Is the UN Convention on the Rights of Persons with Disabilities Impacting Mental Health Laws and Policies in High-Income Countries? A Case Study of Implementation in Canada

A quantitative analysis of human rights-related attitude changes towards people with mental health conditions and psychosocial, intellectual, or cognitive disabilities following completion of the WHO QualityRights e-training in Ghana

BACKGROUND

Despite growing recognition of essential human rights, people with mental health conditions and psychosocial, intellectual, or cognitive disabilities' rights are known to be frequently violated in mental healthcare worldwide, with common use of coercive practices and limited recognition of people's right to exercise their legal capacity and make decisions for themselves on treatment and other issues affecting them. To tackle this issue, Ghana adopted the WHO QualityRights Initiative in 2019. This aims to introduce a right-based, person-centred recovery approach within the mental health care system, protecting and promoting the rights of people with mental health conditions, psychosocial, cognitive, and intellectual disabilities in the healthcare context and community.

METHODS

E-training (capacity-building) was provided in Ghana across a broad array of stakeholder groups including healthcare professionals, carers, and people with lived experience. The training covered legal capacity, coercion, community inclusion, recovery approach, service environment, and the negative attitudes commonly held by stakeholder groups; it was completed by 17,000 people in Ghana as of December 2021. We assessed the impact of the e-training on attitudes through comparing trainees' pre- and post-questionnaire responses on 17 items, each measured on a 5-point Likert scale (strongly disagree to strongly agree), such that higher scores indicated negative attitudes towards persons with mental health conditions and psychosocial disabilities as rights holders. Analyses were conducted on two main groups: matched pairs (417 pairs of baseline and follow-up questionnaire responses matched to a high degree of certainty), and the unmatched group (4299 individual completed questionnaire responses).

RESULTS

We assessed the impact of the WHO QualityRights e-training on attitudes: training resulted in highly significant attitude changes towards alignment with human rights, with scores changing by approximately 40% between baseline and follow-up. In particular, attitude changes were seen in items representing treatment choice, legal capacity, and coercion. This change was not affected by age, gender, or background experience.

CONCLUSIONS

The QualityRights e-training programme is effective in changing people's (especially healthcare professionals') attitudes towards people with mental health conditions and psychosocial, intellectual, or cognitive disabilities: this is a step towards mental healthcare being more with human rights-based worldwide.

Human rights in mental healthcare; A review of current global situation

The relationship between mental health and human rights is complex and bidirectional. Global mental health movements have been emphasizing the promotion of human rights in mental health care in accordance with the UN Convention on the Rights of Persons with Disabilities and the WHO QualityRights Initiative. The main objective of this review is to have an overview of the current global situation of human rights in mental health services by performing a review of scientific literature. The literature search and elimination process yielded a total of 26 articles focussing on human rights-related reports and tools. Further assessment of these articles clearly shows that despite significant improvements in mental health service delivery in the past decade, there is still substantial reporting of the continuing prominence of stigmatizing attitudes, and human rights violations and abuses in mental health settings. The human rights perspective requires society, particularly policymakers, to actively promote necessary conditions for all individuals to fully realize their rights. We suggest developing a more comprehensive model in mental health that integrates human rights into existing services and approaches. A model that recognizes that all people with mental health conditions and psychosocial disabilities are rights holders.

Best interests, benefit, will and preference: The influence of international human rights and external actors on decision-making frameworks in the United Kingdom and Ireland

This article examines the development of the law relating to decision-making on behalf of adults that lack capacity in Scotland, Ireland and Northern Ireland. Using two points of tension evident in the recent Northern Irish legislative consultation process, namely the suitability of the 'best interests' standard and international debate regarding domestic compliance with the United Nations Convention on the Rights of Persons with Disabilities (United Nations, 2006) this contribution exposes the impact of international human rights and influence of external actors, principally advocacy groups and their individual members, on the resulting legislation. Given the recency of the Irish and Northern Irish legislation and the current law reform review in Scotland, the article concludes by highlighting points of tension that may emerge between domestic standards for decision-making and the CRPD.

