Why a rights-based approach is not anti-psychiatry

In a recent ‘Debate’ article, Dharmawardene and Menkes (2018) criticize the 2017 Report of the Special Rapporteur on the ‘right of everyone to the enjoyment of the highest attainable standard of physical and mental health’ (UN Human Rights Council, 2017). While praising the Report for drawing attention ‘to the pernicious problem of human rights abuses of the mentally ill’, they conclude that it is imbalanced and ideologically biased against biomedical approaches (p. 1). To facilitate discussion and debate about how best to integrate a rights-based discourse into mental health policy and practice, we list their three main criticisms below and offer the following responses.

The Report is ideologically biased and anti-psychiatry

Positioning those who ask challenging questions about ‘scaling up’ mental health efforts as anti-psychiatry risks further polarizing an already contentious debate about the allocation of resources and undermines an important opportunity for constructive dialogue on areas of disagreement. For example, Dharmawardene and Menkes make several straw man arguments: they state ‘In a striking example of ideological bias, the Report views inpatient psychiatric care as inconsistent with the principle of doing no harm’ (p. 1). However, the quote in context reads: ‘Overreliance on pharmacological interventions, coercive approaches and in-patient treatment is inconsistent with the principle of doing no harm, as well as with human rights’ (emphasis added; UN Human Rights Council, 2017: 13).

Moreover, Dharmawardene and Menkes conflate in-patient treatment with forced treatment/coercion. The Special Rapporteur is both identifying a critical problem—inappropriate overreliance on segregated and coercive practices—and acknowledging the experiences of those most affected by the policies and practices of the global mental health movement. Respecting the autonomy of persons with mental disabilities necessitates ‘our own emancipation from institutional thinking and practice’ (Mezzina et al., 2019).

As further support of a purported anti-psychiatry bias, Dharmawardene and Menkes state that ‘a meta-analysis cited as evidence of the general inefficacy of psychotropics in fact applies only to antidepressants and mainly reflects the predominance of the placebo effect in mild-moderate cases in wealthy countries’ (p. 1). However, the Report is explicit that the concern is about overuse of ‘antidepressants, specifically for mild and moderate depression’ (p. 6), which is not only an issue in wealthy countries.

Similarly, they criticize ‘The Report’s assertion that biological psychiatry violates human rights’ as being ‘an alarming distraction from enduring deficits in treatment availability in the developing world’ (p. 1). In fact, the Report notes, ‘a biomedical component remains important’ (UN Human Rights Council, 2017: 17). Criticisms are always about the misuse of the biological paradigm (e.g. ‘the abuse of biomedical interventions, including the inappropriate use or overprescription of psychotropic medications and the use of coercion and forced admissions, compromise the right to quality care’, p. 6). The Report does not seek to eliminate biological psychiatry, but to find an ‘equilibrium between the … extremes of the twentieth century’ (p. 4).

There is too much emphasis on psychosocial interventions and a lack of recognition that the main issue is access to care

Dharmawardene and Menkes maintain that ‘The Report focuses repeatedly on biological versus psychosocial models of care, when the fundamental issue for many is access to any sort of care’ (p. 1). In contrast to this criticism, the Report acknowledges that access to care is a critical issue (e.g. ‘Certainly, many people are in need of mental health services and often they do not have access to them’, p. 19). Thus, psychosocial treatments are not pitted against biological ones, nor does the Report make simplistic claims about psychosocial causation, noting that, ‘discrimination and inequality are both a cause and a consequence of poor mental health’ (UN Human Rights Council, 2017: 11). Rather, the Special Rapporteur’s focus is on the need to critically evaluate—both empirically and epistemologically—efforts to ‘scale up’ mental health services and encourage more inclusive participation from indigenous communities. For example, methodologically rigorous epidemiological data suggest estimates of depression are unreliable and likely exaggerated. Brhlikova et al. (2011) found poor concordance with criteria for Global Burden of Disease (GBD) estimates. (These are calculations of disease burden derived from epidemiological estimates of life-years lost and life-years lived with disability.) They concluded, ‘[T]he uncritical application of these estimates to international healthcare policymaking could divert scarce resources from other public healthcare priorities’.

Relatedly, the stance of the Report is not anti-medication:

While psychotropic medications can be helpful, not everyone reacts well to them and in many cases they are not needed. Prescribing psychotropic medications, not because they are indicated and needed, but because effective psychosocial and public health interventions are not available, is incompatible with the right to health. (p. 18)

The Report lacks balance and leadership

Although the Report is criticized for ‘[F]ailing to provide the balance and leadership required to address the vast global burden of untreated mental illness’ (p. 2), it actually recognizes the leading role that professional psychiatry could play by championing reform efforts. Thus, the focus and intent of the Report is to include the voices of those most affected by global mental health policies, to provide a thoughtful challenge to the hegemony of the disease burden framework and to offer suggestions for reform. Advocating for a ‘global burden of obstacles’ approach (i.e. one that attends to structural issues such as poverty, discrimination and gender-based violence) is well-reasoned and congruent with the social determinants of health framework. It also represents the exact type of leadership we need in order to develop a robust rights-based approach to mental health. For example, the Special Rapporteur notes that a particular concern is the growing prevalence of mental health tribunals, which instead of providing a mechanism for accountability, legitimize coercion and further isolate people within mental health systems from access to justice (p. 12). Indeed, the Report identifies what is needed to reconceptualize the right to health as a component in a fulfilling life rather than simply as a component in an economic equation (e.g. disability-adjusted life years; see MacNaughton and Frey, 2018).

Conclusion

[There is an] important connection and balancing point between the right to adequate care and the right to all fundamental human rights. It is not a matter of ‘this or that’ but of the rights to both. (Mezzina et al., 2019)

There is agreement from a wide variety of stakeholders that we must commit to viewing mental health through a human rights lens. Enhancing this commitment means that mental health professions must be on the forefront of advocacy efforts even when doing so challenges institutional thinking and runs counter to our guild interests (Gill, 2019). The UN has endorsed the Convention on the Rights of Persons with Disabilities (CRPD), especially the right for all people to participate fully in society. As Mezzina et al. note, there are competing priorities and different sets of rights to consider when determining how various articles of the CRPD should be interpreted, none of which will be easy to resolve. However, genuine advocacy for a human rights discourse in mental health requires sustained efforts to facilitate difficult dialogues and avoid further polarization. We hope that our response to the commentary by Dharmawardene and Menkes will contribute to those efforts.