jueves, 11 de enero de 2018

Human Rights: Let us all bring our experiences to Madrid in 2018!

Michaela Amering.
Michaela Amering is a Professor of Psychiatry at the Medical University of Vienna, Department of Psychiatry and Psychotherapy.
Michela Amering, Chair WAPR Human Rights Committee.

     The shared knowledge will allow comprehensive discussions so that we can leave with tools for real change towards a human rights-based psychiatry.  The title of the XIII.WAPR World Congress – ‘Recovery, Citizenship, Human Rights; Reviewing Consensus” – is well chosen and poses a formidable challenge for this important congress.

     With new legislation through the UN-CRPD the 2017 report of the UN Special Rapporteur on the right of everyone to the enjoyment of the highest attainable standard of physical and mental health defines the task ahead as

       - a shift in paradigm
         - …towards right-compliant mental health systems’

     UN Special Rapporteur and psychiatrist colleague Danius Puras calls our attention to the fact that ‘we are all potential users of metal health services’ and thus
-      ‘everyone is a rights holder’.
-      Correspondingly, mental health workers and policy makers are duty-bearers.

     How do we go about meeting our duties? The WAPR Task Force on Human Rights has defined the specific task of formulating the main consequences of entitlements rights according to the UN-CRPD articles pertinent to the core tasks of psychosocial rehabilitation:
-           - Article 19 - Living Independently and Being Included in the Community
-           -  Article 24 – Education
-           - Article 26 - Habilitation and Rehabilitation
-           - Article 27 - Work and employment
-           - Article 28 - Adequate standard of living and social protection
-           - Article 29 - Participation in political and public life
-           - Article 30 - Participation in cultural life, recreation, leisure and sport -

     As well as those articles that focus on research, evaluation and international collaboration:
-           - Article 31 - Statistics and data collection
-           - Article 32 - International cooperation

     In order to increase the effects of entitlement rights on an individual as well as on the health care system level (including effects of these rights on implementation of recovery-orientation of services and strengthening the awareness of the significance of social determinants of mental health).

     WAPR wants to further a process of understanding and participating in shaping the effects of the CRPD in different countries and internationally with regards to accessibility and assistance needs and rights. Such a process concerns especially also, the questions of:
-      Definition of psychosocial disability
-      Definition of reasonable accommodation
-      Assessment of assistance needs to replace current deficit assessment.

     Ideally, we want to come up with a consensus on the main consequences of the rule of law of the CRPD for the field of psychosocial rehabilitation.

     These tasks can only be addressed through working in partnership between Users, Carers, different mental health professionals, lawyers, human rights activists, WHO, and the general public and supporting this multi stakeholder approach to all developments, discussions and decisions in the mental health field.

     In order to advance towards the goal of mental health services compliant with human rights we want to invite to Madrid contributions pertaining to the topics of the most burning current chances and challenges for the human rights-based approach in psychiatry:
-      Inclusive Housing, Supported Housing and Housing First
-      Supported Education.
-      Supported Employment.
-      Supported Parenting.
-      Supported Decision Making.
-      Experiences with WHO-Quality Rights.
-      Medical and Dental Care for Persons with Psychosocial Disabilities.
      Alternatives to acute hospital care, like acute Day Clinic, Home Treatment and Assertive Outreach.
-     Open Dialogue and local examples such as Trieste Services.
              -     Non-violence in acute psychiatric care and reform of guardianship laws in accordance with CRPD
R            -     Reforms of Forensic Services. R
              -     User and Carers’ involvement.
              - The rights of women and girls with psychosocial disabilities.

domingo, 7 de enero de 2018

Reinventing ourselves: the art of personal reconstruction.

Martin Vargas, FEARP.
Crisis (from Latin crisis, and that from Greek, κρίσις krísis): profound change with important consequences in a process or situation, or the manner they are appreciated (dictionary of the Real Academia Española).

The celebration in Madrid, next July, of the 13th World Congress of Psychosocial Rehabilitation, coincides with a triple crisis: epistemological, economical and inter-subjective.

