39/36 Mental health and human rights - Report of the United Nations High Commissioner for Human Rights

GE.18-12245(E)



Human Rights Council Thirty-ninth session

10–28 September 2018

Agenda items 2 and 3

Annual report of the United Nations High Commissioner

for Human Rights and reports of the Office of the

High Commissioner and the Secretary-General

Promotion and protection of all human rights, civil,

political, economic, social and cultural rights,

including the right to development

Mental health and human rights

Report of the United Nations High Commissioner for Human Rights*

Summary

In accordance with Human Rights Council resolution 36/13, a consultation on

human rights and mental health was held in Geneva on 14 and 15 May 2018. Participants

discussed the topic of mental health as a human rights issue and agreed that the situation

could be improved through system-wide strategies and human rights-based services to

combat discrimination, stigma, violence, coercion and abuse. The present report contains a

summary of the discussions, as well as conclusions and recommendations from the

consultation.

* The annex is reproduced as received, in the language of submission only.

United Nations A/HRC/39/36

Contents

Page

I. Introduction ................................................................................................................................... 3

II. High-level opening ........................................................................................................................ 3

III. Summary of the proceedings ......................................................................................................... 5

A. Setting the scene: mental health as a human rights issue ...................................................... 5

B. Improving human rights in mental health through system-wide strategies ........................... 7

C. Human rights-based services and support to improve the enjoyment of

human rights in the context of mental health ........................................................................ 9

D. Improving practices to combat discrimination, stigma, violence,

coercion and abuse ................................................................................................................ 11

IV. Conclusions and recommendations ............................................................................................... 13

Annex

List of participants ......................................................................................................................... 17

I. Introduction

1. The Human Rights Council, in its resolution 36/13, requested the United Nations

High Commissioner for Human Rights to organize a consultation to discuss all relevant

issues and challenges pertaining to the fulfilment of a human rights perspective in mental

health, the exchange of best practices and the implementation of technical guidance in that

regard.

2. The consultation took place on 14 and 15 May 2018 and benefited from the

participation of a wide range of stakeholders, including Member States, United Nations

agencies, funds and programmes, special procedures and civil society, including persons

using mental health services, persons with mental health conditions and persons with

psychosocial disabilities, and their representative organizations. Participants discussed

mental health as a human rights issue, and how to promote human rights through system-

wide strategies and human rights-based services and support, and the exchange of good

practices to combat discrimination, stigma, violence, coercion and abuse in the context of

mental health.

II. High-level opening

3. The President of the Human Rights Council, Vojislav Šuc, introduced the objective

of the consultation, which was to discuss challenges pertaining to the fulfilment of human

rights in mental health and the exchange of good practices. He thanked Portugal and Brazil

for their leadership in organizing the consultation and extended his gratitude to civil

society, particularly to persons using mental health services, persons with mental health

conditions and persons with psychosocial disabilities, for their valuable participation.

4. The Chair of the Indonesian Mental Health Association, Yeni Rosa Damayanti,

stressed that the discussion on mental health and human rights must be centred on inclusion

of the rights of persons with psychosocial disabilities, which went beyond the traditional

mental health approach narrowly focused on treatment. She listed barriers that persons

faced, in both the global South and the global North, in accessing housing, employment,

social protection and the right to political participation. Those barriers were made worse by

stigma and discrimination embodied in laws and policies and reflected in attitudes held by

the authorities, employers and the public at large. She emphasized that the current response

and growing trend around the world towards medication and institutionalization generated

further violations, which were compounded by the loss of legal capacity, ultimately leaving

persons with psychosocial disabilities further behind. She expressed alarm about the

ongoing process within the Council of Europe of drafting an additional protocol to the

Convention for the Protection of Human Rights and Dignity of the Human Being with

regard to the Application of Biology and Medicine (the Oviedo Convention) to legitimize

involuntary treatment of persons with psychosocial disabilities, in violation of the

Convention on the Rights of Persons with Disabilities, in a deliberate move away from the

advances made to ensure human rights in mental health, such as the QualityRights initiative

of the World Health Organization (WHO). She stressed the importance of the participation

and the voices of people with psychosocial disabilities themselves, and their representative

organizations, in the discussions, saying: “No talk about mental health should exclude us

ever again”.

5. The United Nations High Commissioner for Human Rights, Zeid Ra’ad Al Hussein,

stated that the right to the highest attainable standard of health was fundamental to human

dignity, and that there was no health without mental health. Yet harmful stereotypes had an

impact on the participation and inclusion of persons on account of actual or perceived

mental health conditions, and could lead to arbitrary detention in institutions that were often

the locus of abusive and coercive practices potentially amounting to torture. He deplored

institutionalization as an inadequate response at all levels for children and adults with

disabilities and called for the elimination of practices such as forced treatment, including

forced medication, forced electroconvulsive treatment, forced institutionalization and

segregation. Instead, he called on States to ensure access to a range of support services

within the community, including peer support, and reminded participants that the

Convention on the Rights of Persons with Disabilities offered the legal framework to

uphold the rights of people with psychosocial disabilities — including the exercise of legal

capacity, free and informed consent, the right to live and be included in the community and

the right to liberty and security, without discrimination. He welcomed the participation of

rights holders, with their real-life experience, and called for a strengthening of the support

for the framework provided by the Convention, which had already generated change in

restoring respect for the autonomy, choices and rights of persons with psychosocial

disabilities.

6. The Director-General of the International Labour Organization, Guy Ryder,

expressed his organization’s commitment to join the collective efforts to promote mental

well-being and the right to work of persons with mental health conditions. He pointed to

stereotypes and discrimination within the workplace due to lack of awareness on the part of

employers and recruiters, which led to exclusion and lower rates of participation in

employment. He described the work that the International Labour Organization carried out

with Member States and enterprises to identify good practices contributing to a more

inclusive work environment, including through the provision of reasonable accommodation.

He announced that the International Labour Conference would negotiate a new instrument

against violence, stigmatization, discrimination and harassment at work.

7. An Assistant Director-General of WHO, Dr. Svetlana Akselrod, underscored the

importance of prioritizing, in the discussions, the voices of people with real-life experience.

