Best Practices
Strategic Stigma Change (SSC):
Five Principles for Social Marketing
Campaigns to Reduce Stigma
Patrick W. Corrigan, Psy.D.
This column describes strategic
stigma change (SSC), which comprises five principles and corresponding practices developed as a
best practice to erase prejudice
and discrimination associated
with mental illness and promote
affirming behaviors and social inclusion. SSC principles represent
more than ten years of insights
from the National Consortium on
Stigma and Empowerment. The
principles, which are centered on
consumer contact that is targeted,
local, credible, and continuous,
were developed to inform the
growth of large-scale social marketing campaigns supported by
governments and nongovernmental organizations. Future social
marketing efforts to address stigma and the need for evidence to
determine SSC’s penetration and
impact are also discussed. (Psychiatric Services 62:824–826, 2011)
A
significant body of evidence has
begun to emerge for changing
stigmatizing public attitudes toward
mental illness. Strategic stigma
change (SSC) is, in a nutshell, in vivo
contact between people in recovery
and targeted members of the general
public. Public stigma represents the
prejudice and discrimination that affect people with mental illness when
appreciable segments of the general
population endorse negative stereotypes about psychiatric disorders
Dr. Corrigan is affiliated with the College
of Psychology, Illinois Institute of Technology, 3424 South State St., Chicago, IL
60616 (e-mail: corrigan@iit.edu). William
M. Glazer, M.D., is editor of this column.
824
(1,2). Although eliminating prejudicial attitudes is important, most advocates desire behavior change—
quashing discrimination or, viewed
more affirmatively, promoting social
inclusion (3).
The convergence of evidence has
led to five principles that constitute
SSC. This column reviews their implications for social marketing, the
paradigm that now guides large-scale,
mainly government-funded, antistigma programs. SSC targets many types
of stigma. Although this column addresses public stigma, SSC can be
adapted for other types, including
self-stigma and label avoidance (4,5).
SSC evolved over ten years of collaboration among investigators at the
National Consortium on Stigma and
Empowerment (NCSE), which is
housed at the Illinois Institute of
Technology. NCSE and coinvestigators at Yale University, the University
of Pennsylvania, Temple University,
and Rutgers, the State University of
New Jersey have been supported by
funds from the National Institute of
Mental Health and have completed
research and development through
extensive partnerships with consumer
advocacy groups and other stakeholders. Many of our first-generation
studies were summarized in a 2005
article (1), and the entire portfolio of
research can be found on the NCSE
publications page (www.stigmaandempowerment.org). More recently,
SSC has been informed by evaluations of social marketing efforts of the
U.S. Department of Veterans Affairs
and Department of Defense and of
the State of California.
The Best Practices column typically addresses strategies of interest to
PSYCHIATRIC SERVICES
service providers of all kinds. A different audience is addressed here,
namely advocates whose agenda is
defined by the pernicious effects of
stigma and the importance of stigma
change. Advocates are broadly defined and include current and past
service users, persons who are eligible for services but have chosen not
to seek them, and persons who might
identify themselves as survivors or expatients. Family members frequently
join advocacy groups, as do many
provider organizations. Professional
groups such as the American Psychiatric Association and World Psychiatric Association have joined the
“movement” against stigma in the
past few years.
The five principles of
strategic stigma change
The five principles or strategies are
defined by the acronym TLC3: targeted, local, credible, continuous
contact.
Contact is fundamental
to public stigma change
Contact with people with mental illness is fundamental to public stigma
change. In this context, contact
should be distinguished from education. Education is the most common
form of antistigma program and typically contrasts the myths of mental illness with facts. Contact involves
planned interactions between people
with mental illness and key groups.
Although research has examined
video or other media-based contact,
in vivo or face-to-face contact seems
most effective (6). Research generally
shows that contact (or contact integrated with education) has greater ef-
o ps.psychiatryonline.org o August 2011 Vol. 62 No. 8
fects than education alone on attitudes and behaviors (although behaviors are more difficult to assess and
thus are less often examined) and that
positive outcomes of contact seem to
last longer than the effects of education (1,7). Several factors enhance
contact and are incorporated into the
other four SSC principles.
