Global mental health is entering a rights-based era

In an era marked by a critical re-evaluation of mental health care practice, a project called Zero tolerance for coercion?The historical, cultural and organizational context for effective implementation of coercion-free mental health services around the world The global journey towards more humane and rights-based mental health services is revealed.

The study, authored by European researchers Richard Whittington, Deborah Oyine Aluh and Jose-Miguel Caldas-de-Almeida, explores the complex historical, legislative and economic landscape that shapes the current state of mental health care.

Over the past few decades, we have made important conceptual developments in dealing with the nature and causes of mental illness, the factors involved in disability, and the organization of services. Important paradigm shifts have occurred and are still occurring, the authors write, from the custody paradigm to the care paradigm, then to the rehabilitation paradigm, and now to the human rights paradigm.
The goal of reducing coercion still faces important obstacles. However, with growing awareness of the risks involved in using coercive practices, growing knowledge of the availability of current alternatives to coercion, and the challenges associated with their implementation, conditions have never been more favorable and fertile to achieve these goals . The project towards a more humanistic and multifaceted conception of mental health patients and their care continues to advance and is going through a particularly exciting phase.

This seminal article delves into the evolution of mental health care, tracing its path from historically coercive practices to today’s emphasis on human rights and patient autonomy. The authors explore the historical background of obsessive-compulsive behavior in mental health, the contextual factors that influence it, and the challenges and innovations in reducing the persistence of obsessive-compulsive behavior. As the world grapples with the ethics of mental health care, this study provides a hopeful perspective on the progress that has been made and the potential for a future in which coercive practices in mental health are a thing of the past.

Although the use of coercion in mental health remains prevalent around the world, it is important to recognize the significant progress made in global and local mental health. The authors of one particular work remind us of this journey through three sections that include the historical background of coercion in mental health care, contextual factors influencing coercion, and current issues related to coercion.

They explain that throughout history, attitudes toward the use of coercive measures to treat people with mental disorders have always been closely tied to the cultural, religious, and political context of the time. If we go back in time, we can find examples as early as the 13th and 14th centuries in Europe of people with mental disorders being treated humanely and integrated into the community.

Not surprisingly, however, these human practices are few and far between. Most people who suffer mental torture and pain are imprisoned in prison cells, asylums, or live on the streets. By the time of the Enlightenment, attitudes toward madmen gradually began to change, with those caring for the mentally ill becoming less superstitious and fearful and embracing a more humane attitude. However, these humanistic attitudes evolved gradually. The end of World War II popularized human rights rhetoric, paving the way for global postwar mental health care reform. From Argentina to Lebanon, mental hospitals are closed.

The author quotes Franco Basaglia, the Italian psychiatry reform leader:

When we say no to asylum, we say no to suffering in the world, and we join all the peoples of the world in the struggle for human liberation.

After World War II and the push for deinstitutionalization, the world began to change. The Universal Declaration of Human Rights (UDHR) was born. Then, in 1948, the World Health Organization created the first official document stating that mental health is vital to overall health. Subsequently, in 2008, the United Nations adopted the Convention on the Rights of Persons with Disabilities (CRPD).

The ratification of the Convention on the Rights of Persons with Disabilities represents a major step forward in promoting the rights of persons with mental disorders, as it is based on the general consensus among the international community (governments, NGOs and citizens) on the need to effectively ensure respect for the rights of persons with mental disorders. The integrity, dignity and personal freedom of persons with mental disabilities and strengthening the prohibition of discrimination against these citizens through laws, policies and programs that specifically meet the needs of these citizens and promote their participation in society.Included are several articles specifically related to reducing coercion [Article 12].

Enforcement will still exist in 2023 due to a variety of factors including service design, national legislation and policy, economic factors, social attitudes, and even the impact of COVID-19. However, as these factors come to light, implementation scientists and rights advocates can work to reduce their impact. While there is no clear roadmap to achieving the ultimate goal of zero enforcement, there is reason to be optimistic. Despite international declarations and conventions such as the Convention on the Rights of Persons with Disabilities in the past, the global mental health world seems to be changing for the better.

However, the transformation we are witnessing now is different because it is supported and made possible by a new culture of applied science and evidence-based policy, which also characterizes contemporary health care planning in many countries.

The authors also identified three recent systematic reviews revealing concentrated research on the elimination of global coercion. Additionally, they identified promising and innovative research on safety and restraint education.

However, the author realistically points out:

Unfortunately, innovation in health care alone is rarely enough to ensure that practice continues to change over long periods of time. Most complex human systems have an inherent inertia that resists new interventions, and this can only be overcome through significant effort, including additional resources for transformation and real commitment from the people needed to deploy new interventions. Innovation therefore also requires an understanding of implementation, which raises a completely different set of questions than those answered in successful effectiveness trials.

Whittington and colleagues highlight the importance of implementation science (IS) as a key way for the world to adopt new methods and ideas to combat a culture of coercion. They assert that IS provides practical and replicable methods for integrating innovative ideas into daily mental health care practice. While ISIS may not be the ultimate solution to the current state of mental health care coercion, their work emphasizes that we are in a better place globally than we were 50 years ago.


Whittington, R., Aluh, DO, & Caldas-de-Almeida, JM (October 2023). Zero tolerance for coercion? The historical, cultural and organizational context for the effective implementation of coercion-free mental health services around the world.exist health care (Volume 11, Issue 21, Page 2834). MDPI. (associated)

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