Referring to the constitution of WHO, which referred to mental health, she admitted that

little progress had been made to advance mental health as a human right. She affirmed that

people with mental health conditions and psychosocial disabilities lacked access to quality

services that were respectful of their rights and dignity, and faced marginalization,

frequently being institutionalized and more likely than the general population to die

prematurely. She drew attention to the adoption by the World Health Assembly of a mental

health action plan guided by the Convention on the Rights of Persons with Disabilities and

other international human rights instruments. She referred to the QualityRights initiative,

which had resulted in a significant shift in human rights awareness by mental health

workers, decreased violence and abuse, and increased empowerment of people with mental

health conditions and psychosocial disabilities.

8. The Permanent Representative of Portugal to the United Nations Office and other

international organizations in Geneva, Pedro Nuno Bártolo, highlighted mental health as an

important frontier of human rights, and welcomed the transformative nature of Human

Rights Council resolution 36/13 on mental health and human rights, which reflected States’

individual responsibilities within their societies as well as the collective responsibility to

uphold the principles of humanity, dignity and equality at the global level. The resolution

broke new ground, by moving away from the perpetuation of violations through arbitrary

institutionalization, exclusion and segregation and moving towards a human rights-based

approach. Collaborative efforts were needed to address the discrimination, stigma, violence,

abuse, torture and degrading treatment or punishment that continued to have an impact on

persons with mental health conditions and persons with psychosocial disabilities. He

highlighted the support from the United Nations system, particularly the Office of the

United Nations High Commissioner for Human Rights and WHO, including the latter’s

QualityRights initiative, as well as the work by the three special rapporteurs on the panel,

and reaffirmed the new approach to mental health, which was based on human rights. He

said that mental health conditions were just one incident away from each one of us, and yet

there was still a major stigma attached to them. He concluded by recalling the golden rule

of all civilizations: do unto others as you would have them do unto you, and do naught unto

others that you would not have them do unto you.

9. The Permanent Representative of Brazil to the United Nations Office and other

international organizations in Geneva, Maria Nazareth Farani Azevêdo, was hopeful that

the consultation could leverage efforts to ensure that mental health policies and practices

were aligned with human rights law. She affirmed that the right to mental and physical

health implied negative and positive obligations, including access to universal health

coverage, and the adoption of non-discriminatory laws, policies, practices and responses to

ensure the social determinants of health. She recalled that Brazil, Portugal and WHO had

been partnering through different initiatives to raise mental health as a human rights priority

for persons with mental health conditions and psychosocial disabilities.

10. During the interactive dialogue, representatives of the European Union, Brazil on

behalf of the Foreign Policy and Global Health group, Colombia, Ecuador, Australia, the

Plurinational State of Bolivia, the World Network of Users and Survivors of Psychiatry,

Disability Rights International, the International Disability Alliance and the Parliamentary

Assembly of the Council of Europe took the floor. Brazil called for concerted efforts to

support the paradigm shift away from coercion and exclusion. Colombia, Australia and

Disability Rights International highlighted the need to take into account the intersecting

identities of individuals — which compounded the disadvantage and discrimination facing

women and girls, children, older persons, lesbian, gay, bisexual, transgender and intersex

persons, indigenous peoples, persons on a low income or living in poverty and those living

in rural communities. The Plurinational State of Bolivia suggested that new ways of

thinking and promoting health could be derived from the traditional knowledge and values

of indigenous peoples to strengthen the harmony of the individual within the family and the

community. The representative of the Parliamentary Assembly of the Council of Europe

announced the Assembly’s continued opposition to the drafting of the additional protocol to

the Oviedo Convention concerning “the protection of human rights and dignity of persons

with mental disorder with regard to involuntary placement and treatment”, joining other

high-profile human rights bodies. She called for its withdrawal, as it was contrary to the

Convention on the Rights of Persons with Disabilities; that was supported by the World

Network of Users and Survivors of Psychiatry and the International Disability Alliance.

The World Network of Users and Survivors of Psychiatry warned against any reform

initiatives that reinforced the status quo by continuing to place psychiatry and the mental

health system at the centre of power, and stressed the need for an approach that restored,

and was centred on, the voices and rights of persons with psychosocial disabilities.

III. Summary of the proceedings

A. Setting the scene: mental health as a human rights issue

11. The panel, composed of three special rapporteurs, a representative of Transforming

Communities for Inclusion-Asia and a representative of the United Nations Children’s Fund

(UNICEF), referred to the human rights abuses within mental health settings, ranging from

discrimination and stigmatization to overmedicalization and the use of force. All speakers

called for the abolition of those practices and concurred that the right to mental health could

be promoted only in supportive and enabling environments at home, at school, in the

workplace or in health-care settings that addressed the underlying determinants of health,

such as poverty, discrimination, social exclusion and violence, which disproportionately

affected persons with disabilities. All speakers stressed that persons using mental health

services and persons with psychosocial disabilities, including children, women, and those

living in poverty or belonging to other marginalized groups, must be the principal

interlocutors in discussions about their rights, and that States had an obligation to take into

account their opinions in all matters affecting them directly or indirectly, including the

development of mental health services.

12. The Special Rapporteur on the right of everyone to the enjoyment of the highest

attainable standard of physical and mental health, Dr. Dainius Pūras, exposed the pervasive

stigmatization, overmedicalization and use of force that resulted in violations of the human

rights of users of those services and persons with psychosocial disabilities worldwide. He

referred to the deep power asymmetries, the predominance of the biomedical model and the

biased use of knowledge, within psychiatry and mental health, as obstacles to the

realization of rights. He asserted that the status quo was maintained by the concepts of

dangerousness and of medical necessity to “fix a disorder”, which was not supported by

modern evidence and continued to justify the use of non-consensual measures as

“exceptions”.