Contact needs to be targeted
Rather than focusing on the population as a whole, contact is more effective when it targets key groups, typically people in positions of power,
such as employers, landlords, and
health care providers (8). Other important SSC target groups include
faith-based and other community
leaders, legislators, school personnel,
entitlement counselors, and media
outlets. Targeting not only suggests
the “who” of strategic contact but also
the corresponding “what”: what
needs to be changed. Negative behaviors need to be changed to affirming behaviors: more employer hires,
landlord leases, and high-quality
health services for people with mental illness. Each of these goals involves specific behaviors that are included in SSC objectives. For example, employers with job openings
need to interview people with mental
illness, consider reasonable accommodations, offer positions, and provide appropriate supervision that may
include job coach participation.
Venue and timing must be considered in plans to contact targets.
Where are good places to contact targets? Large numbers of employers
can be contacted through civic groups
such as Rotary International. Times
and opportunities for planned contacts may already exist. For example,
weekly staff meetings and grand
rounds offer excellent opportunities
for contacting health care providers.
All elements that define the target
inform the message. What information should be incorporated in the
message? As research has shown,
contact stories include “way down”
messages (the person experienced
symptoms and disabilities that impeded goals) and “way up” messages
(the person achieved recovery and attained goals). These stories culminate
in the stigma punch line, namely, that
PSYCHIATRIC SERVICES
despite the way-up message, many
goals are impeded by stigma and ongoing discrimination. However, this
generic message typically needs to be
enhanced for specific target groups.
Employers want to know that employee recovery means successful
work outcomes, and landlords want to
know that tenants with mental illness
respect property.
Local contact programs
are more effective
The interests of target groups are influenced by locally defined exigencies. “Local” has several meanings
but may include geopolitical and diversity factors. For example, it seems
reasonable to assume that a target
group’s interests are shared within a
geographical region, such as the
Northeast, or more narrowly within a
state, such as Vermont. Nevertheless,
Vermont is more homogeneous than
many other states, where there is
usually greater variation in rural, urban, and suburban considerations. It
is also important to consider sociopolitical factors in more narrowly defined areas. Large cities include
neighborhoods of varying socioeconomic status, and this variation is
likely to influence target group interests. For example, employers in impoverished parts of a city and in
wealthy suburbs will require different types of contact. Resources for
people with mental illness differ in
rural and urban areas, which calls for
different contact programs. Research
findings on racial-ethnic disparities
in health and health care underline
the importance of considering ethnicity and religious background in
crafting local contact programs.
These are just a few examples of the
array of factors that need to be considered in developing local strategies.
Contacts must be credible
Three considerations guide credibility. First, the contact should embody
the considerations of the crafted program—that is, the individual in the
contact role should be similar in ethnicity, religion, and socioeconomic
status to the target group. Second, the
contact should be in a role similar to
that of the target group. Ideally, employers, landlords, health care
o ps.psychiatryonline.org o August 2011 Vol. 62 No. 8
providers, and police officers who
have mental illness should make a
presentation to other employers,
landlords, health care providers, and
police officers. Although this goal is
appealing, it has inherent problems.
People in certain roles who publicly
disclose their mental illness may experience serious consequences; for
example, police officers may lose
their gun permit, thereby ending
their law enforcement career.
In response to the contact’s message that people with mental illness
recover, a member of the target group
should provide an additional message: a person in recovery can be successful. For example, employers
should tell other employers that a
person in recovery will be a good
worker. A good solution is the contact
partnership, which combines a consumer in the role of the contact and a
target group member who also speaks
to the group. A compelling Rotary
meeting would feature a person with
mental illness who talks about her recovery, followed by a presentation
from her boss, who describes the successes that resulted from hiring her.
The third consideration is a bit
more complex: namely, the consumer
contact should be in recovery. Research suggests that not all contact
decreases stigma; for example, exchanges with people who are actively
psychotic and homeless may yield no
change or make things worse (9). Interactions are most effective with
people with serious mental illnesses
who work, live independently, have
good relationships, and have a satisfactory quality of life, which are all
benchmarks of recovery. However,
researchers have also noted that recovery is an elusive concept; some
studies suggest that it may have been
attained before people accomplished
work and independent living goals
per se—for example, the person with
hope about achieving his or her personal goals. In fact, many advocates
and researchers prefer to define recovery as a process (a journey marked
by hope and goal attainment regardless of symptoms) rather than an outcome (being symptom free, for example). Moreover, limiting consumer
contacts to people who are “symptom
free” may increase public stigma by
825
implying that others with mental illness are somehow less than whole.
People in the process of recovery are
good contacts for stigma change.
