Why Does Mental Health Need a Human Rights Approach

Thomas Szasz, one of the most vocal proponents of the anti-psychiatry movement, in his book The Myth of Mental Illness passionately argues that the notion of mental illness is a myth, falsely equated with physical illness or disease. Instead, he argues that what are considered as ‘mental illnesses’ are actually “problems in living” since for most people life is a continuous struggle, not for their biological survival, but their personal and social troubles.

Mental health problems are a response to life’s adversities which are rooted in our social, cultural and economic contexts which profoundly shape our identities, experiences and overall well-being. Existing evidence points to the role of discrimination, social oppression, poverty, unemployment, and violence in causing distress. Mental health problems are then, most often, individuals’ idioms of responding and adapting to these adversities with the internal and external resources available to them.

However, mental healthcare, for much of history, has been driven by an approach which centres the biology and psychology individuals as the basis of any engagement with mental health problems. This approach, manifesting as the bio-medical model, has traditionally focussed solely on ‘curing’ or ‘fixing’ the individual, while ignoring the wider contexts which give rise to mental health problems. It gives primacy and power to mental health ‘experts’ and ‘professionals’ who are usually trained in applying paternalistic models of care and treatment which are concerned more with ‘symptoms’ and less with the individual’s personhood and life-world. It leaves little to no agency for individuals to direct their own journeys of care, treatment or recovery which focus on leading a fulfilling life despite one’s mental health problems.

Persons with mental health problems (also referred to as persons with psychosocial disabilities), constitute one of the most marginalised groups in society. They are subjected to human rights violations, discrimination, poverty, premature mortality, and increased risk to violence. Legal systems across the world, including India, continue to deny persons with severe mental health problems basic rights such as entering into contracts, inheritance, marriage, voting, making one’s own healthcare decisions, and so on. These human rights violations are based on the unscientific and stigmatising belief that persons with mental health problems are not ‘rational’ and don’t possess the ability to make the ‘right’ decisions for themselves. On the contrary, research indicates that human beings are naturally inclined to make irrational decisions, which are, quite often, not necessarily the best decisions for them.

Our mental health systems prioritise medical treatment, failing to recognise that persons with mental health problems may often require social support designed specifically for their needs, to enable living and participation in their communities, and making everyday decisions to exercise their rights as any one else. Mental health professionals and institutions continue to force treatments on unwilling and uninformed patients, emphasise medication, use coercive treatment methods and prolong long-stay admissions.

In India, an estimated 197 million people are living with mental health problems, yet anywhere between 70 to 90 % do not have access to the care they need, creating a huge mental healthcare gap. Reasons for which range from unaffordability of mental healthcare, inadequate mental health resources, near absence of community-based services and poor quality services which do not abide by a rights-based approach.

The rights-based approach advocates for a radically different model, in which persons with mental health problems are no longer at the receiving end of a chain of treatment related decisions; instead, they are entitled to their own understanding and narrative of wellbeing, are active collaborators in all discussions concerning them, and have the right to integrate in mainstream society as equal participants in all domains.

The rights-based approach places obligations on duty bearers in the mental health system, such as governments, mental health professionals, law enforcement officials, employers and organisations, to enforce laws, policies and practices which protect the rights of persons with severe mental health problems. Simultaneously, it also creates space for prioritising community-led mental healthcare, in which communities take ownership of their mental healthcare, not only defining what wellbeing means for them, but also becoming active collaborators in designing and establishing community-based care suited to their contexts.

Finally, this model upholds the right of people with psychosocial disabilities to hold mental health practitioners and service providers, whether in the private or public realm, accountable to the standards of human rights, and having legal mechanisms to address complaints of rights violations.

The continued marginalisation of persons with disabilities (including psychosocial disabilities) across the world and the failure of existing international laws to protect their rights, led to various voices from the disability rights movement demanding for a new international legal framework to specifically address the needs of this heterogeneous group by placing duties on countries across the world.

This led to the adoption of the United Nations Convention on the Rights of Persons with Disabilities (UNCRPD), an international treaty formalising the demands of the disability rights movement through a global legal framework for protecting, promoting and fulfilling the rights of persons with disabilities. India’s ratification of the UNCRPD has provided huge momentum for radical changes in how we understand and envision mental healthcare in India.

This can be seen in the recently enforced Mental Healthcare Act, 2017 and the Rights of Persons with Disabilities Act, 2016 which adopt a rights-based approach to address the specific needs of persons with mental health problems (both in terms of their access to quality mental healthcare and protection of socio-economic rights).

However, while we continue to address challenges in implementing these legislations, we are faced with the challenge of re-envisioning the rights-based approach to mental healthcare in India’s context, given the relationship between mental health and a society with a deep rooted history of inequality and structural discrimination.

In this context, we are faced with some crucial questions: how do we implement, evaluate and scale-up evidence-based interventions that support rights-based approaches to mental health care in the context of India’s wide inequalities along the lines of caste, class, sexuality, gender, and other social determinants? How do we shift the focus of our interventions away from just the individual – where the problems are experienced – to the society at large – where the problems originate? How do we expand our idea of mental health as inextricable from the realisation of all other rights both in the private and public realms?

History has taught us that looking at different forms of discrimination in silos has led to a dangerously incomplete understanding of any form of discrimination. This could not be truer for mental health, which is integral to the very idea of social justice.

Arjun Kapoor and Jasmine Kalha are Programme Managers and Research Fellows, and Manasa Veluvali was an Intern at the Centre for Mental Health Law and Policy, ILS, Pune.

Curated by the Centre for Mental Health Law and Policy