Series

Global Mental Health 6

Human rights violations of people with mental and
psychosocial disabilities: an unresolved global crisis
Natalie Drew, Michelle Funk, Stephen Tang, Jagannath Lamichhane, Elena Chávez, Sylvester Katontoka, Soumitra Pathare, Oliver Lewis,
Lawrence Gostin, Benedetto Saraceno

Lancet 2011; 378: 1664–75 This report reviews the evidence for the types of human rights violations experienced by people with mental and
Published Online psychosocial disabilities in low-income and middle-income countries as well as strategies to prevent these violations
October 17, 2011 and promote human rights in line with the UN Convention on the Rights of Persons with Disabilities (CRPD). The
DOI:10.1016/S0140-
6736(11)61458-X
article draws on the views, expertise, and experience of 51 people with mental and psychosocial disabilities from
18 low-income and middle-income countries as well as a review of English language literature including from UN
See Comment page 1613
publications, non-governmental organisation reports, press reports, and the academic literature.
See Comment Lancet 2011;
378: 1441 and 1534
See Online/Comment
Introduction reports, and the media, rather than from scientific
DOI:10.1016/S0140- All over the world, people with mental and psychosocial research. Furthermore, the knowledge and opinions of
6736(11)61270-1 disabilities experience violations of many civil, cultural, people with mental and psychosocial disabilities have
This is the sixth in a Series of economic, political, and social rights. We investigate the rarely been sought. We therefore undertook a broad
six papers about global types of human rights violations experienced by people consultation of 51 people with mental and psychosocial
mental health
with mental and psychosocial disabilities (panel 1) in disabilities from 18 low-income and middle-income
World Health Organization,
low-income and middle-income countries, and review a countries to draw from their expertise and perspective.
Geneva, Switzerland
(N Drew MA, M Funk PhD); series of effective strategies to end violations and promote We consulted people from the following countries: Belize
Department of Psychology and human rights. (n=3), Bosnia and Herzegovina (n=3), Egypt (n=4),
College of Law, Australian Although human rights violations against people with Georgia (n=3), Ghana (n=1), Indonesia (n=3), Jordan (n=8),
National University Canberra,
ACT, Australia (S Tang LLM);
mental and psychosocial disabilities occur in all countries Kenya (n=1), Lithuania (n=1), Mexico (n=1), Nepal (n=9),
Nepal Mental Health irrespective of income level, the focus of this Series is occupied Palestinian territory (n=2), Paraguay (n=1),
Foundation, Kathmandu, Nepal low-income and middle-income countries, where this Peru (n=2), South Africa (n=2), Sri Lanka (n=4), Tajikistan
(J Lamichhane MA); Comité issue has been under-researched. Most evidence from (n=1), Zambia (n=1), unspecified (n=1). We attempted to
Nacional de Salud mental—
Miembro de Salud Peru, Alamo
these countries comes from reports by non-governmental
Mental Health service user organisations (NGOs), UN documents, government
organization, Lima Peru Search strategy and selection criteria
(E Chávez); Mental Health Users
Network of Zambia, Lusaka, We have selectively summarised the English-language
Key messages
Zambia (S Katontoka DipMH); evidence, including from the WHO/UN publications,
Centre for Mental Health Law • Stigma and discrimination lead to pervasive human rights non-governmental organisation and press reports, and the
and Policy, Indian Law Society,
violations against people with mental and psychosocial academic literature (using the PubMed/Medline and Google
and Consultant Psychiatrists,
Ruby Hall Clinic, Pune, India disabilities in low-income and middle-income countries Scholar databases) published from January, 1994, to January,
(S Pathare MRCPsych); Mental • Human rights violations span basic civil, cultural, 2011. A wide range of search terms were used. In summary,
Disability Advocacy Centre economic, political, and social rights terms were used to limit the literature to evidence for mental
(MDAC), Budapest, Hungary
• In the health-care context, two major concerns are lack of health (eg, “mental health problems”, “mental illness”,
(O Lewis MPA); O’Neil Institute
for National and Global Health access to mental health care, and ill treatment and abuse “mental disorder”, and “mental health services”) and restrict
Law, Georgetown University by health workers the focus to low-income and middle-income countries where
Law Centre, Washington, DC, • Issues central to human rights violations are the denial of possible (eg, “low-income countries”, “middle-income
USA (Prof L Gostin JD); and
people’s right to exercise legal capacity and discrimination countries”, and “low- and middle-income countries”). If no
Department of Psychiatry,
University of Geneva, Geneva, in employment data for these countries were available, the broader literature
Switzerland, and Global • Adopting and applying the framework of the UN (typically from high-income countries) was reviewed if we
Initiative on Psychiatry, Convention on the Rights of Persons with Disabilities and judged it reasonable to apply the findings to low-income and
Hilversum, Netherlands
(Prof B Saraceno MD)
using a range of evidence-based strategies can help put middle-income countries. Search terms were also used to
an end to these violations and to promote human rights return results relevant to general or specific human rights
Correspondence to:
Natalie Drew, Avenue Appia 20, • These strategies include: changing negative and incorrect violations (eg, “violations”, “abuse”, “discrimination”,
1211 Geneva 27, Switzerland beliefs, providing services in the community and “stigma”, “exclusion”, “financial”, and “employment”); and
[email protected] empowering people with mental and psychosocial identify strategies (eg, “mental health literacy”,
disabilities, reforming law and policy, and establishing “empowerment”, “service user organisations”, “complaints
legal and oversight mechanisms mechanisms”, “rehabilitation”, and “advocacy”).