Contact must be continuous
A one-time contact may have some
positive effects, but the effects are
likely to be fleeting. Multiple contacts should occur, and the quality of
the contact should vary over time.
“Carbon copies” have limited effects.
This calls for different consumer and
target partners and an array of messages, venues, and opportunities.
This principle reminds advocates
that stigma change is not easily accomplished and requires ongoing efforts and continuous quality assessment of those efforts.
Implications for social marketing
The Substance Abuse and Mental
Health Services Administration, the
Department of Defense, the Department of Veterans Affairs, many state
governments, and nongovernmental
organizations have funded social marketing programs in the United
States. These programs can be categorized as population-focused public
service campaigns and consumer
contacts. Public service campaigns,
often anchored by compelling public
service announcements (PSAs), have
several benefits. They provide the
best penetration into the population
and the most efficient way for the
message to be heard by the greatest
number of people. They typically in-
826
clude shrewdly crafted sound bites,
which viewers of the PSA may recall
some time later. The concern, however, is whether penetration leads to impact. Does learning a sound bite yield
any meaningful behavior change in
any important group?
SSC programs have alternative benefits that may enhance impact. They
yield more personalized messages.
The contact can extemporaneously
identify stigmatizing issues emerging
from the group and craft responses in
the situation. As a result, SSC is more
interactive, reflecting a give and take
among audience and contact. The exchange provides an opportunity for assessing how the contact and message
are affecting the target group. It also
provides a first step for ongoing efforts to brainstorm with the audience
about ways to overcome stigma. SSC
programs can help ensure less redundant messaging. Programs can schedule future contacts to approach prejudice and discrimination with different
stories and messages.
Acknowledgments and disclosures
This work was supported in part by National
Institute of Mental Health grants MH62198-01
and MH08598-01 to support the National Consortium on Stigma and Empowerment.
The author reports no competing interests.
References
1.
Corrigan P: On the Stigma of Mental Illness: Practical Strategies for Research and
Social Change. Washington, DC, American Psychological Association, 2005
2.
Link B, Phelan J: Conceptualizing stigma.
Annual Review of Sociology 27:363–385,
2001
3.
Corrigan P, Penn D: Lessons from social
psychology on discrediting psychiatric stigma. American Psychologist 54:765–776,
1999
4.
Corrigan P, Watson A, Barr L: The selfstigma of mental illness: implications for
self-esteem and self-efficacy. Journal of Social and Clinical Psychology 25:875–884,
2006
5.
Corrigan P: How stigma interferes with
mental health care. American Psychologist
59:614–625, 2004
6.
Corrigan P, Larson J, Hubert M, et al: Will
filmed presentations of education and contact diminish mental illness stigma? Community Mental Health Journal 43:123–
128, 2006
7.
Corrigan P, Roe D, Tsang H: Challenging
the Stigma of Mental Illness: Lessons for
Advocates and Therapists. London, Wiley,
2011
8.
Corrigan P: Target-specific stigma change:
a strategy for impacting mental illness stigma. Psychiatric Rehabilitation Journal 28:
113–121, 2004
9.
Reinke R, Corrigan P, Leonhard C, et al:
Examining two aspects of contact on the
stigma of mental illness. Journal of Social
and Clinical Psychology 23:377–389, 2004
Conclusions
SSC programs combined with other
antistigma efforts have great potential
to eliminate stigma, to ensure that
people with mental illnesses have the
same opportunities as others, and to
promote personal empowerment. In
a community that embodies these
principles, people with serious mental illnesses are better able to achieve
their goals and enjoy the quality of
their life.