13. The Special Rapporteur on the rights of persons with disabilities, Catalina Devandas

Aguilar, agreed that coercion and exclusion had become the rule in the majority of mental

health systems, particularly in developed countries, and that involuntary interventions, such

as electroconvulsive therapies, psychosurgery, forced sterilization and other invasive,

painful and irreversible treatments, continued to be permitted, contrary to the Convention

on the Rights of Persons with Disabilities. In that regard, she expressed her opposition to

the initiative of the Council of Europe to draft an additional protocol to the Oviedo

Convention that would serve to legitimize those coercive practices, and called upon

member States of the Council of Europe to stand against it, as it represented an

unacceptable backward step in rights protection. She drew attention to good practices and

tools from within and outside the health system that offered solutions and support in crisis

or emergency situations, which were respectful of medical ethics and of the human rights of

the individual concerned, including of their right to free and informed consent. They

included programmes for personal assistance, psychosocial support and housing, which

reduced the risk of institutionalization and of being subjected to physical and sexual

violence. She recalled that the participation of persons with disabilities themselves was an

essential precondition for development based on human rights.

14. The Special Rapporteur on torture and other cruel, inhuman or degrading treatment

or punishment, Nils Melzer, joined the other special rapporteurs in condemning as unlawful

forced institutionalization and any detention based on disability and noted that it may

amount to torture and ill-treatment. He drew attention to the fact that people with

psychosocial disabilities often lost their legal capacity, causing them to fall below the radar

of legal purview, including within court proceedings, which might result in “voluntary”

institutionalization through the consent of a third party, in being subjected to forced

medication for restraint or punitive purposes, and in other intrusive treatments such as

forced sterilization, abortion, contraception, or electroconvulsive therapy, which might also

amount to torture and ill-treatment.

15. Bhargavi Davar, of Transforming Communities for Inclusion-Asia, drew particular

attention to the situation in the Asia-Pacific region, indicating that the traditional mental

health system and its biomedical approach had been imported through colonial frameworks

(e.g. incapacity laws and guardianship) and had been sustained through the growing trend

of pills and institutions fuelled by pharmaceutical interests. She warned that such practices

and mental health laws had led only to greater violence and violations, through new forms

of coercion and forced institutionalization. She recalled that legal capacity, liberty, equality,

non-discrimination and inclusion were rights belonging to everyone, as enshrined in human

rights instruments, and that the Convention on the Rights of Persons with Disabilities called

for all rights for all persons with disabilities, without exception. She underscored that old

practices led only to old outcomes, and for innovation to emerge, new approaches must be

adopted. She affirmed that reforming mental health and incapacity laws was not enough,

and called for their repeal and for a moratorium on new mental health laws. She cited

examples of emerging practices and called for further support for new community practices,

guidance and pilot programmes for deinstitutionalization, socially innovative caregiving

within communities, and a shift of mentality in all services linked to development and

human rights. She called for persons with psychosocial disabilities to be at the centre of,

and to lead, that transformation.

16. Nina Ferencic, of UNICEF, recalled that mental ill-health was often a direct

consequence of violence, emotional neglect and ill-treatment experienced during childhood,

including due to institutionalization, and that it had a disproportionate impact on children

with disabilities, whose families often lacked information and support to raise their child at

home. She expressed concern about the criminalization, control and policing of mental

health, which had no parallels in other areas of health. She highlighted commonalities with

juvenile justice, where the majority of incarcerated youth had mental health or substance

use disorders and had experienced traumatic victimization, such as physical abuse,

domestic violence or neglect. She pointed to the need to implement approaches that would

reduce incarceration and provide youth with access to a broader range of measures to help

them grow and develop in the community. She suggested working across health, education,

social protection and legal systems and directly with children, youth, parents, teachers, care

providers, schools and communities to raise awareness about mental health and facilitate

support for children.

17. During the interactive dialogue, representatives of Lithuania and of Autistic

Minority International, Support-Fundació Tutelar Girona, Mental Health Europe, Salud

Mental España and Human Rights Watch took the floor. Lithuania welcomed the

consultation and called for continued efforts to be made towards a human rights-based

approach in mental health. The comments and questions that followed touched on: (a) the

fact that the absolute prohibition, in the Convention on the Rights of Persons with

Disabilities, of institutionalization applied equally to autistic children and other people on

the basis of “health” reasons; (b) the need to ensure that all approaches were centred on the

views of people with psychosocial disabilities themselves; and (c) the fact that practices

that were compliant with the Convention could precede and trigger legal reform and should

be encouraged, including through the training of professionals. Echoing the comments of

the Special Rapporteur on the rights of persons with disabilities, representatives of several

organizations expressed opposition to, and called for the withdrawal of, the draft additional

protocol to the Oviedo Convention.

18. In response, the panellists welcomed the support for the paradigm shift,

acknowledged persistent barriers, including traditional psychiatric practices, and called for

laws and attitudes to be changed, as well as for the eradication of detention of children on

the basis of their mental health or any health condition.

B. Improving human rights in mental health through system-wide

strategies

19. Dr. Michelle Funk, of WHO, elaborated on the WHO QualityRights initiative to

advance the human rights-based approach to mental health and the work undertaken by

WHO with countries to: build capacity on human rights and mental health; transform those

systems to promote quality and rights, including by supporting civil society; and support

policy and legal reform that was compliant with the Convention on the Rights of Persons

with Disabilities, particularly in relation to legal capacity, liberty, community inclusion and

the elimination of violence. She emphasized that the QualityRights tools had had a

significant impact in changing attitudes, practices and service delivery — for respect of the

right of the individual to make his or her own decisions, to provide people with information

and choice about treatment options, and to end forced treatment, seclusion and restraint.

She shared results that illustrated reductions in violence, an increased use of support instead

of force, and a reorientation of services towards a recovery approach. WHO was developing

a best practice guide on community services that operated without coercion, supported

recovery, and promoted autonomy and inclusion.

20. Dr. Vincent Girard, of the Agence régionale de santé Provence-Alpes-Côte d’Azur,

described the “Housing First” programme, which had been operating in France for over 20

years, supporting the inclusion of persons with psychosocial disabilities. Although France

had the second-highest mental health budget in Europe, human rights violations persisted:

psychiatric coercion was on the rise (with a 15 per cent increase since the 2011 law reform,

the objective of which was to strengthen the rights of forcibly hospitalized patients), and

nearly 45,000 people with psychosocial disabilities were living in the streets, and 25,000 in

prisons. He explained that the “Housing First” model did not condition access to housing

on the acceptance of care or on restriction of the consumption of drugs or alcohol, that the

person concerned was supported by a team, which included peer workers and was

coordinated by a social worker, and that the psychiatrist was not the one in charge. He said

that the intervention was effective because it focused on all aspects of an individual’s

needs, not on reducing symptoms, and that the results of the programme showed savings in

terms both of resource expenditure and of respect for human rights, by decreasing and

preventing hospitalization. He agreed that scientific research and projects must be used to

inform and reform policy in regard to the misconceptions of dangerousness and of medical

necessity to “fix a disorder”, which were not supported by modern evidence.