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contact respondents from low-income and middle-income

countries across different parts of the world, but this was Panel 1: People with mental and psychosocial disabilities
limited by time, resources, and the constraints of our We use the phrase “mental and psychosocial disabilities” to refer to people who have
convenience sample. As such, we bring together different received a mental health diagnosis, and who have experienced negative social factors
sources of evidence from reports and publications in including stigma and discrimination and exclusion. The concept of disability is set out in
addition to the experiences of the consultation group, to article 1 of the UN Convention on the Rights of Persons with Disabilities, which states that
provide a comprehensive picture of the situation. “[p]ersons with disabilities include those who have long-term physical, mental,
We interpret our findings to offer guidance on how best intellectual or sensory impairments which in interaction with various barriers may hinder
to act on the UN Convention on the Rights of Persons their full and effective participation in society on an equal basis with others”. Accordingly,
with Disabilities (CRPD), which since its entry into force we refer to people who have a longer-term impairment, as opposed to transient or
in 2008 provides the first comprehensive and legally predominantly situation-responsive distress (such as where a person experiences one
binding international framework for promoting the rights episode of a mental health condition in her or his lifetime). Although the personal and
of people with mental and psychosocial disabilities. The social impacts of shorter-term mental health conditions should not be downplayed, it is a
CRPD was drafted with the active participation of topic beyond the scope of this article.
disability organisations, including organisations that
represent people with mental and psychosocial disabilities,
and has been embraced widely by the disability movement Panel 2: WHO QualityRights Project
as the universal standard for the human rights of all
The WHO’s QualityRights Project aims to improve quality and human rights conditions in
people with disabilities.
mental health facilities and social care homes, and promote a civil society movement for
mental health. The project includes a number of different components:
Consultation with people with mental and • Visiting committees are established, consisting of people with mental and
psychosocial disabilities psychosocial disabilities and their family members, mental health professionals, and
We undertook individual consultations with 51 people
legal and human rights experts.
with mental and psychosocial disabilities from 18 low-
• The visiting committee receives training on the QualityRights Assessment Tool, used
income and middle-income countries (see webappendix).
to assess the quality and human rights in outpatient and inpatient mental health and
In each consultation we sought the respondent’s opinion
social care facilities.
on, and experiences of, mental health and human rights
• After the assessment of the facility, the visiting committee works collaboratively with
issues. All respondents were informed about the purpose
residents of facilities, family, and staff to develop a plan to improve conditions in the
of the consultation and the use of their views as part of
facilities. This is also an opportunity to raise awareness and educate everyone involved
this report. Informed consent was built into the
on human rights issues.
questionnaire. The beginning of the questionnaire
• Technical and administrative support is provided to people with mental and
contained a statement about voluntary participation,
psychosocial disabilities from the facilities and community on how to set up and
confidentiality, and how responses would be used,
strengthen organisations led by people with mental and psychosocial disabilities, to
allowing respondents to indicate how they would or would
provide mutual support and information about mental health and human rights, to
not want their responses to be used. Their expertise was
undertake advocacy and campaigning, and to participate in decision-making processes.
sought around three key areas: (1) what kinds of human
rights violations are experienced by people with mental The QualityRights Assessment Tool uses the UN Convention on the Rights of Persons with
and psychosocial disabilities; (2) the context in which Disabilities as a framework for providing countries with information and guidance on
these violations occur; and (3) what changes are required human rights standards that need to be respected in facilities, including living conditions,
to improve the human rights situation. In addition to a the treatment available for physical and mental health care, and how service users are
series of open-ended questions, this qualitative treated by staff. The specific themes covered include:
consultation was guided by a list of potential human • The right to an adequate standard of living
rights violations derived from the WHO QualityRights • The right to the enjoyment of the highest attainable standard of physical and
Assessment Tool (panel 2) for assessing the quality and mental health
compatibility with human rights of mental health • The right to exercise legal capacity and to personal liberty and the security of person
facilities, and their adherence to the CRPD. • Freedom from torture or cruel, inhuman or degrading treatment or punishment and
Respondents were contacted by use of a convenience from exploitation, violence, and abuse
sampling method. The authors identified organisations • The enjoyment of civil, cultural, economic, political and social rights
representing people with mental and psychosocial
disabilities and other relevant entities (eg, NGOs,
disabled people’s organisations, and foundations working distribution to potential respondents. Respondents who See Online for webappendix
with people with mental and psychosocial disabilities) in wished to take part were able to submit their completed
low-income and middle-income countries as the initial questionnaire directly and anonymously to us
contact point. Organisations that were willing to partici- electronically. After a coding comparison process between
pate and that had direct contact with people with mental ND, MF, and ST, to ensure consistency, responses were
and psychosocial disabilities were provided with a categorised into themes by use of an open coding
questionnaire (available in English and Spanish) for method—ie, the thematic codes were generated directly

