November 17, 2019

From ‘Mental Health’ to ‘Inclusion’ – Reframing the Momentum

Blog contributed by TCI Asia Pacific 


#WhatWENeed – Reframing the momentum: From ‘mental health’ to ‘inclusion’ [1]

TCI Asia Pacific advocates that the action field for persons with (psychosocial) disabilities is not the ‘mental health’ sector, but the Development sector. When we ask for ‘inclusion’, we have a more universal frame for our advocacy. Introducing these ideas in the Plenary meeting in Bali, we enumerated the steps required to “reframe” from the medical model to the social model of disability, and to ask different kinds of policy, program and movement questions. This “reframing” found strong articulation in the Bali Declaration, as a call for action – 

“That recognize, inclusion of persons with psychosocial disabilities involves a paradigm shift and reframing of policy environment from medical model to social model; mental disorder to psychosocial disability; public health to inclusive development; institutionalization to inclusion; treatment to support systems, evoking the guidance of CRPD and the SDGs to bridge such reframing;
That will place Inclusion of persons with psychosocial disabilities as the purpose, process and outcome of all social, legislative, policy, program, service actions, across all sectors, involving all actors including, but not limited to health care, and within all Development agendas, plans, programs, and partnerships for change”.

The following re-formulations have been crucial to TCI’s journey of understanding inclusion, and advocating for Article 19:
Firstly, TCI recognizes that a large part of the mental health law is a replica of the colonial period legal frameworks, passing through unaltered within the Commonwealth. In some states which were not colonized, there is no mental health law, even though, informally, social care institutions may exist in open communities[2]. Therefore, it is important for us to question the assumption that has been forced on us, originating from the WHO in the 80s and 90s, that having a mental health law is a sign of ‘modernisation’ of mental health care; that having such a law is in fact the precondition for providing mental health care. 

This is negated by the experiences of (1) countries which do not have a mental health law and yet have a good social infrastructure to support persons with psychosocial disabilities, with minimum or no support from governments (2) countries which do have a mental health law invariably and predictably have high rates of institutionalization, the terrors, traumas and abuses thereof, with the laws only getting more and more sophisticated and inaccessible, in terms of access to justice by the incarcerated persons. Large public bursaries mobilized for mental institutions and costly regulatory mechanisms has not ensured zero violence within the system. 

On the question of whether it is more empowering to call ourselves “users or survivors of psychiatry”, TCI Asia found that the terminology of “persons with disabilities” to be more closer to our lived experiences in the region. The Asian movement was born after the CRPD came in; in the wake of CRPD trainings received; and the CRPD created new identity pathways and allowed one to claim space through the identity of a ‘person with disabilities’. In contrast, the ‘user/ survivor identity’ pitches us solely against the medical system and negates the question of development.

However, this is not to negate the role of the right to health care, only to keep it within perspective, as one small part of human development. The social sector needs to shift from “voluntarism”, which often is about consenting to medication or institutionalisation, is disqualifying of all else, is conditional to agreeing anyway, which is experienced as a “Catch 22” situation. The service sector needs to shift to “choice” that includes a number of life choices, including each and every one of the rights provided for in the CRPD and amplified by the SDGs, especially employment and housing.

The Bali plenary raised some questions, which for TCI, is rhetorical, viz. 

1. Does institutionalization bring us inclusion?
2. Does medication/treatment bring us inclusion?
3. Does CBR bring us inclusion?
4. Does “Recovery” bring us inclusion?

How do we move from a narrow view of community, involving a restriction of participation, stigma and being confined to just “treatment”, to a more diverse, rich community life that we want for ourselves? Zero coercion must inform future laws and policies, and the CRPD requires preparing communities for inclusion. Therefore, a re-framing based on TCI Asia’s guiding advocacy principles would require: 

• An overhaul in the attitudes of service providers, whereby “institutionalization” is seen not just as a physical structure, but rather a 
mentality which allows service providers to be gatekeepers and determine the best interests of persons with psychosocial disabilities

• Providing multiple, accessible and affordable, formal and non-formal services of care as well as various services such as housing, 
education and employment enabling choice and the right to live independently.

• Besides a mental health system that fosters exclusion and segregation, stigma and exclusion starts at the level of communities in many 
countries. Therefore, it is important to creating enabling environments within communities and families, and allowing other development 
actors and services to come in as needed by the person.

Source: Alexander Cote, Bali Plenary, 2018

• Understanding that while the CRPD gives persons with psychosocial disabilities the compass, CRPD alone cannot ensure inclusion. 
• The CRPD is strengthened by the movement of persons with psychosocial disabilities. Not being contained within the disability movement but also reaching out to other social movements that cater to the different identities of persons with psychosocial disabilities. 


(2018) Source: Alexandre Cote, TCI AP Bali Plenary

References

[1] “Reframing the momentum”, at the “Classic Edition” Plenary of TCI Asia Pacific, Hotel Ayodhya, Bali, Indonesia, August 26th, 2018. Documentation by Shreshtha Das. 

[2](2016). Human Rights Watch. “Living in Hell. Abuses against people with psychosocial disabilities in Indonesia”. A Report. https://www.hrw.org/report/2016/03/20/living-hell/abuses-against-people-psychosocial-disabilities-indonesia

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