21. Dr. Alberto Minoletti, of the University of Chile, provided an overview of mental

health reform in Chile from 1990 to 2018, outlining the main achievements, which had

included increased availability, accessibility and quality of community mental health

services, and social inclusion for persons with psychosocial disabilities. Over the years,

there had been a reduction in the number of inpatient stays in mental health facilities, as

well as a reduction in levels of coercion, abuse and violence within those services. Legal

reform measures had included protection of the right to informed consent for treatment and

research, restrictions on involuntary hospitalization, prohibition of psychosurgery, and the

establishment of a monitoring agency to protect the rights of persons using mental health

services. While challenges remained, those changes had increased inclusion in the

community with comparatively few resources.

22. Dr. Roberto Mezzina, of the Azienda Sanitaria Universitaria Integrata, in Trieste,

described the mental health reform in Italy, which had led to a deinstitutionalization process

involving the closure of psychiatric hospitals (between 1978 and 1999) and forensic

hospitals (in 2017). Law No. 180 of 1978 had recognized human rights as a key tool in

mental health care, which had led to a shift within psychiatry and to the wider provision of

welfare and services in the community, centring on the person rather than the diagnosis.

That approach required proactive and assertive care, rapid responses to crises, open doors,

no restraint, and continuity of care and practices following the principles of choice,

personalization and rights, the objective of which was to promote shared responsibility,

dialogue, recovery, and early support. He described the model operating in the Veneto

region, which had an assessment and emergency unit placed within the general hospital as a

point of first contact, and a home treatment team that applied the principle of open

dialogue. Some 94 per cent of the mental health budget was spent within the community. It

facilitated the tailoring of recoveries in an individual way, within an overarching approach,

which emphasized that liberty was not the outcome of care, but rather a precondition for it.

He highlighted the need to ensure the social determinants of health in order to achieve

equality and overcome exclusion, which included stability in connection with one’s home,

work, income, social support and relationships. He stressed the importance of involving

stakeholders, including service users, fostering therapeutic alliances that respected

individuals’ will and preferences, and prioritizing participation as central to democracy and

social justice.

23. A human rights expert, Dr. Amalia Gamio, referred to the persistent gap in terms of

respect for human rights in the context of mental health care, owing to prejudice and

stigma, which increased the risk of violations such as forced treatment, including forced

sterilization. She remarked that insufficient attention was paid to equal recognition before

the law, as enshrined in article 12 of the Convention on the Rights of Persons with

Disabilities. She called for urgent structural reform, to explicitly prohibit

institutionalization and forced treatment, to develop community-based strategies, and to

ensure resources, capacity-building and monitoring at all levels. She shared a positive

example of cooperation by more than 30 organizations, which had led to the successful

withdrawal of the mental health bill in Mexico because it would have continued to allow

involuntary internments. She commended the Political Constitution of Mexico City, which

explicitly recognized the legal capacity of all individuals and which would come into force

in September 2018.

24. During the interactive dialogue, representatives of the Plurinational State of Bolivia,

of Ecuador, and of civil society — namely the Citizens’ Commission on Human Rights, We

Shall Overcome and Salud Mental España — took the floor. The delegates from the

Plurinational State of Bolivia and from Ecuador shared good practices from their respective

countries to promote human rights in mental health care, which included prioritizing the

quality and accessibility of services within the community, and eliminating social exclusion

through participation in decision-making processes. Speakers reiterated the call to shift

from the biomedical model and deprivation of liberty in mental health care, to increased

focus on the root causes and social determinants to promote a recovery approach. They also

called for increased attention to be paid to the multiple and intersecting forms of

discrimination operating within mental health systems, which had a disproportionate impact

on women with psychosocial disabilities. The representative of We Shall Overcome shared

the example of the introduction of medication-free wards in Norway, an initiative that had

been proposed by user/survivor organizations and was now established as part of the State

health-care system in all regions of Norway. The medication-free alternative did not

threaten community-based inclusion or support, and was aimed at ensuring that persons

could choose and receive support without being subjected to forced drugging, thus

maintaining their agency and self-determination. She emphasized that that measure,

however, could not replace wider legal reform to abolish forced treatment.

25. In response, panellists agreed that more focus was needed to address the social

determinants that had an impact on mental health. Improving access and support were

essential, but the use of force and coercion must simultaneously be addressed to promote

inclusion and a recovery-based approach — including ensuring access to justice and

seeking redress for violations. The changing role of psychiatrists was also raised; they had

an important role to play in developing innovative practices, yet many remained resistant to

the human rights model, which placed the individual at the centre as an expert in his or her

own right. Panellists referred to the need for political will for a human rights-based

approach to be adopted in mental health.

C. Human rights-based services and support to improve the enjoyment of

human rights in the context of mental health

26. Olga Runciman, of Psycovery, introduced the work of the Hearing Voices Network,

a movement working outside of psychiatry in 33 countries. She referred to the case of an

individual to illustrate how psychiatry silenced and dominated by forcing one into a

diagnosed role. The case concerned a woman subjected to treatment and medication

without her consent; no steps had been taken to explore the causes of distress linked to

trauma she had experienced in her past, rather, the focus was on her diagnosis of

schizophrenia and the voices she heard. Ms. Runciman concluded that the Hearing Voices

movement and network allowed individuals to find their own voice, and allowed fellow

voice hearers and peers to help one another find meaning and understanding. The network

encouraged activism and raising public awareness about the harm psychiatry could cause.

27. Dganit Tal-Slor described the experience of the New York social service agency

Community Access, whose mission was to expand opportunities for people living with

mental health conditions to recover from trauma and discrimination and to advocate for

affordable housing, education, vocational training and healing-focused services.