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and guaranteeing basic freedoms (eg freedom from

Panel 3: Most common human rights violations as discrimination, freedom of expression), respondents
described by respondents, sorted by descending frequency believed that human rights allow a person to “live a
• Exclusion, marginalisation, and discrimination in the decent life in society”, and have a life that is “harmonious
community and happy”. Respondents further noted that human rights
• Denial or restriction of employment rights and involves the freedom to participate in community life
opportunities while being able to live independently. By contrast with
• Physical abuse/violence alienation, marginalisation, and denied opportunities,
• Inability to access effective mental health services human rights confer “full recognition of a sense of being
• Sexual abuse/violence human” with “mutual respect of our human dignity”.
• Arbitrary detention In the context of disability, according to one respondent
• Denial of opportunities for marriage/right to found a family from Nepal, human rights are “that which says that all
• Lack of means to enable people to live independently in are equal despite their disabilities and that [everyone]
the community should be treated the same without discrimination”.
• Denial of access to general health/medical services Another respondent from Jordan said that “the most
• Financial exploitation important right is my right to have the knowledge of all
of my rights and to be empowered to [confront] violations
against my rights”. The most common types of human
Panel 4: Environments in which human rights violations rights violations that respondents described from their
are most likely to take place, as described by respondents, own experience are shown in panel 3.
sorted by descending frequency
Restriction of civil, cultural, economic, political,
• General community settings in everyday life and social rights
• Home and family settings The stigma and misconceptions associated with mental
• The workplace or potential workplace and psychosocial disabilities often result in people being
• Psychiatric institutions and mental health services ostracised from their community. Pervasive stigma and
• Hospitals and health-care services discrimination affects a person’s ability to earn an
• Prisons, police, and the legal system income, lift themselves out of poverty, and gain access to
• Government and official services treatment and support to integrate or reintegrate into
• Schools and the education sector their community and recover from their illness.1
The denial of the right to work because of stigma and
discrimination is a frequent rights violation with far-
from the responses, as opposed to attempting to fit reaching consequences. Respondents reported that dis-
responses into pre-existing themes or codes. crimination at all stages of the employment process was
All respondents were current or former users of mental one of the main kinds of human rights violation that takes
health services, and identified themselves as having a place, both in terms of pervasiveness and impact (panel 4).
mental or psychosocial disability. 17 respondents were Difficulties begin at the stage of finding work, even when
female (33⋅3%), 32 were male (62⋅7%), and two were the person is well qualified. A respondent from Ghana
unspecified (3⋅9%), and the median age was 41⋅0 years reported that “even though I’m trained as an auto
with a range of 18–71 years. 31 respondents (60⋅8%), two mechanic, I find it difficult to get jobs because I’m deemed
unspecified (3⋅9%), were members of organisations of to be ‘insane’ and not in the right frame of mind to do any
people with mental and psychosocial disabilities. All meaningful work”. Even when a person has a job, the
respondents were literate, and most were involved in discrimination continues. A respondent from Belize
advocacy around mental health issues. As such, one reported that “we [people with mental and psychosocial
limitation of our consultation is that it captures the disabilities] tend to be underpaid and overworked. We are
expertise and opinions of people already knowledgeable considered unprofessional, dangerous and incapable…
about issues of mental health and human rights. Our years of experience and performance are totally
disregarded because we always receive entry-level pay and
Violations of human rights do not get benefits that others do”.
To explore the lived-out reality of rights and their violation According to a previous report,2 unemployment rates
in countries with low and middle incomes, we first asked of up to 90% are not uncommon among people with
respondents to give their personal definition of human mental and psychosocial disabilities—a far higher rate
rights. Although there was some variability in the compared with people with other types of disabilities
responses, several broad themes emerged. Human rights and people without disabilities. Discrimination in
were seen by respondents to be “inherent entitlements” employment contributes to poverty, with some studies
which “no one can take [away]”. In addition to meeting showing that mental and psychosocial disabilities are
basic needs (eg, health, food, education, and employment) twice as frequent among people in the lowest income