Crisis Response as a Human Rights Flashpoint: Critical Elements of Community Support for Individuals Experiencing Significant Emotional Distress

This paper proposes a set of nine critical elements underpinned by human rights principles to support individuals experiencing a serious crisis related to mental health problems or psychosocial disabilities. These elements are distilled from a range of viable alternatives to traditional community mental health approaches and are linked to a normative human rights framework. We argue that crisis response is one of the areas of mental health care where there is a heightened risk that the rights of service recipients may be infringed. We further make the case that the nine critical elements found in advanced mental health care models should be used as building blocks for designing services and systems that promote effective rights-based care and supports.

A Key, Not a Straitjacket: The Case for Interim Mental Health Legislation Pending Complete Prohibition of Psychiatric Coercion in Accordance with the Convention on the Rights of Persons with Disabilities

The practice of coercion on the basis of psychosocial disability is plainly discriminatory. This has resulted in a demand from the Committee on the Rights of Persons with Disabilities (the CRPD Committee) for a paradigm shift away from the traditional biomedical model and a global ban on compulsion in the psychiatric context. However, that has not occurred. This paper considers conflicting pronouncements of the CRPD Committee and other United Nations bodies. Assuming the former's interpretations of the Convention on the Rights of Persons with Disability (CRPD) are accurate, involuntary psychiatric detention and enforced treatment on the basis of psychosocial disability are prima facie discriminatory and unlawful practices. However, dedicated mental health legislation both permits discrimination and protects and enhances rights. This paper proposes a practical way out of the present impasse: the global introduction of interim "holding" legislation lacking full compliance with the CRPD. While imperfect, such a framework would facilitate a move toward a complete ban on psychiatric coercion. The paper outlines four essential ingredients that any interim legislation ought to contain, including clear timebound targets for full CRPD implementation. It concludes by urging the CRPD Committee to take the unprecedented step of issuing a general comment providing reluctant "permission" for the progressive realization of respect for articles 12 and 14 of the CRPD.

Supported decision making for people with mental health disorders in clinical practice: a systematic review

Objectives: The Convention on the Rights of Persons with Disabilities (CRPD) was adopted at the United Nations Assembly in 2006. The main aim of the convention is to ensure equal rights for people with disabilities including the expression of people's own "will and preferences" concerning health treatment. Article 12 demands the respect of a person's "rights, will and preferences" (CRPD) and suggests supported decision making (SDM) when possible. The aim of this review was to gather information regarding the SDM implementation from a clinical perspective for people with mental health disorders.Methods: A systematic literature search was performed on electronic databases MEDLINE, PsycARTICLES, and PsycINFO using the keywords "supported decision making" and "UN convention on the rights of persons with disabilities" in March 2018.Results: Eleven articles were included in the final review, which focussed on three themes: (1) different models of SDM, (2) stakeholder views, and (3) challenges for implementation. A limited number of papers described clinical models that had good theoretical consistency with SDM. The main challenges of implementation related to critical situations when "will and preferences" are poorly understood or appear contradictory. Future studies should assess specific models of SDM implementation, including related outcomes and process measures.

Gendered denials: Vulnerability created by barriers to legal capacity for women and disabled women

This article explores the vulnerability that is created when legal capacity is denied to women and disabled women. It argues that vulnerability is largely contingent on social constructs - as opposed to being an inherent quality of disability or gender. It discusses barriers to the exercise of legal capacity that women and disabled women experience - such as limitations on reproductive choice, higher rates of substituted decision-making, and unique experiences with forced mental health treatment. It then explores evidence that such barriers are disempowering and can leave women and disabled women vulnerable to abuse and marginalisation. It explores financial, physical and sexual abuse that can occur as a result of this vulnerability. Finally, it concludes that autonomy and power are inextricably linked and can be essential for minimising vulnerability.

