mental health policy and service development …...mental health policy and service development...

Mental Health Policy and Service Development Department of Mental Health and Substance Abuse

Paris, March 2016

The context • Inhuman and degrading

conditions in facilities

• Violence and abuse

• Denial of right to exercise legal capacity (make decisions for themselves)

• Discrimination in education, employment, social welfare, housing

• Denial of civil and political rights

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The context People with mental health conditionsexperience wide ranging discrimination and human rights violation In the health care context Conditions inhuman, harmful and degrading Practices harmful – restraints, locked up in cells, physical & sexual abuse, neglect, no informed consent, no dignity, no respect People are severely restricted in exercising legal capacity –making decisions on all aspects of their lives (medical treatment, financial affairs, personal affairs, where they want to live etc). In the community – discrimination denied opportunities to an education, to employment, to housing and social services. Denial of civil and political rights (vote, marry, have children in some countries).

UN Convention on the Rights of Persons with Disabilities (CRPD) 2006

• First international human rights treaty of the new millennium • Protects and promotes the rights of all persons with disabilities,

including persons with mental and intellectual impairments • Sets out a full range of, civil, cultural, economic, political, and

social rights • Legally binding & requires countries to adopt all appropriate

legislative, administrative and other measures for the implementation of rights in CRPD

• As of January 2016, Convention has been ratified by 161 Member States

France ratified the Convention in 2010

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But when the CRPD was adopted in 2006 it set a new paradigm for how people with disabilities, including people with mental disabilities, should be viewed and treated. Note: CRPD was adopted by Gen Assembly 2008 It came into force in 2008.

CRPD Paradigm Shift

Changing perceptions, attitudes, and approaches towards persons with disabilities from

Objects of charity

Paternalism

Burden on society

Subjects with rights

Autonomy

Contributing members of society

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The CRPD aims to bring about a paradigm shift in perceptions, attitudes and approaches towards persons with disabilities, from: Being viewed as 'objects' of charity or objects of medical treatment or people to be pitied to - being viewed as people who have rights on an equal basis as everyone else. Away from Paternalistic model (where people need to be 'taken care of' and 'protected') to one based on autonomy and empowerment, where persons are recognized as capable of making decisions about their lives, their personal and financial affairs, their medical treatment, where they want to live etc. persons with disabilities no longer ‘treated’ as a burden on society – but active members of their communities with many things to contribute

Key CRPD Principles

• Legal capacity

• Autonomy and recovery

• Supported decision-making

• Independent community living

• Participation

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Legal capacity: Principle that people with mental disabilities have the right to exercise their legal capacity on an equal basis with everyone else. People with disability must be seen as people who are capable in all respects; capable to make decisions about treatment matters, financial decisions, personal affairs, where they want to live and so on. Another key principle is that of autonomy and recovery People must be encouraged to participate in their own treatment and recovery program, to set their own goals and to take responsibility for their recovery as well as learn new knowledge and skills to help themselves stay well. Supported decision making should also guide mental health reform: This means helping and supporting people to make decisions during times where their capacity may be reduced, as opposed to taking away their right to make decisions altogether (eg. allowing people with mental disabilities to nominate a trusted person or people who can help them to understand the choices and options available to them, and communicate their choices and preferences where necessary.) Independent community living is another key principle: A full range of community based services must be established, not only in health but also social welfare, housing, employment and education, so as to enable people to have the skills, income and supports to live independently and be included in their communities. Participation: requires that we embrace the knowledge, experience and expertise of people with mental disability and use it to inform the development and implementation of mental health laws, policies, plans and services.

WHO QualityRights Objectives

Assess and improve the quality and human rights conditions in inpatient and outpatient mental health facilities

Build capacity among people with mental health conditions, families and health workers to understand and promote human rights

To support efforts to develop civil society movement of people with mental health conditions and families

Reform national policies and laws in line with best practice and international human rights standards

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QualityRights was launched in 2012 (in New York)

Improve the quality of services and human rights conditions in inpatient and outpatient mental health services

– Assessment using the QualityRights Toolkit

– Feedback and discussion on the results

– Collaborative development of improvement plans (involving users, health staff and families

Objectives 1

Build capacity among people with mental health conditions, families and health workers to understand and promote human rights

• People with mental health conditions- so that they can claim their rights

• Family members and carers - so that they respect rights and support their relative to claim rights

• Health workers – so that they can change their practices

Objectives 2

Support countries to develop civil society movement of people with mental health conditions and families

Peer support groups —Mutual support —Sharing knowledge, experiences & information

Advocacy organizations —Advocate for rights —Lobby for change —Participate in decision making processes

Objectives 3

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Reform national policies and legislation in line with best practice and international human rights standards Mental health policies and strategies:

— Deinstitutionalisation — Integration of mh into general health care settings — Development of community mh services

Mental health legislation:

— Stop violations and discrimination — Promote human rights — Encourage autonomy, liberty & exercise of legal capacity — Promote access to legal mechanisms