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groups compared with people in the highest income few issues to have received attention in the literature.7 At
groups.1,3 31 respondents (60⋅8%) said that having a the heart of the issue is the dearth of funding and services
mental and psychosocial disability adversely affected provided by governments in many low-income and
their ability to find or maintain a job, and 28 respondents middle-income countries. Mental health services are
(54⋅9%) said that their disability contributed to their or non-existent in many places. One respondent from Belize
their family’s poverty. A common theme was the need to said that his country “does not have enough trained
hide mental and psychosocial disabilities from employers. [professionals] in [mental health] areas to serve the entire
One respondent from Kenya said that “one has to lie or population. It took me 15 years to meet a psychiatrist”.
deny having a mental illness in order to be considered for Even when mental health services are available, they are
employment. When employed one has to hide the illness often inaccessible.6,17 Consistent with previous studies,18
and blame it on any other more ‘appropriate illness’ that 12 respondents (23⋅5%) noted that services were
is socially acceptable or risk termination”. disproportionately concentrated in major cities, which
Additionally, many people with mental and psychosocial can be many hours away.18 One Jordanian respondent
disabilities do not have access to social security benefits who lived 3 hours away from the nearest services said that
or health insurance, which often leads to difficulties in “it is costly financially and physically to get to the services”.
reintegrating into society. When social security is available, These accessibility problems inhibit a large part of the
which tends to be limited to middle-income, rather than population from having proper access to mental health
low-income countries, it is often structured in a way that services because they cannot afford the journey, the
creates a disincentive for recovery, financial independence, transportation systems are too unreliable, or the
and workplace participation.4 This tends to perpetuate opportunity costs involved are too high.19
patterns of unemployment and dependence.1,5–8 In most countries with low and middle incomes, the
As reviewed in WHO’s Mental Health and Development absence of community-based mental health care means
report, children and adolescents with mental and there is a disproportionate reliance on psychiatric
psychosocial disabilities (including intellectual disabil- institutions as the main provider of mental health
ities) face disproportionate barriers in accessing their services.20 Not only does this discourage access to services
right to inclusive education.1 Poverty-related constraints and hinder a person’s ability to live and participate in
mean they are usually the first to be deprived of the their own community, but these institutions are often
possibility of going to school.1 In many low-income and associated with gross human rights violations (panel 4).
middle-income countries, children and adolescents with
mental or psychosocial disabilities are institutionalised in Abuses in residential facilities and places of
facilities that do not offer any kind of education.9,10 If they detention
are able to go to school, children in many countries are Many previous reports have documented the poor
sent to segregated or so-called special schools that offer physical conditions in many facilities accessed by people
low-quality education, rather than being included in with mental and psychosocial disabilities.1,21–23 Although
mainstream education with tailored support.9,11 Failure to this usually refers to substandard living conditions in
provide appropriate support can result in poor academic residential mental health facilities and psychiatric
performance, school failure, and high drop-out rates hospitals, it is important to recognise that poor conditions
compared with other children and adolescents.12 and infrastructure are also prevalent in prisons, nursing
People with mental and psychosocial disabilities are homes, halfway houses, and facilities for traditional or
also restricted from exercising many civil rights.13,14 In spiritual healing.24
many low-income and middle-income countries, people The absence, or denial, of the basic necessities of living
with mental and psychosocial disabilities are denied the (including adequate shelter, food, and sanitary facilities)
right to marry and have children.13,15 Marriage legislation is itself a violation of a person’s fundamental human
in a number of these countries states that being of rights. Several previous reports and responses from
“unsound mind” or having a long-term mental health respondents have documented living conditions in
condition can be grounds for annulment or divorce.1 residential facilities that are inhuman and degrading
Legislation in other countries with low and middle because of problems such as overcrowding, outbreaks of
incomes prohibits people with mental or psychosocial preventable diseases caused by unsanitary conditions,
disabilities from filing for divorce because these decisions poor physical infrastructures, hypocaloric food, and
are made for them by their guardian. Their parental pervasive tobacco smoke.23,25,26 Deficiencies in the built
rights are often also terminated.16 environment of mental health facilities can impede
effective treatment and recovery,27 which can result in
Lack of access to mental health services worsened mental and physical health of service users.1
In many low-income and middle-income countries, This is shown by the account of one respondent’s
people do not have access to basic mental health care. admission to a psychiatric institution in Zambia: “alas,
The problems associated with affordability and access to the place of my treatment and care turned out to be a
mental health services in these countries is one of the horrible place to live in. It was characterised [by]

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which is done without anaesthesia or muscle relaxants—a