PSYCHIATRIC SERVICES
o ps.psychiatryonline.org o August 2011 Vol. 62 No. 8
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
Published Online
October 17, 2011
DOI:10.1016/S01406736(11)61458-X
See Comment page 1613
See Comment Lancet 2011;
378: 1441 and 1534
See Online/Comment
DOI:10.1016/S01406736(11)61270-1
This is the sixth in a Series of
six papers about global
mental health
World Health Organization,
Geneva, Switzerland
(N Drew MA, M Funk PhD);
Department of Psychology and
College of Law, Australian
National University Canberra,
ACT, Australia (S Tang LLM);
Nepal Mental Health
Foundation, Kathmandu, Nepal
(J Lamichhane MA); Comité
Nacional de Salud mental—
Miembro de Salud Peru, Alamo
Mental Health service user
organization, Lima Peru
(E Chávez); Mental Health Users
Network of Zambia, Lusaka,
Zambia (S Katontoka DipMH);
Centre for Mental Health Law
and Policy, Indian Law Society,
and Consultant Psychiatrists,
Ruby Hall Clinic, Pune, India
(S Pathare MRCPsych); Mental
Disability Advocacy Centre
(MDAC), Budapest, Hungary
(O Lewis MPA); O’Neil Institute
for National and Global Health
Law, Georgetown University
Law Centre, Washington, DC,
USA (Prof L Gostin JD); and
Department of Psychiatry,
University of Geneva, Geneva,
Switzerland, and Global
Initiative on Psychiatry,
Hilversum, Netherlands
(Prof B Saraceno MD)
Correspondence to:
Natalie Drew, Avenue Appia 20,
1211 Geneva 27, Switzerland
drewn@who.int
1664
This report reviews the evidence for the types of human rights violations experienced by people with mental and
psychosocial disabilities in low-income and middle-income countries as well as strategies to prevent these violations
and promote human rights in line with the UN Convention on the Rights of Persons with Disabilities (CRPD). The
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
publications, non-governmental organisation reports, press reports, and the academic literature.
Introduction
All over the world, people with mental and psychosocial
disabilities experience violations of many civil, cultural,
economic, political, and social rights. We investigate the
types of human rights violations experienced by people
with mental and psychosocial disabilities (panel 1) in
low-income and middle-income countries, and review a
series of effective strategies to end violations and promote
human rights.
Although human rights violations against people with
mental and psychosocial disabilities occur in all countries
irrespective of income level, the focus of this Series is
low-income and middle-income countries, where this
issue has been under-researched. Most evidence from
these countries comes from reports by non-governmental
organisations (NGOs), UN documents, government
reports, and the media, rather than from scientific
research. Furthermore, the knowledge and opinions of
people with mental and psychosocial disabilities have
rarely been sought. We therefore undertook a broad
consultation of 51 people with mental and psychosocial
disabilities from 18 low-income and middle-income
countries to draw from their expertise and perspective.
We consulted people from the following countries: Belize
(n=3), Bosnia and Herzegovina (n=3), Egypt (n=4),
Georgia (n=3), Ghana (n=1), Indonesia (n=3), Jordan (n=8),
Kenya (n=1), Lithuania (n=1), Mexico (n=1), Nepal (n=9),
occupied Palestinian territory (n=2), Paraguay (n=1),
Peru (n=2), South Africa (n=2), Sri Lanka (n=4), Tajikistan
(n=1), Zambia (n=1), unspecified (n=1). We attempted to
Search strategy and selection criteria
Key messages
• Stigma and discrimination lead to pervasive human rights
violations against people with mental and psychosocial
disabilities in low-income and middle-income countries
• Human rights violations span basic civil, cultural,
economic, political, and social rights
• In the health-care context, two major concerns are lack of
access to mental health care, and ill treatment and abuse
by health workers
• Issues central to human rights violations are the denial of
people’s right to exercise legal capacity and discrimination
in employment
• Adopting and applying the framework of the UN
Convention on the Rights of Persons with Disabilities and
using a range of evidence-based strategies can help put
an end to these violations and to promote human rights
• These strategies include: changing negative and incorrect
beliefs, providing services in the community and
empowering people with mental and psychosocial
disabilities, reforming law and policy, and establishing
legal and oversight mechanisms
We have selectively summarised the English-language
evidence, including from the WHO/UN publications,
non-governmental organisation and press reports, and the
academic literature (using the PubMed/Medline and Google
Scholar databases) published from January, 1994, to January,
2011. A wide range of search terms were used. In summary,
terms were used to limit the literature to evidence for mental
health (eg, “mental health problems”, “mental illness”,
“mental disorder”, and “mental health services”) and restrict
the focus to low-income and middle-income countries where
possible (eg, “low-income countries”, “middle-income
countries”, and “low- and middle-income countries”). If no
data for these countries were available, the broader literature
(typically from high-income countries) was reviewed if we
judged it reasonable to apply the findings to low-income and
middle-income countries. Search terms were also used to
return results relevant to general or specific human rights
violations (eg, “violations”, “abuse”, “discrimination”,
“stigma”, “exclusion”, “financial”, and “employment”); and
identify strategies (eg, “mental health literacy”,
“empowerment”, “service user organisations”, “complaints
mechanisms”, “rehabilitation”, and “advocacy”).
www.thelancet.com Vol 378 November 5, 2011
Series
contact respondents from low-income and middle-income
countries across different parts of the world, but this was
limited by time, resources, and the constraints of our
convenience sample. As such, we bring together different
sources of evidence from reports and publications in
addition to the experiences of the consultation group, to
provide a comprehensive picture of the situation.