Objectives 4

QualityRights ToolKit

QR toolkit provides practical information, tools and guidance on: • How to conduct a comprehensive

assessment based on observation, review of documentation and interviews

• How to report the findings of the

assessment

• How to use the results and recommendations to improve quality of care and human rights

WHO QualityRights Toolkit

Toolkit establishes key standards to be met in all inpatient and outpatient facilities

1. Right to an Adequate Standard of Living (CRPD Art 28)

2. Right to the Enjoyment of the Highest Attainable Standard of Physical and Mental Health (CRPD Art 25)

3. Right to Exercise Legal Capacity and to Personal Liberty and the Security of Person (CRPD Art 12 & 14)

4. Freedom from Torture or Cruel, Inhuman or Degrading Treatment or Punishment and from Exploitation, Violence and Abuse (CRPD Art 15 & 16)

5. The Right to Live Independently and Be Included in the Community (CRPD Art 19)

WHO QualityRights Toolkit

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5 overarching themes (drawn from CRPD). 1st theme : right to an Adequate Standard of Living living conditions are safe and hygienic, social interaction between staff and service users based on equality and respect. 2nd theme: right to health People are provided with good quality, evidence based care for both mental and physical health problems. promoting a recovery approach to care. 3rd theme: Legal Capacity and to Personal Liberty and the Security of Person facilities are geared towards enhancing people’s autonomy so that they can make decisions about their own treatment on basis of free and informed consent. 4th theme: freedom from Torture, Violence and Abuse Ending seclusion and restraint and other harmful practices, Putting in place measures to prevent and report violence, abuse and neglect 5th theme: right to Live Independently and Be Included in the Community facilities support people to access community resources and services (eg. educational, employment/income generating, vocational opportunities, social welfare benefits, housing etc.) to enable community living

QualityRights Implementation in countries

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implementation of QR in countries Global initiative which has been taken up by several countries in different regions around the world Italy (Sardinia) Lebanon Morocco Tunisia Albania Spain (Asturias in the past – now Valencia has embarked on QR) Jamaica Brazil (already undertaken in in Bahia – plans for national roll out) Malaysia South Africa (2016) Portugal (2016) Chile Somaliland India (State of Gujarat)

Asturias, Spain • 28 facilities, 186 service users, family members and health

professionals interviewed • Covered full range of facilities • Project has produced some important outcomes

– Bill of Rights for people with psychosocial disabilities – A new resolution formalised creation of a mental health

commission to advise the Ministry – Development of mh strategic plan

• Specific recommendations were made based on the assessment

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in Asturias, Spain (2010/11), WHO QualityRights has been implemented in 28 facilities. interviews with 186 service users, family members and health professionals. QR assessment covered the full range of facilities in Asturias including general hospital, communities services, residential facilities for mental health and substance use IMPACT: Bill of Rights for people with psychosocial disabilities (May 2011) has been established. new resolution (No 429) 14 February 2011, formalised the creation of a mental health commission with 8 representatives (service users, family members, human rights experts and a psychiatrist) to advise the Ministry on the ongoing evaluation of mental health services as well as suggestions for improvements. Development of mh strategic plan based on the results Specific recommendations were made as a result of the QR assessments, eg: staff to provide service users and their families with information on their mental health condition and how it can be managed Improve procedures for receiving, examining and responding to complaints / ensure that confidentiality is preserved throughout the whole process Improve knowledge and training of health professionals on the rules and legal basis governing the rights of users training on values and skills required of staff to guarantee treatment of service users with humanity, dignity and respect

QualityRights: Gujarat • Assessment of quality & human rights conditions has been undertaken in each

facilities

• Results have been fed back to facilities and improvement plans have been developed and are being implemented in each facility

• Capacity building on human rights and recovery •Rights of people with mental health conditions (completed) •Recovery approach (completed) •Alternatives to seclusion and restraint (ongoing)

• Service user and family peer support groups have been established at facilities •recovery and self care •building relationships & communication •stress management •assertiveness and decision making •accessing services and supports in the community •self-advocacy

• Peer workers (service users) have been recruited and trained at facilities to: •Support service users build recovery plans •Support and act as advocates for service users and families

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To date the most comprehensive work has been undertaken in Gujarat India – with a population of 63 million.

Peer support groups Gujarat Mr Mansuri, a family member attending a peer support group in Gujarat:

‘I have felt a lot of communal discrimination in life, but the caregiver group (Saathi) is a space where people are just caregivers sharing their difficult experiences. The emotions that we share bring us together. . . [In the caregiver group] we provide support by listening to each other’s pains and miseries’. ‘I have learned a lot. I feel more confident and filled with energy and [I now have a] positive approach towards whatever challenges life throws at us. I find myself hopeful and determined to help Shamma (his daughter) become the person she can and wants to be’.

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In Gujarat the process of setting up family peer support groups has started to have an impact.

Thank you

mental health policy and service development …...mental health policy and service development...

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