Community Access followed a person-centred approach that promoted self-determination,

harm reduction, recovery, dignity and human rights. It had been instrumental in developing

the peer movement in New York, and in integrating peers as advocates into practically all

programmes on mental health. It had also worked in police precincts to develop crisis

intervention training for police officers to enable them to better understand the challenges

and needs of individuals in crisis. The aim of the agency was to work with the City of New

York to develop mental health teams composed of peers and social workers as first

responders to emergency calls. Furthermore, the agency was working with the City and the

State of New York to develop alternatives to hospitalization and emergency visits, and the

City had initiated “respite centres” run and operated by peers. Ms. Tal-Slor said that most

of the agency’s service recipients lived in poverty, many without food security or homes,

and that the system failed to recognize the need for a holistic approach to supporting and

empowering individuals living with mental health conditions, as the front-line approach

remained medicalization, forced treatment in hospitals, and imposing conditions of

“treatment compliance” for services, including access to housing. She observed that

funding for medication and hospital visits was more easily provided than funding needed

for inclusion in the community through housing and job training.

28. Michael Njenga, of the African Disability Forum, affirmed that article 12 of the

Convention on the Rights of Persons with Disabilities, and general comment No. 1 (2014)

on equal recognition before the law, of the Committee on the Rights of Persons with

Disabilities, identified peer support as a form of supported decision-making for the exercise

of legal capacity. Peer support valued lived experience, as peers held knowledge and

expertise to support others going through difficult times in their lives, and it thus helped

advance autonomy during times of emergency decision-making, and was an integral part of

recovery-based services and inclusion in the community. Mr. Njenga described the work of

Users and Survivors of Psychiatry in Kenya — in documenting peer support as a tool for

supported decision-making, boosting agency and autonomy for individuals as it provided a

safe space for sharing of experiences and information, developing collective knowledge,

and providing advice and support in risk-taking. He said that peer-support group meetings

might entail discussion of day-to-day decisions and decisions with legal and financial

consequences, and that members discussed medication and treatments, were informed about

their human rights and were supported in claiming them (e.g. refusing treatment). He noted

that, over time, members became more assertive about making their own decisions, and

regaining control of their lives as empowered agents, rather than as objects of treatment. He

mentioned the commitment by the Government of Kenya to scale up the operation he had

described, to establish peer-support groups across the country, motivated by the findings of

Users and Survivors of Psychiatry in Kenya.

29. Sashi Sashidharan, of the University of Glasgow, celebrated the paradigm shift

anticipated by the Convention on the Rights of Persons with Disabilities, but regretted that

there had been little progress in the area of mental health. Nonetheless, he argued that all

actors involved could carry out microtransgressions of the current paradigm by engaging in

practices and experiences that challenged it. He described the experience of employing

persons who had real-life experience of mental health problems as part of every community

mental health team, with equal pay, which made a significant difference to integrating peer

support, establishing advanced directives and ensuring choice of treatment. Furthermore,

Governments could set simple targets for services, in order to reduce admissions under their

mental health act. Mr. Sashidharan highlighted the creation of crisis-resolution home

treatment teams, available 24 hours and 7 days a week, to support people in crisis at home,

which had served to decrease the number of compulsory admissions. He commended the

example from Norway on medication-free alternatives. He argued that the most difficult

challenge was to reform the current practice of forensic psychiatry, as there was no

evidence to support its effectiveness, despite 18 per cent of mental health resources being

spent on locking people up in psychiatric care.

30. During the interactive dialogue, representatives of the World Network of Users and

Survivors of Psychiatry, the Indonesian Mental Health Association, the Centre for Inclusive

Policy, Autistic Minority International and We Shall Overcome, and of the Plurinational

State of Bolivia and the United Kingdom of Great Britain and Northern Ireland, took the

floor. The issues raised included: the benefits of peer support detached from the mental

health system; psychiatry as the gatekeeper for access to public services, such as housing;

how to “demedicalize” resources invested in support services in the community that did not

need to be attached to the mental health system; and the need to confront discrimination

against autistic persons based on pathologization and diagnosis leading to prevention

measures and therapies that denied the preservation of and respect for autistic identity. The

Plurinational State of Bolivia addressed concerns about the funding of medicalization, and

about the biomedical perspective, and the United Kingdom stressed the urgent need to

tackle stigma, abuse, forced treatment, and unlawful or arbitrary institutionalization. In the

context of the draft additional protocol to the Oviedo Convention, the withdrawal of

Portugal from that process was commended, and a call was made to other States to follow

that good example for fulfilment of the obligations enshrined in the Convention on the

Rights of Persons with Disabilities.

31. Panellists gave various responses concerning psychiatry as a gatekeeper to services,

emphasizing that psychiatry should be one choice among many. Panellists warned that peer

work organized by psychiatrists risked legitimizing traditional treatment and might remove

power from the peer movement, and emphasized the need for approaches that contributed

to empowering individuals. It was affirmed that the priority should be to ensure autonomy

and dignity, restoring voice, power and choice to persons with psychosocial disabilities, and

also that there was a need to shift from a model of containment to a model of recovery and

inclusion in mental health. Panellists presented positive examples of practices regarding

peer support and peer certification, and observed that peer support helped overcome the

trauma linked to having been forcibly removed from the community (through forced

hospitalization). They noted the positive impact of peer support in liaising with police and

hospital staff to prevent such trauma. Speakers highlighted the lack of research and

evidence about the benefits of force in psychiatry, and the fact that, on the contrary, several

findings documented negative experiences and lasting anger by those subjected to forced

treatment. It was concluded that human rights violations still took place in mental health

settings, which caused inequalities to proliferate, and that that was compounded by

intersecting identities. Any successful reform would require a change of heart within

psychiatric and clinical practice to move beyond the biomedical model of psychiatry.