Panel 5: Major strategies for improving the human rights condemned practice that can constitute torture or ill-
of people with mental and psychosocial disabilities as treatment, but one that continues in several countries
identified by respondents, sorted by descending frequency with low and middle incomes.27,31,37 In other contexts,
• Running public-awareness and anti-stigma campaigns, harmful treatment practices can involve abuse by some
and providing education about the rights of people with traditional healers and religious practitioners, including
mental and psychosocial disabilities, as well as about beatings and the use of shackles and chains as purportedly
mental health in general curative measures.1,5,19,24
• Providing better training of mental health professionals,
increased funding for mental health services, and Restriction on the exercise of legal capacity
provision of better mental health services, especially in Human rights violations often occur when individuals
the community are denied their right to exercise their legal capacity. In
• Promoting the empowerment, rehabilitation, and many countries, including some with low and middle
participation of people with mental and psychosocial incomes, people with mental or psychosocial disabilities
disabilities in their communities are deprived of their legal right to make decisions, and
• Implementing effective and humane laws and policies to the authority is handed to a third person, a guardian. This
protect and promote the human rights of people with guardian—often a family member, a government official,
mental and psychosocial disabilities or a local service provider—can then make decisions on
• Encouraging the formation of, and providing ongoing behalf of the person in areas such as where and with
support to, organisations of people with mental and whom they should live, how their money, property, and
psychosocial disabilities personal affairs should be managed, and other aspects of
• Monitoring and assessment of human rights of people their daily lives.16,38 Decisions concerning health care are
with mental and psychosocial disabilities, and of mental also made by guardians, which can result in people being
health services generally detained in mental health facilities and treated against
• Integrating mental health into overall health and their will. Despite the far-reaching powers that can be
development policies exercised by guardians, there are very often few or no
judicial mechanisms to enable people to appeal their
involuntary admission and treatment or protect their
unhygienic living conditions, physical abuse, nakedness, right to exercise their legal capacity more generally.1,27
and lack of enough food. This experience taught me that The denial of legal capacity can also mean that a person
mental hospitals are more of a torture chamber causing is excluded from participation in social and political life,
more mental anguish and torment than ameliorating the such as the right to vote or be elected, and to participate
mental situation of patients…It led to feelings [of ] in the development and implementation of laws and
worthlessness, helplessness and hopelessness”. policies that concern them.1,38
Beyond the human rights violations caused by the poor
conditions in facilities, people with mental and psycho- Evidence-based strategies to improve human
social disabilities are often subjected to ill-treatment rights
including physical, mental, and sexual abuse, and neglect. Such a pervasive pattern of systemic violations of human
These are common occurrences in facilities throughout rights of people with mental and psychosocial disabilities
the world and are well documented in previous reports requires a range of strong, inclusive, and integrated
and in the responses of respondents.22,25,28 strategies to be adopted in response. Unfortunately, there
Arbitrary detention takes place in many low-income and is a paucity of evidence for the effectiveness of such
middle-income countries, whereby psychiatric confinement strategies in low-income and middle-income countries.
is ordered without any basis by the justice system or others We review the available evidence in conjunction with the
in a position of power.21,29 The result is that people are often recommended strategies suggested by respondents
locked in hospitals for years without their legal or medical (panel 5) and the obligations set out in the CRPD. The
status being assessed, and subjected to psychiatric CRPD is an important reference point because of its
interventions without informed consent.30–32 Seclusion, authoritative status in both informing and enforcing
isolation, and restraint—used as punishment or coercion— strategies to improve rights for people with mental and
are another feature of many institutions.5,19,33,34 In many psychosocial disabilities.
low-income and middle-income countries, there is an Overall, there was a very good match between these
absence of recovery-oriented treatment,35 with people with three components (the existing evidence, the respondents,
mental and psychosocial disabilities chained to beds or and the CRPD). However, respondents also identified
posts and made immobile for long periods of time.1,36 several specific strategies relating to participation and
A further problem is the use of harmful practices often empowerment that have not yet been considered. These
described as mental health treatments. One such so-called strategies emerged as consistent themes from respondents
treatment is unmodified electroconvulsive therapy (ECT), from a range of different low-income and middle-income

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countries and with different life experiences, and as such

warrant greater attention. Panel 6: Raising awareness of the UN Convention on the
At the outset, it is important to be mindful that the Rights of Persons with Disabilities (CRPD): the
strategies discussed below should not exist in isolation International Diploma on Mental Health Law
from each other, nor can they be seen as a set of In 2008, the Indian Law Society in Pune, India, in
discretionary goals that receive attention by governments collaboration with WHO, set up the International Diploma in
and development stakeholders only when it is Mental Health Law and Human Rights. The Diploma aims to
convenient.39 As one respondent from Nepal pointed out, build capacity in countries to promote the rights of persons
all strategies “must be interwoven within the overall with mental disabilities in line with the CRPD and other
planning of national development. The permanent international human rights standards.
solution to this problem cannot be imagined outside the
Participants on the course include government officials,
overall development strategy of the government”.
people with mental and psychosocial disabilities, families,
health professionals, lawyers, human rights defenders, and
Information, training, and education campaigns
social workers. The aim of the diploma is to equip national
The attitude of society as a whole has an important role
actors with the skills needed to be able to advocate for
in the way people with mental and psychosocial
human rights and influence national reform efforts.
disabilities are treated in the community and by mental
health professionals. Respondents stated that ignorance
or false beliefs about people with mental and psychosocial in high-income countries.40 However, there are few
disabilities is one of the leading reasons that human examples of such campaigns in low-income and middle-
rights violations occur—a theme that is substantiated in income countries, and fewer assessments of their
previous reports. Studies from low-income and middle- effectiveness.43 The available evidence suggests that
income countries show that people with mental and campaigns lead to improved public knowledge about
psychosocial disabilities are incorrectly perceived to be mental health conditions, increased awareness of mental
violent, dangerous, or unpredictable. Such negative health services and effective treatment, knowledge about
attitudes are held not only by the general public, but also mental health and attitudes towards people with mental
by health professionals and policy makers.40–42 and psychosocial disabilities, and increased demand for,
A respondent from Georgia said that the prevailing belief and use of, community-based mental health services.44–47
in his country is that “a person with mental disabilities is Several factors have been shown to improve the
not considered as a human being at all”. These perceptions effectiveness of information campaigns. People with
are associated with greater social distance from people mental and psychosocial disabilities, their families, and
with mental and psychosocial disabilities.28 According to carers should have an active role in identifying priority
one respondent from Nepal: “society perceives [us] as areas to be addressed by campaigns, and be involved in
degraded human beings facing punishment for their their design, delivery, and assessment.48 Research to
past actions. Wrong beliefs of illness give society an open understand the characteristics of the recipients of
social license to discriminate against mentally affected information campaigns makes it more likely that the
people. Therefore, people with mental and psychosocial messages will be targeted, and the use of appropriate
disabilities experience human rights violations”. media channels improves the likelihood of effectively
In response, information and education campaigns are engaging specific groups. The testimony of people with
crucial. Article 8 of the CRPD mandates that State Parties mental and psychosocial disabilities themselves has been
adopt measures to initiate and maintain awareness identified to be a very significant factor in reducing
campaigns and human rights training to promote a stigmatising attitudes.49 Finally, information campaigns
greater understanding of the “skills, merits and abilities” should be conducted on a long-term, routine basis.48
of persons with disabilities. Raising awareness among Many respondents noted that people with authority
different stakeholders about government obligations in (including health professionals, government ministers,
relation to the CRPD is also important, and efforts are and officials) are the most resistant groups when it
being made in this direction (panel 6). comes to improving the human rights of people with
A large proportion of respondents saw education mental and psychosocial disabilities. Previous reports
campaigns as a necessary precondition for reform. For have also emphasised that negative attitudes towards
example, one respondent from Nepal said that although people with mental and psychosocial disabilities are
a multifaceted approach is needed, “at the basic level, frequent among mental health professionals.34,50,51 Such
nothing can be done without the awareness in people, attitudes must be addressed through the specific training
so [the] government must invest amply to spread and education of people acting on behalf of the state or
such awareness”. with other social authority so that all sections of society
Such campaigns have already been used widely to are aware of the rights of people with mental and
advance public understanding on mental health, reduce psychosocial disabilities. This view was summarised by
stigma and discrimination, and promote human rights a respondent from Sri Lanka: “the whole society needs