Psychiatry, as focused in the biological level of the reality, has delivered less fruit than expected. The promissory “Decade of the brain” said goodbye at the turn of the millennium accrediting low clinical results. At the same time, genetic studies in psychiatry have clashed with the ambiguous wall of epigenetics, where the mechanistic causality characteristic of chemistry becomes diluted in the unpredictable world of life. Psychiatry suffers a profound epistemological crisis, some of which symptoms are the polemic DSM-V versus RDoCs, or the proliferation of divulgation essays opposing psychoactive drugs prescription. Although only indirectly, psychosocial rehabilitation, which is closely attached to the peremptory social and service-providing necessities of people with severe mental disorders, has participated in this crisis too. The fact that schizophrenia is still predominant in the highly developed industrialized societies and in urban areas hurts the pride of the psychiatry as a science. The human being, as a biographical being, even in the state of extreme fragility and suffering, seems to escape from the positivistic fishing nets. Therefore, psychiatry appears at 2018 as a disarmed giant in front of his main adversary.

The economic crisis, lasting a decade in Spain, has deepened social differences and has diminished in a disturbing way the capacity for economic and civic reaction of the middle classes and of the poor or at risk of poverty. People with severe mental disorders have especially suffered from this socioeconomic drop. Furthermore, one of the main achievements in contemporary spanish politics, the right for a wellfare protection when a state of personal dependence is suffered, is undergoing a praecox involution. The Act 39/2006, December 14th, of Promotion of Personal Autonomy and Attention of People in a Situation of Dependence was conceived, as its headline proclaims, for the promotion of the autonomy of people at risk of dependence. The state economic help to the family core of the dependent person was an operative tool for the exercise of the right to protection. The capitalization of dependence carried a risk of commoditization that seems to be taking place. Nowadays not only people with severe mental disorders are an element of the psychiatric-drug commerce, but also an element of the rising socio-sanitary market too. If the professionals do not make a correct use of the economical resources invested by the State in the Dependence Act, this can become an “objectifying” risk for the patients instead of an ally for recovery and personal development. A rigorous scientific research of the adverse effects of psychosocial rehabilitation and of the differential aspects of the different clinical and socio-sanitary practices is still pending.

In the field of psychosocial rehabilitation, inter-subjective relationships are complex and nuanced in a special manner. As referring to a clinical relationship, the general frame can not be other than that of medical compassion, which in the general ambit of medicine has developed from paternalism towards a democratic relation. Compassion emerges from the radical inter-subjectivity of the human being in virtue of which the “Me” is no more than one of the perspectives of the “Me- you” dialogic core  and the “he” is a projection of the “Me” and nothing more. This “Me – you – he” system can be paternalist, authoritarian or democratic depending on the values that animate it. Furthermore, in psychosocial rehabilitation the inter-subjective relational system includes other perspectives beyond the mere medical one: cognitive, functional, labour, vocational, citizen and other. In the new millennium, this relational net has experimented deep changes: “first person” movements, alliances between families associations and the pharmaceutical industry or the renaissance of antipsychiatry, to take in account only some examples. In medicine, an evolution has occurred from paternalism to the autonomy of patients, and it has gone even further in psychosocial rehabilitation. Today, in a kind of “nietzschean” experiment, the “value of madness” is claimed today. At a time, technical knowledge is under suspicion as a kind of authoritarianism. Up to what point must psychosocial rehabilitation be an emancipating praxis, beyond the axiological health frame, is still waiting for a consensus.

Therefore, the epistemological crisis of psychiatry seems no more than the shadow of deep changes occurring in the social, economic and politic system implied by the potentially disabling mental disorders.

A crisis is a profound change with important consequences. Whether these consequences are problematic or fortunate strongly depend on the course determined by the acting agents: patients, families, professionals, civil society and the State. As an alternative to the “objectifying alienation” of the affected people, who could become mere instruments of the pharmaceutical and socio-sanitary markets, the hope of a society of people structured around dignity can be conceived. The dignity of the person seems a good utopia acting as the key for a meaning. Recovery from a severe mental disorder is not only a return to actively participating in society or recovering the capacity for an autonomous life. To recover oneself is to reconstruct oneself knowing that you are worthy of it. The intrinsic value does not change in a person whether healthy or recovered, as well as in an artwork whether original or rehabilitated. It would be a good idea for all the implied agents to line up towards this maxim: recovering oneself is the art of recovering the personal worth. Let’s recover ourselves as people overcoming disease, as professionals, and also as economic and social agents. Let’s reinvent ourselves in Madrid, July 2018!