D. Improving practices to combat discrimination, stigma, violence,

coercion and abuse

32. The panel was composed of representatives of the United Nations Population Fund

(UNFPA), the Joint United Nations Programme on HIV/AIDS (UNAIDS), the International

Committee of the Red Cross (ICRC), Human Rights Watch, and Akershus University

Hospital, Norway. The panellists highlighted the centrality of mental health to general

health, human rights and dignity. All panellists agreed that in order to promote inclusion

and mental health, multiple forms of discrimination and inequality must be addressed —

relating to youth, women, persons living with HIV/AIDS, persons living in poverty,

persons living in rural regions, persons with disabilities including persons with

psychosocial disabilities, and other intersecting identities. The panellists promoted a

people-centred approach to empower communities as agents of change, by including rights

holders in the design and implementation of programmes and services and in the training

for them.

33. Monica Ferro, of UNFPA, emphasized that mental health was a component of

sexual and reproductive health and rights, and that mental health issues could develop due

to lack of choice in reproductive decisions and could arise in connection with the

psychological dimensions of conception, pregnancy, childbirth, post-partum care, and

events relating to abortion, miscarriage, HIV/AIDS and female genital mutilation. She

suggested that mental health should be integrated into all sexual and reproductive health

and rights policies, strategies, programmes and statistics. She referred to the determinants

of mental health, and emphasized that gender discrimination often led to detrimental

impacts on women’s rights; for example, the increased likelihood of women being

subjected to sexual violence linked to the prevalence of post-traumatic stress disorder

suffered by women; women’s higher rates of diagnosis with depression, compared to men

with identical symptoms; and the greater challenges for women in accessing reproductive

health services due to a lack of economic resources.

34. Tim Martineau, of UNAIDS, emphasized that people living with HIV, like other

marginalized and stigmatized groups, faced significant levels of depression linked to the

fear of having their status disclosed, and to accessing treatment. Often, discrimination and

exclusion were exacerbated by other layers of identity, such as race, sexual orientation and

age, leading to further isolation and poorer health outcomes and the added risk of violence

and oppression due to widespread stigma. UNAIDS placed human rights and health at the

heart of its response to AIDS, by concentrating on prevention, treatment and human rights

to fight stigma and discrimination and promote accountability, through a global monitoring

system to which approximately 170 countries reported with indicators on discrimination,

stigma, and community empowerment. UNAIDS also engaged in global advocacy with

other agencies, and supported countries in eliminating stigma and discrimination,

improving monitoring, laws, legal literacy and access to justice, raising the awareness of

lawmakers, and building the capacity of health-care workers to improve quality of care. Mr.

Martineau emphasized the importance of empowering communities as agents of change.

35. Milena Osorio, of ICRC, shared information about the ICRC Mental Health and

Psychosocial Support Unit, designed to assist victims of armed conflict, violence and

disasters. ICRC interventions were implemented in 105 multidisciplinary programmes in 50

countries and provided a comprehensive package of services in a continuum of care to

eliminate stigmatization and discrimination. She specified that her unit supported victims of

torture, families with missing relatives, victims of violence and injured persons. It applied

inclusive and multidisciplinary approaches to its work with the communities and

individuals themselves in designing programmes and providing training to professionals,

and holistic services combining physical and mental health, psychosocial, social and

economic support, and protection.

36. Kriti Sharma elaborated on investigations conducted by Human Rights Watch into

violations of the rights of persons with psychosocial disabilities in over 25 countries

worldwide. Human Rights Watch had found that persons with psychosocial disabilities

routinely experienced stigma and discrimination and often did not enjoy basic human

rights. She called for the repeal of laws and policies that normalized coercion, including

practices of involuntary treatment, electroshock therapy and the use of restraints. She

pointed out that stigma may also be pervasive among officials responsible for protecting the

rights of persons with psychosocial disabilities, and that even where training was provided

on rights and mental health, there was commonly resort to the default response of isolation

and force, due to a lack of understanding of support needs. In order to change the mindsets

of key actors, they needed to witness first-hand the failings of the current system, but also

to become familiar with examples of good practice across all contexts, including

humanitarian situations. She called for strengthened cooperation between representative

organizations of persons with disabilities and mainstream civil society, in order to tackle

multiple and intersecting forms of stigma and discrimination.

37. Peter McGovern shared his experience conducting training for mental health

personnel with the WHO QualityRights initiative, which provided a transformative and

practical framework translating the rights-based and recovery-orientated approaches

enshrined in the Convention on the Rights of Persons with Disabilities into a reality for

services and service users. Training necessarily included representation from all stakeholder

groups, including health professionals and policy advisers, alongside persons with real-life

experience of using services, and entailed engaging in discussions to identify rights denials

in services through analysis of case studies, and exploring barriers to change and how to

overcome them. The QualityRights initiative addressed resistance, engaged participants and

built momentum to support people in a different way. Participants at training sessions

concurred that rights-based approaches not only benefited service users but also service

providers. Mr. McGovern stressed that the training was a call to action and a guide to how

everyday changes could take place, and cited demonstrable changes in attitude to the use of

coercive practices in crisis scenarios and in the respect for the individual’s right to make

decisions for himself or herself after a few days of training. He concluded that the result of

training was a shared ownership of service improvement plans — which opened up

opportunities for wider culture change promoting a shift towards human rights-based

approaches in mental health support.

38. During the interactive dialogue, statements were made by delegates from Australia,

the Plurinational State of Bolivia and Peru, and by representatives of the International

Network Toward Alternatives and Recovery, Mental Health Europe, Disability Rights

International, Salud Mental España, the International Disability Alliance, the World

Network of Users and Survivors of Psychiatry, Human Rights Watch, Autistic Minority

International, the Hearing Voices Network, the Indonesian Mental Health Association and

the Azienda Sanitaria Universitaria Integrata, Trieste. The Peruvian delegate explained the

Government’s commitment to broadening the role of community centres in mental health

care, and the Bolivian delegate stressed that its mental health system also drew on

indigenous healing in the national health service, integrating both into a holistic system.

