19 February 2011

Advocacy and social exclusion in mental health: A global challenge *



 
Recently,  another  “scandal”  emerged  from  the asylum’s  labyrinth  of  Mental  Hospital  of Dromocaiteion  in  Athens:  Violation  of  human rights  of  mentally  ill  persons,  limitation  of  their contractual  power  as  workers  in  a  small  social firm, decrease of the quality of care and treatment for socially excluded people suffering from mental disorders. We  are witnessing  an  “as  if”  situation where  the  gap  between  the  declarations  and practices of human  rights  is once again widening. Yet,  it  is not  just another  local “as  if” situation.  It is  remarkably notable  that 53% of  the psychiatric admissions  in  Greek  mental  health  hospitals  are involuntary  and  therefore  this  leads  one  to  admit the  existence  of  a permanent  national  scandal  for our country.

During  the actual economic crisis  in Greece, new phenomena  appear  challenging  the  limits  of  the public and psychiatric system of care: a constantly growing population,  a  “no man’s  land” people  in the  centre  of  the  metropolitan  area  of  Athens living  in  extremely precarious  conditions  as well as a dramatic increase in psychiatric admissions in mental  health  hospitals  for  homeless people with no present mental disorder.

In  the  early  70s,  under  the  influence  of  radical ideologies,  psychiatry  was  defined  through  its scientific  object  as  “the  knowledge  and  practice dealing with  the singularity of  the others, without violating the recognition and respect of the dignity of  the  suffering  person”  (B.  Doray,  Ethique  et Psychiatrie, MIRE Paris, 1985).

The  key  strategy  of  a  progressive  mental  health movement  of  this  period was  the suppression  of the  old  asylums  and  their  transformation  in  a comprehensive,  accessible  and  effective community  –  based  mental  health  system, covering the needs of the population.

The  questions  actually  raised,  in  the  era  of globalization  and  domination  of  neo  –  liberal market – oriented culture, are the following:

•  How  should  the  wider  field  of  mental health  including  psychiatric  practice  and PSR services  change,  in  order  to  respond better  and  more  accurately  to  the  mental health needs and new complexity of urban suffering,  social  exclusion, poverty,  social discrimination, lack of dignity and hope?

•  Why  do  we  raise  the  matter  of  ethical principles of psychiatric practice when the basic civil and political  rights are violated and denounced? Why is there no integrated   part  of  today’s  struggle  and  process  to improve  mental  health  care,  combining advocacy  issues  with  good  practices  and evidence  promoting  recovery  and  full citizenship? It seems that the answer of both questions ought to be the same: The core of the psychiatric scientific community  denies  these  new  realities  or underestimates  the  huge  impact  of  social determinants  on  mental  health  (Patel,  Saraceno, Kleinman 2006).

Despite  the  general  statements  of  most psychiatrists  in  favor  of  a  “bio-psycho-social model”  of  understanding  and  treating  mental illness,  there  is a huge mental health gap between official statements and strategies to promote social inclusion and defend human  rights of people with mental  health  problems  and  the  real  today’s practice.

According to the World Health Organisation (2005) “Advocacy  is  an  important  means  of  raising
awareness  on  mental  health  issues  and  ensuring that  mental  health  is  on  the  national  agenda  of governments. Advocacy can lead to improvements in  policy,  legislation  and  service  development.” Promoting  advocacy,  empowerment  and  social inclusion  requires a  radical change of  the existing psychiatric  culture  of  bio-medical  model  and  a shift  to  a  new  paradigm  of  understanding  and promoting  mental  health  under  a  global perspective.

This  change  should  include,  among  other  issues, an  in-depth  transformation  of  medical  and
psychiatric  curricula,  an  active  participation  of mental  health  professionals,  users,  families  and other  stakeholders  to  a  process  of  an  inclusive, involving  and  accountable  governance,  new political  and  social  alliances  in  order  to  promote communication  and  active  interaction  of  health, mental health and social services  in education and training,  in employment opportunities,  in housing rights,  in  transport,  in  leisure  and  cultural activities  and  the  active  protection  of  civil  and human  rights.  Involuntary admissions are a major and  thorny  issue  in  the  protection  of  human  and civil  rights.  The  way  the  psychiatric  services operate,  results  in  the  reproduction of stigma and social  discrimination  for  people  who  constantly reside in the chambers of a mental health hospitals through  a  “revolving  door”  phenomenon.  The legal  mechanisms  of  defense  of  the  human  and civil  rights  should  also  be  empowered  through good practices such as the Observatory for Human Rights or the Ombudsman.

Consequently,  if we  are  set  to  implement  its  full meaning  it  has  to  be  integrated  as  an  attitude  in today’s  practice  with  person-centred  services, recovery  oriented  services,  with  active involvement  of  users  and  families.  As professionals, we  should  invent  feasible ways  to
increase  government  budget  for  mental  health which  is  significantly  low  to non-existent  in most of  the  countries worldwide  (Mental Health Atlas, 2005). Additionally,  the  poor  existing  budget  for mental  health  should  be  wisely  spent  in  the direction  of  Psychiatric  Reform.  We  should promote deinstitutionalization and enhance the use of  local  resources  to  serve  the  needs  of  the  local population with  the existing means  for  this. Mass media  should  be  on  our  side.  The  matter  of publicity  is  an  important  one  and  our  advocation  towards  it,  should  be  aware  of  the  local  and national trends.  

Last but not  least, nothing  is ever good  if  there  is no  monitoring  and  evaluation.  WHO  refers  to evidence and ethical based practices which are not partial  but  part  of  a  whole  life-whole  system approach.  Thus,  monitoring  and  evaluating  the process of change  is absolutely vital  to ensure the success  of  our  work.  WAPR’s  challenge  is  to advocate towards a change of the political agenda of  International  Organisations  emphasizing  on  a better  mental  health  care  and  respect  of  human dignity.  

S. Stylianidis
VP of WAPR, Greek Counterpart for mental health in WHO,
Ass. Prof. of Soc. Psychiatry, Panteion University

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