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to become aware of mental [and psychosocial disabilities]. meet the multiple needs of people with mental and
From the President to the ordinary voter, people must psychosocial disabilities. Strong links are needed with
become aware—especially [people] from government other sectors to ensure that people have access to housing,
organisations, temples, schools, transport services, [and education, and employment.1,17
the] police”. Employment schemes, in which people with mental
and psychosocial disabilities undertake paid work with
Provision of services in the community ongoing support and training, have been consistently
As already discussed, low-income and middle-income shown in studies in low-income and middle-income
countries face several challenges in relation to access to countries to result in higher employment rates, better
mental health care. Psychosocial care and rehabilitation wages, more hours of employment per month, and better
services and essential medicines are often unavailable, mental health.1,56–58 Additionally, income generation
inaccessible, or unaffordable, which further constrains programmes and social grants have been shown to
treatment and recovery, often with cross-generational benefit people with mental and psychosocial disabilities,
consequences.6,7,52,53 their families, and communities, but are absent in many
In the limited number of low-income and middle- countries with low and middle incomes.1,6,59
income countries where budgets for mental health Successful community inclusion also relies on making
services exist, most expenditure goes on psychiatric educational opportunities available and accessible to
hospitals or other forms of custodial care associated with children with mental and psychosocial disabilities, and
violations of human rights,6,54 rather than on community- ensuring that barriers preventing their attendance at
based services. An important response to this is the need schools are removed. Once in the educational system,
for low-income and middle-income countries to provide school-based mental health programmes can prevent
mental health and other services in the community to the onset or worsening of mental health conditions into
improve both access and quality of services and promote adulthood, and help to maximise the number of people
independent living in society in accordance with articles completing education, which improves opportunities
19 and 25 of the CRPD. Providing better mental health for employment.1
service is necessarily contingent on providing better
training for mental health professionals, a view echoed Empowerment of people with mental and
by many respondents. It also entails equipping primary psychosocial disabilities
health-care providers with skills in evidence-based mental As already discussed (panel 3), marginalisation, exclusion,
health treatment and care. As a respondent from Kenya and discrimination against people with mental and
noted, “mental and physical health exist as separate psychosocial disabilities were seen by respondents as the
entities”, and “other physicians and nurses…have no most common human rights violations. One respondent
training or information on mental health. Existing from Sri Lanka noted that: “social discrepancy is high.
medical personnel need to be trained continuously on The human rights of those who are unable to do anything
mental health issues so that they can…handle both issues are violated more”. Accordingly, empowering people with
as well as put into place referral systems”. mental and psychosocial disabilities both individually and
When mental health services are available and collectively is one of the key strategies for change (panel 5).
adequately staffed by trained professionals in primary The participation of people with disabilities as equal
and community settings they are known to be more members of society in all aspects of living is one of the
acceptable, accessible, and affordable, and produce better fundamental principles that underpins the entire CRPD.
health and mental health outcomes. As a Jordanian At the individual level, efforts need to focus on ensuring
respondent noted: “the clinic where I get my medications that people with mental and psychosocial disabilities are
and therapy sessions is close to my house and my able to exercise their legal capacity in line with article 12
workplace. It’s in a strategic place where anybody can get of the CRPD. By contrast with traditional but rights-
to it within [the city]”. Despite this evidence, no country in restricting models of plenary guardianship, the CRPD
the world has yet managed to effectively provide services requires that State Parties recognise the right of people
in the community nationwide.1,17,55 with disabilities to enjoy legal capacity on an equal basis
However, simply providing mental health services in with others in all aspects of life. Additionally, the CRPD
the community is not sufficient. A broad set of services puts forward a supported decision-making model. This
or programmes are needed to enable people to attain and model enables people to retain their legal capacity and at
maintain maximum independence and full inclusion in the same time choose to receive support in exercising
society in line with the CRPD. Habilitation and rehab- this right when they desire it and when it is needed.60,61
ilitation services, including vocational and life-skills The person remains at the centre of decision making on
development but also in-home, residential, personal issues that affect him or her, and when necessary, support
assistance and other community-support services, are can be on-hand to explain relevant issues and interpret
vital to achieving independence and inclusion. Social and and communicate the signs and preferences of the
health-care services need to adopt a holistic approach to individual.62 Types of support might include advocates, a