The Australian delegate spoke of the compounded discrimination for marginalized

populations, such as indigenous peoples and lesbian, gay, bisexual, transgender and intersex

persons, and referred to programmes to reduce stigma in health services by building

awareness and knowledge about the impact of health issues within those communities. Civil

society participants called for the elimination of coercion from mental health services and

for effective legal protection and remedies, keeping rights holders, persons with

psychosocial disabilities, autistic children and adults at the centre of all initiatives, stressing

that their voices must not be substituted by parents or family members who were often

empowered by the law to restrict their rights (through forced contraception of women with

disabilities under guardianship). Good practices were noted, which included precautionary

measures granted by the Inter-American Commission on Human Rights to protect the life

and integrity of institutionalized persons with disabilities, leading to the first orders for their

integration back into the community; the forthcoming international gathering of the

International Network Toward Alternatives and Recovery, in Kenya in 2019, focusing on

dialogue among survivors and users of services, human rights advocates, psychiatrists and

practitioners, to develop non-medical and non-coercive approaches to replace traditional

psychiatry; and the work of Mental Health Europe to compile practices on alternatives to

coercion. The International Disability Alliance warned against the adoption of the draft

additional protocol to the Oviedo Convention and Mental Health Europe commended the

leadership by Portugal against that instrument.

39. In response, the panellists referred to innovative strategies to promote a positive

image of persons with psychosocial disabilities within the media, through awareness-raising

and training to combat negative stereotypes and overcome stigma, as well as to multiply

their voices and ensure that they remained at the centre of all initiatives.

IV. Conclusions and recommendations

40. In closing, the United Nations Deputy High Commissioner for Human Rights,

Kate Gilmore, highlighted the significance of the all-encompassing agenda for

inclusion at the critical intersection of human rights, physical and mental integrity

and the enjoyment of mental health. She thanked, in particular, the advocates and

activists and the persons with real-life experience, who were at the forefront of that

transformative process, observing that rights-based change had always come from the

vision of those whose rights had been denied. It was to them that the work going

forward must be held accountable — to their perspective, views and experience. Ms.

Gilmore underscored that many practices that directly violated the principles and the

intent of rights persisted, such as forced institutionalization, forced treatment, and

criminalization of those with mental health conditions; in those instances, the key

friend of rights — the law — was often the key foe. She condemned the unlawful use

of the law to dominate and discriminate, and its conversion into a threat to the

enjoyment of rights. She concluded by remarking that everyone held the responsibility

of knowledge: change was within reach, it was affordable and it was reasonable, and

she thus called upon all actors to co-design services and work together to create

health-enabling environments.

41. The Special Rapporteur on torture and other cruel, inhuman or degrading

treatment or punishment made concrete recommendations for moving forward. He

stressed the pressing need to abolish legislation that allowed persons with disabilities

to be institutionalized and to ensure regular review of any decision for

institutionalization, including independent monitoring frameworks by human rights

experts, national human rights institutions, national preventive mechanisms, civil

society and international mechanisms. In addition, States must adopt legislation

recognizing the legal capacity of persons with psychosocial disabilities, linked to

community living and support. Thus States should facilitate deinstitutionalization by

introducing social welfare laws and by the provision of various forms of support

services that should be available to persons requiring them. He highlighted the crucial

need for guidelines on free and informed consent and the impact of

institutionalization, on treatment, and on living conditions for persons with

psychosocial disabilities. Furthermore, adequate training and awareness-raising of

prison staff was necessary. He underscored the imperative of recognizing violence and

abuse perpetrated against persons with disabilities as being a form of torture or other

cruel, inhuman or degrading treatment or punishment, in order to afford victims and

advocates stronger legal protection for those violations. He concluded by calling for an

inclusive society to end marginalization and discrimination.

42. The Special Rapporteur on the rights of persons with disabilities highlighted

the strong consensus on the urgent need for change in the area of mental health. The

reigning biomedical model had created an increasing gulf of exclusion of persons with

psychosocial disabilities, leading to the loss of autonomy and independence and to the

entrenchment of forced treatment, violence and forced sterilization. There was a need

for community systems and interventions that were evidence-based and were

respectful of human rights and of the principle of free and informed consent. She

welcomed the growth of good practices, which confirmed that forced treatment and

institutionalization were damaging and unnecessary. She called for greater political

commitment from States to implement the way forward by addressing the social

determinants of mental health, inclusive of, and in collaboration with, persons with

psychosocial disabilities, including through housing support groups, respite care,

personal assistance services and other means. The Convention on the Rights of

Persons with Disabilities and the 2030 Agenda for Sustainable Development provided

the opportunity to build a new narrative based on human rights that fostered

inclusion and not segregation. There could be no sustainable development without

mental health, and mental health without human rights amounted to oppression. She

called upon the United Nations system to internalize the urgent need for change, and

to foster cooperation across agencies and cooperation actors. She affirmed that the

mental health agenda could not move forward when it continued to ignore the human

rights of persons with psychosocial disabilities.

43. The Special Rapporteur on the right of everyone to the enjoyment of the

highest attainable standard of physical and mental health noted that the consultation

had demonstrated that there was agreement on the root causes of the failure of the

system, and on the required actions to address those challenges: eliminating force and

biomedical interventions, which led to violations of human rights and bred

hopelessness for service users and for service providers who were “forced to use

force”. To promote mental health, the individual should be in healthy and respectful

relationships, including between service providers and users, and forced measures

impeded that. He stressed the need for all stakeholders to work together and

understand that the best way to promote mental health was to fully integrate the

human rights-based approach and foster relationships in all settings. He concluded by

stating that the future was a win-win situation for everyone — including psychiatrists,

who should let go of the monopoly of power and share responsibility — with stronger

commitment by States, and led by a rising critical mass of empowered users.

44. In light of the discussions, the following recommendations were proposed.

45. States should re-examine the biomedical approach to mental health, which

maintains the imbalance of power between practitioners and users of mental health

services, through a collective process that includes all stakeholders. Users of mental

health services, persons with mental health conditions and persons with psychosocial

disabilities should play a leading role in developing the conceptual framework that

determines mental health services, and in their design, delivery and evaluation.

46. States should ensure that all health care and services, including all mental

health care and services, are based on the free and informed consent of the individual

concerned, and that legal provisions and policies permitting the use of coercion and

forced interventions, including involuntary hospitalization and institutionalization,

the use of restraints, psychosurgery, forced medication, and other forced measures

aimed at correcting or fixing an actual or perceived impairment, including those

allowing for consent or authorization by a third party, are repealed. States should

reframe and recognize these practices as constituting torture or other cruel, inhuman

or degrading treatment or punishment and as amounting to discrimination against

users of mental health services, persons with mental health conditions and persons

with psychosocial disabilities. States should ensure their enjoyment and exercise of

legal capacity on an equal basis with others by repealing laws that provided for

substituted decision-making, and should provide: a range of voluntary supported

decision-making mechanisms, including peer support, respectful of their individual

autonomy, will and preferences; safeguards against abuse and undue influence within

support arrangements; and the allocation of resources to enable and ensure the

availability of support.