Public attitude towards restrictions on persons with mental illness in greater Hanoi area, Vietnam

BACKGROUND AND AIMS

In recent years, there has been a growing awareness of the need to protect human rights in psychiatry. Within the last years, considerable effort has been made to reduce restrictive measures in mental health settings. Reducing restrictive measures within mental health care has also moved increasingly into the focus of public debate. This study aims, for the first time in a Southeast Asian sample, to explore whether socio-demographic factors affect public attitudes toward restrictions on mentally ill people in Hanoi, Vietnam.

METHODS

A general population-based survey (self-report questionnaire) was carried out in 2013 in the greater Hanoi area. The survey sample ( N = 813) was recruited according to the latest published census (2009) and micro-census (2013) in Vietnam and Hanoi with regard to the socio-demographic factors gender, age, urbanity, household size and marital status. Multinomial logistic regressions for odds ratios with 95% confidence intervals were calculated to examine the influence of epidemiological variables, like gender and age, on the public attitude toward restrictions imposed on mentally ill people in Vietnam.

RESULTS

This study found, for the first time in a large Vietnamese sample, that gender and age were associated with public attitudes toward restrictions on mentally ill people. In detail, significantly fewer men endorsed compulsory admission to a hospital and abortion than Vietnamese women. In addition, endorsement of abortion was significantly higher in older people.

CONCLUSION

The results offer some insight into roles of women in the Vietnamese society and might reflect the traditional gender expectations in Vietnamese families. Moreover, the results emphasize the need for supporting female psychiatric patients and their families within their communities and in the Vietnamese society.

Canada's global health role: supporting equity and global citizenship as a middle power

Canada's history of nation building, combined with its status as a so-called middle power in international affairs, has been translated into an approach to global health that is focused on equity and global citizenship. Canada has often aspired to be a socially progressive force abroad, using alliance building and collective action to exert influence beyond that expected from a country with moderate financial and military resources. Conversely, when Canada has primarily used economic self-interest to define its global role, the country's perceived leadership in global health has diminished. Current Prime Minister Justin Trudeau's Liberal federal government has signalled a return to progressive values, driven by appreciation for diversity, equality, and Canada's responsibility to be a good global citizen. However, poor coordination of efforts, limited funding, and the unaddressed legacy of Canada's colonisation of Indigenous peoples weaken the potential for Canadians to make meaningful contributions to improvement of global health equity. Amid increased nationalism and uncertainty towards multilateral commitments by some major powers in the world, the Canadian federal government has a clear opportunity to convert its commitments to equity and global citizenship into stronger leadership on the global stage. Such leadership will require the translation of aspirational messages about health equity and inclusion into concrete action at home and internationally.

Likely impact of the UN Convention on disability on mental health services

PURPOSE OF REVIEW

After a large majority of UN member states ratified the Convention on the Rights of Persons with Disabilities (UNCRPD), this article aims to provide an overview of its implementation and possible effects in the area of mental health services in individual contract states.

RECENT FINDINGS

This article looks at the implementation processes of the UNCRPD in individual industrialized, emerging and developing countries. In addition to changes in national legislation, potential influences on the supply and support systems for persons with mental illness are considered. Positive approaches and efforts are described. Difficulties and barriers that could be responsible for the long process of implementation of the UNCRPD are described, and so is the restructuring and development of adequate supply and support systems in the area of mental healthcare in industrialized, emerging and developed countries.

SUMMARY

The UNCRPD is a groundbreaking encouragement for various changes in the area of mental health services. The path to subject orientation and individual support structures is long and slow in all countries - in industrialized, emerging and developed countries. National law and health legislation must be adjusted and developed to create an obligatory context for inclusive services required for persons with mental illnesses. Community-based care is prioritized, and this facilitates participation and inclusion.