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personal ombudsperson, community services, personal

assistants, peer supports, and advance planning.63 Panel 7: Key UN and regional human rights instruments
Public and collective participation can be encouraged UN instruments
by establishing or strengthening organisations of people • Convention on the Rights of Persons with Disabilities
with mental and psychosocial disabilities. In most low- • International Covenant on Economic, Social and
income and middle-income countries, there are few Cultural Rights
organisations made up of and run by such people.1 The • International Covenant on Civil and Political Rights
resultant lack of social support creates a sense of isolation • Convention Against Torture and Other Cruel, Inhuman
and powerlessness for many people. A respondent from or Degrading Treatment or Punishment and its
Belize commented that “[people with mental and psycho- Optional Protocol
social disabilities] are vulnerable and are still camouflaged
in the community; they are not a strong and united Regional instruments
group”, while a respondent from Egypt commented that • African Charter on Human and Peoples’ Rights
“they cannot defend themselves and they cannot speak • American Convention on Human Rights
out for themselves out loud”. • Additional Protocol to the American Convention on
In fact, the lack of independent organisations of people Human Rights in the area of Economic, Social, and
with mental and psychosocial disabilities was seen by Cultural Rights
some respondents as a principal reason that human • Inter-American Convention on the Elimination of All
rights violations occur. This is consistent with respondents’ Forms of Discrimination Against Persons with Disabilities
view that the establishment of such organisations would • European Convention for the Protection of Human Rights
be a crucial way of promoting acceptance and positive and Fundamental Freedom
change in attitudes. Empowering people with mental and • European Convention for the Prevention of Torture and
psychosocial disabilities to self-organise and advocate for Inhuman or Degrading Treatment or Punishment
their interests and needs promotes their recognition and
develops their strengths, resources, and skills.64 Such
empowerment also ensures that people with mental and psychosocial disabilities.1,68,70 Participation also leads to
psychosocial disabilities are given a collective political assessments that are more likely to address people’s
voice to influence and lobby for policy and legislative requirements and concerns.71,72 Additional benefits
reform.65–67 One respondent from Tajikistan said that include the development of more relevant outcome
belonging to such an organisation “[has] made my life indicators, a better quality of information obtained from
more positive and useful despite the huge stigma and service recipients, and practical change strategies to
discrimination I experienced before and a bit now. The improve services.73 Despite these benefits there is little
positive side is that I can understand users and their evidence of countries involving people with mental and
feelings so that…we [can] help each other”. psychosocial disabilities in service assessment.71
States have an obligation, under article 29 of the CRPD,
to “promote actively an environment in which persons Law and policy reform
with disabilities can effectively and fully participate in the Law and policy reform is a key strategy identified in
conduct of public affairs, without discrimination and on previous reports and by respondents to promote human
an equal basis with others”. This can be achieved by rights. Well formulated policies and laws can promote the
encouraging people’s participation in or forming of development of accessible services in the community,
NGOs and political parties. The participation of people stimulate advocacy and education campaigns, and
with mental and psychosocial disabilities is a key strategy establish legal and oversight mechanisms to prevent
to ensure that their personal experience and knowledge human rights violations.1,74–77 Mental health policies and
drives reform and that laws, policies, and services are laws in low-income and middle-income countries are
acceptable, address their needs, and respect their human absent in many cases, and where they exist they fail to
rights in accordance with article 4 of the CRPD.1,68,69 Such incorporate current international human rights and best
steps must be carried out together with a dismantling of practice standards, in some cases actively violating human
overarching legal barriers such as restrictions on the rights.1,6,78–80 In reference to legislation specifically, one
exercise of legal capacity, which prevents people from respondent from Nepal said that “[our] laws are
joining associations and exercising their political rights. discriminatory. They encourage the authorit[ies] to
A systematic review on the effect of involving people imprison and then [ forcibly] start treatment on mentally
with mental and psychosocial disabilities in the training affected persons”. It is therefore crucial that policies and
of mental health service providers and in the assessment laws are introduced in line with international human
of mental health services found that involvement rights standards including the CRPD and other
improved service users’ quality of life and social instruments (panel 7). This requires the active involve-
functioning and resulted in trainees having a more ment of people with mental and psychosocial disabilities
positive attitude towards people with mental and in the policy-making process. Historically, the development