47. States should implement people-centred and human rights-based support and

services, including on mental health, which are community-based, participatory and

contextually and culturally respectful and which enable and facilitate participation in

society. These services should be available in the communities where people live,

ensuring that their family and personal networks are not jeopardized but are

promoted and strengthened. States should evaluate multiple strategies for the

implementation of such services, building partnerships with users, including user-led

services, such as peer support, and should make available accessible services offering

non-coercive spaces, support and respite, including during crisis situations, for

example medication-free spaces.

48. States should strengthen data-collection efforts and undertake and invest in

evidence-based and participatory research, inclusive of users of these services and of

persons with psychosocial disabilities, in order to: identify the multiple and

intersecting forms of discrimination operating in the context of mental health and

evaluate the impact of services; and design and make available accessible and

affordable non-coercive spaces, support and respite, respectful of the individual’s free

and informed consent. International cooperation actors should be encouraged to

provide funding and technical assistance to fulfil these efforts, and to refrain from

implementing or supporting projects or research contravening the Convention on the

Rights of Persons with Disabilities.

49. States should revise and adopt legislation to combat stigma and discrimination

against users of mental health services, persons with mental health conditions and

persons with psychosocial disabilities. States should implement training programmes,

such as the WHO QualityRights initiative, to build capacity among mental health

professionals, practitioners and policymakers on how to implement a human rights-

based and recovery approach in accordance with the Convention on the Rights of

Persons with Disabilities. Complementary to this, States should design and implement

information campaigns and programmes to raise community awareness, in order to

eliminate negative stereotypes, labelling, stigma and discrimination against users of

mental health services, persons with mental health conditions and persons with

psychosocial disabilities, with their central involvement in the design and delivery

across training and awareness-raising programmes.

50. States should ensure that users of mental health services and persons with

psychosocial disabilities have access to justice, including through maintaining their

legal capacity within proceedings to challenge human rights violations in mental

health contexts, and ensure that redress and reparation is provided for the individual

while addressing systemic change through legal and policy reform and capacity-

building.

51. States should design and implement policies and programmes addressing the

underlying determinants of mental health — among others, multiple and intersecting

forms of discrimination, the right to social protection, access to housing and water and

sanitation, the right to work, and the right to live independently and be included in

the community.

52. States should adopt immediate steps towards deinstitutionalization, by

developing action plans in a participatory manner, and using the maximum of their

available resources, including through international cooperation. States should

recognize in the law the right to access support services to enable independent living

and inclusion in the community, and ensure that support is provided and arranged

according to the individual’s will and preferences. Deinstitutionalization plans should

incorporate the development of support services in the community that do not

replicate biomedical or coercive approaches.

53. Given that, throughout the consultation, participants expressed their concern

about the ongoing process within the Council of Europe to draft an additional

protocol to the Convention for the Protection of Human Rights and Dignity of the

Human Being with regard to the Application of Biology and Medicine (the Oviedo

Convention), indicating that the draft additional protocol on “the protection of human

rights and dignity of persons with mental disorder with regard to involuntary

placement and treatment” contradicted the Convention on the Rights of Persons with

Disabilities, member States of the Council of Europe should evaluate the potential

impact of the adoption of this instrument vis-à-vis their international obligations

under the Convention on the Rights of Persons with Disabilities and other human

rights law, specifically regarding the individual’s right to free and informed consent to

treatment within mental health services. All States parties to the Convention on the

Rights of Persons with Disabilities should undertake a review of their obligations

before adopting legislation or instruments that may contradict their obligations to

uphold the rights of persons with disabilities.

Annex

List of participants

States Members of the Human Rights Council

1. Australia, Brazil, Chile, China, Croatia, Ecuador, Germany, Hungary, Japan,

Mexico, Panama, Peru, Slovakia, Slovenia, Spain, Switzerland, Togo, Ukraine, United

Kingdom of Great Britain and Northern Ireland, Venezuela (Bolivarian Republic of).

States Members of the United Nations

2. Bolivia (Plurinational State of), Bulgaria, Canada, Colombia, Cyprus, France,

Gabon, Greece, Israel, Italy, Lithuania, Luxemburg, Maldives, Monaco, New Zealand,

Norway, Poland, Portugal, Romania, Thailand, Turkey.

Intergovernmental organizations

3. European Union (EU), International Committee of the Red Cross (ICRC),

International Labour Organization (ILO), Parliamentary Assembly of the Council of

Europe, United Nations Population Fund (UNFPA), United Nations Children’s Fund

(UNICEF), World Health Organization (WHO).

Non-governmental organizations in consultative status with the Economic and Social

Council

Special

4. Association for the Prevention of Torture (APT), CERMI Spanish Committee of

Representatives of People with Disabilities, Disability Rights International, Du Pain Pour

Chaque Enfant, Fundacion Vida — Grupo Ecologico Verde, International Disability

Alliance, Users and Survivors of Psychiatry in Kenya (USP-K), World Network of Users

and Survivors of Psychiatry (WNUSP).

Other non-governmental organizations

African Disability Forum (ADF), Autistic Minority International, Akershus University

Hospital, Azienda Sanitaria Universitaria Integrata Trieste — ASUITs, Citizens

Commission on Human Rights, Centre for inclusive Policy, CEPGL, Citizens Commission

on Human Rights Europe, Contrôleur général des lieux de privation de liberté, Indonesian

Mental Health Association, International Network toward Alternatives and Recovery,

Mental Health Europe, Psycovery, Salud Mental España, SHI Swiss Health Invest, Support-

Fundació Tutelar Girona, The Global Campaign for Mental Health, Transforming

Communities for Inclusion Asia, Universidad de Chile, University of Glasgow, We Shall

Overcome.