) sets an important balancing point between the right to adequate care and all human rights and fundamental freedoms and draws on cross-cutting themes including empowerment, citizenship, recovery and community living as a viable alternative to institutional living. Coercion in care, such as restraints, seclusion, forced medications, locked inpatient units, warehousing and forensic institutions, must be curtailed. The optimal attainment of liberty and freedom in care processes entails change, substitution and systematization of availability of practical alternatives: open doors, open communities, open dialogues, free access, community engagement, advance directives, joint decision-making and co-production of policy with stakeholders and recovery orientation of all services. Absolutist and idealistic insistence on the abandonment of all forms of involuntary treatments straight away will not work, but CRPD has undoubtedly opened a new debate and is definitely setting a new horizon for psychiatry to approach. Deinstitutionalization is a necessary step, by substituting community for hospital care and voluntary for involuntary care wherever possible and changing legislations accordingly. Widening the new frontier involves creating a convergence of clinical and support services with strong advocacy for rights. There is an emerging evidence base for the proposition that optimizing human rights is inherently therapeutic and contributes to healing. In this framework, the WHO has launched The QualityRights Programme for improving quality of care and implementation of core articles of CRPD. An effective action includes challenging social exclusion and inequality, by acting on social determinants of health like quality and stability of home, work, income, supports, relationships and social participation. Political, legal and social action has to be combined with our own emancipation from institutional thinking and practices in mental health and social care, to vastly improve the prospects of a whole life and full citizenship and rights for persons with psychosocial disabilities.