Martin L. Vargas, MD


domingo, 31 de diciembre de 2017

Happy Mental Health in 2018!!! Three wishes for the upcoming year.

2017 has been a very fulfilling year in WAPR. The coming year 2018 is very close. This will be the year of the WAPR XIII World congress. This may be a timely opportunity to express some expectancies and wishes for the coming time in our field.

            As many of us think, the attention to the mentally ill is experiencing a profound change, often characterised as a change of paradigm. There is an increasing awareness of the importance of mental health as potential contributor to disability in general population, and the importance of tackling in the more effective way severe mental health problems as a way to reduce the burden of suffering and disability. Many ideas and proposals have been laid on the table in recent years in areas like prevention, treatment and rehabilitation. But in this opportunity, I will only mention three, from a very subjective way.

            Let us continue understanding the recovery process from mental illness. Beyond treatment as a way to overcome specific symptoms, for the people suffering from severe mental illnesses, recovery means gaining a significative life beyond the residual symptoms treatment cannot eliminate, disability and possible side effects form treatment. The more we learn from users’ experience in successful recovery processes, the best we can use that knowledge in helping new patients in their unique and personal process to recover. This need of new understanding also includes understanding the process to getting ill, understanding vulnerability, the role of adverse biographic events and other traumatic experiences as potential contributor factors to further development of illness. The best we understand the role all these factors, the better we will be able to help patients in tackling them. Understanding will lead to services that better contemplate the extraordinary complexity of getting sick and also in getting better.

            Let us improve accessibility to mental health services. We are aware that many people in the world has a limited access to correct psychiatric treatment, even to a very basic and limited one. As WHO often states –see WHO Atlas database-, in many countries available services are mostly allocated in mental hospitals, that receive the biggest part of public budgets in detriment of community services, more accessible and usually friendlier to people. Improving accessibility entails that policy makers take the responsibility to create mental health plans –whereas they do not exist- and allocating the required budget, in order to ensure that the access to services for the mentally ill is made available in equity basis respect to people with other health problems, usually better funded that mental health. Community services, services allocated near the places where people lives, able to provide quality and continuous services as long as they may be necessary, are the right strategy to improve accessibility to recovery oriented services for the people affected by severe mental illnesses. Year 2017 has offered interesting examples of countries improving dramatically access to mental health services to their citizens –the case of Peru may be paradigmatic-. Let us expect that 2018 may increase awareness of the need to improve access to services and offer similar experiences in other countries.

         Let us succeed in reducing coercive interventionsCoercion and psychiatry have been historically linked for complex reasons. We now know that mental illness is usually a lasting process that begins much sooner that when it is recognised. However, since early signs of mental distress are usually not very specific and are usually neglected, the onset of mental illness is often dramatic and linked to acute conflicts that may involve concerns about security of the patient and of third parties. If we add that madness is an extreme human experience that challenges understanding, and is usually perceived in a stigmatised way, we can understand that coercion is linked to psychiatric interventions, and that psychiatry has received two different tasks- and quite incompatible-: to offer treatment and to guaranty security. That is why along many years, in many psychiatric services all over the world, coercion is widely and uncritically accepted as a “normal” part of the practice. But this perception need readjustment. First, research shows that coercion can be widely and easily reduced by improving training and changing attitudes on staff. Second, although it is difficult to deny that security is sometimes a real concern in practice, it has been proved in different places that a well-trained and motivated team can tackle most emergencies without using coercive methods. And third, the perspective of Human Rights, specially that emerging from the U.N. Convention of Rights of People with Disabilities, obliges to reconsider the use of coercion in psychiatric interventions as a routine practice wherever it takes place. Reducing coercion to the minimum -...may it be close to zero?- may be a good challenge for the new year.

            Let us expect the best for the coming year, and may these three wishes may find their way in it. The WAPR World Congress Madrid 2018 will gather some of the most interesting experiences in the world in these topics and will offer training workshops to make those experiences available to all delegates.

            Happy 2018!