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of policies and laws has excluded people with mental and levels. In its ongoing litigation in the High Court of
psychosocial disabilities, which has meant that their Karnataka, ACMI’s actions have successfully led to
needs have not been adequately addressed. legislative and policy reforms, including setting
There are opportunities to codify human rights minimum standards for hospitals and nursing homes,
standards and proscribe violations and discrimination converting a state psychiatric hospital to an open-ward
not only in specific mental health policy and legislation, system (ie, where patients are free to move around the
but also in laws and policies on anti-discrimination, ward without their movements being restrained in any
general health, disability, employment, social welfare, form or manner), and establishing a budget for mental
education, housing, and other areas. However, well- health in the state. ACMI also continues to lobby for
formulated policies and laws are of no use if they are not mental health legislation to be made consistent with the
put into effect. Indeed, respondents highlighted lack of CRPD, and runs legal literacy workshops for people with
enforcement as a significant reason why human rights mental and psychosocial disabilities and their families.84
violations occur, and that government commitment However, in many countries legal remedies are absent,
is essential in order to establish mechanisms for and in the absence of effective regulatory and oversight
implementation and monitoring. mechanisms within the domestic sphere, many people
in low-income and middle-income countries have relied
Establishment of legal and oversight mechanisms on international and regional human rights systems and
The establishment of legal and oversight mechanisms to organisations for justice and redress. Although the
protect the rights of people with mental and psychosocial jurisprudence of these bodies is in its infancy, the African
disabilities is mandated under articles 13–16 of the CRPD. Court on Human and People’s Rights30 and the Inter-
In many low-income and middle-income countries, there American Court on Human Rights33 have all ruled on
is no well-defined independent judicial procedure or matters related to the rights of people with mental and
mechanism that can be accessed by people admitted psychosocial disabilities. The European Court of Human
involuntarily to mental health facilities to contest their Rights has a more developed case-law on rights issues,29,85
detention.37,81–83 and the European Committee on Social Rights has
In addition to judicial review mechanisms, regular decided on two collective complaints concerning the
visits by independent bodies to mental health facilities education of children with intellectual disabilities.86,87 The
and other places of detention to inspect the conditions in European Committee for the Prevention of Torture also
which residents live is crucial to prevent abuses and visits all places of detention—including psychiatric
ensure that fundamental rights are being respected. One institutions—within member states, and reports its
respondent from Georgia said that “specific cases of the findings and recommendations.88
violation of patients’ rights should be highlighted. International NGOs also have a crucial role in oversight
Regular monitoring of human rights observance [must] and redress. The Mental Disability Advocacy Center
be carried out at psychiatric institutions”. Such (MDAC), for example, has been successful in strategic
monitoring mechanisms are required by the CRPD and litigation at international and national levels that has
the Optional Protocol of the UN Convention Against brought about legislative reform. In the case of
Torture. This role can be undertaken by a dedicated Shtukaturov v Russia, the European Court of Human
independent visiting committee or integrated into the Rights found that Russia had violated several rights of
functions of existing monitoring mechanisms and the European Convention on Human Rights, which
organisations such as national human rights institutions, subsequently led to the Russian Constitutional Court
national ombudsperson offices, or NGOs. striking down three provisions about capacity and
Complaints mechanisms also need to be established consent relating to people with mental and psychosocial
and made accessible to persons with mental and disabilities in Russian domestic law that the MDAC
psychosocial disabilities. Part of the reason why violations argued were unconstitutional.89
continue unabated is that they are unreported. Legal However, although such international mechanisms can
mechanisms therefore need to be in place to enable and be effective for facilitating reform and empowering the
encourage people with mental and psychosocial people and groups involved, they should not be the
disabilities, their family members, friends, and advocates primary method for addressing human rights violations.
to report any human rights violations freely and securely. Oversight mechanisms, judicial review, and access to
legal remedies in domestic law must be available to
Examples of successful legal action people with mental and psychosocial disabilities on an
Legal remedies are being undertaken by local NGOs and equal and accessible basis.
disabled people’s organisations. For example, Action for
Mental Illness (ACMI) is an Indian NGO that, in addition Conclusions
to its other advocacy activities, has undertaken litigation People with mental and psychosocial disabilities in
representing the needs and rights of people with mental low-income and middle-income countries continue to
and psychosocial disabilities at provincial and national experience a wide range of human rights violations,

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including the inability to access adequate mental health number of people for their help and support in the development of this
services in a safe, therapeutic, and affordable setting. article: Albert Maramis, Anita Marini, BasicNeeds Sri Lanka,
Charlene Sunkel, Dan Taylor, Daniel Rivera, George-Tudor Florea,
Rights violations also include being subjected to stigma Jan-Paul Kwasik, Manana Sharashidze, Moody Zaki, Patricia Robertson,
and discrimination in the community, particularly in Sarah Skeen, and Shadi Jaber.
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