We interpret our findings to offer guidance on how best
to act on the UN Convention on the Rights of Persons
with Disabilities (CRPD), which since its entry into force
in 2008 provides the first comprehensive and legally
binding international framework for promoting the rights
of people with mental and psychosocial disabilities. The
CRPD was drafted with the active participation of
disability organisations, including organisations that
represent people with mental and psychosocial disabilities,
and has been embraced widely by the disability movement
as the universal standard for the human rights of all
people with disabilities.
Consultation with people with mental and
psychosocial disabilities
We undertook individual consultations with 51 people
with mental and psychosocial disabilities from 18 lowincome and middle-income countries (see webappendix).
In each consultation we sought the respondent’s opinion
on, and experiences of, mental health and human rights
issues. All respondents were informed about the purpose
of the consultation and the use of their views as part of
this report. Informed consent was built into the
questionnaire. The beginning of the questionnaire
contained a statement about voluntary participation,
confidentiality, and how responses would be used,
allowing respondents to indicate how they would or would
not want their responses to be used. Their expertise was
sought around three key areas: (1) what kinds of human
rights violations are experienced by people with mental
and psychosocial disabilities; (2) the context in which
these violations occur; and (3) what changes are required
to improve the human rights situation. In addition to a
series of open-ended questions, this qualitative
consultation was guided by a list of potential human
rights violations derived from the WHO QualityRights
Assessment Tool (panel 2) for assessing the quality and
compatibility with human rights of mental health
facilities, and their adherence to the CRPD.
Respondents were contacted by use of a convenience
sampling method. The authors identified organisations
representing people with mental and psychosocial
disabilities and other relevant entities (eg, NGOs,
disabled people’s organisations, and foundations working
with people with mental and psychosocial disabilities) in
low-income and middle-income countries as the initial
contact point. Organisations that were willing to participate and that had direct contact with people with mental
and psychosocial disabilities were provided with a
questionnaire (available in English and Spanish) for
www.thelancet.com Vol 378 November 5, 2011
Panel 1: People with mental and psychosocial disabilities
We use the phrase “mental and psychosocial disabilities” to refer to people who have
received a mental health diagnosis, and who have experienced negative social factors
including stigma and discrimination and exclusion. The concept of disability is set out in
article 1 of the UN Convention on the Rights of Persons with Disabilities, which states that
“[p]ersons with disabilities include those who have long-term physical, mental,
intellectual or sensory impairments which in interaction with various barriers may hinder
their full and effective participation in society on an equal basis with others”. Accordingly,
we refer to people who have a longer-term impairment, as opposed to transient or
predominantly situation-responsive distress (such as where a person experiences one
episode of a mental health condition in her or his lifetime). Although the personal and
social impacts of shorter-term mental health conditions should not be downplayed, it is a
topic beyond the scope of this article.
Panel 2: WHO QualityRights Project
The WHO’s QualityRights Project aims to improve quality and human rights conditions in
mental health facilities and social care homes, and promote a civil society movement for
mental health. The project includes a number of different components:
• Visiting committees are established, consisting of people with mental and
psychosocial disabilities and their family members, mental health professionals, and
legal and human rights experts.
• The visiting committee receives training on the QualityRights Assessment Tool, used
to assess the quality and human rights in outpatient and inpatient mental health and
social care facilities.
• After the assessment of the facility, the visiting committee works collaboratively with
residents of facilities, family, and staff to develop a plan to improve conditions in the
facilities. This is also an opportunity to raise awareness and educate everyone involved
on human rights issues.
• Technical and administrative support is provided to people with mental and
psychosocial disabilities from the facilities and community on how to set up and
strengthen organisations led by people with mental and psychosocial disabilities, to
provide mutual support and information about mental health and human rights, to
undertake advocacy and campaigning, and to participate in decision-making processes.
The QualityRights Assessment Tool uses the UN Convention on the Rights of Persons with
Disabilities as a framework for providing countries with information and guidance on
human rights standards that need to be respected in facilities, including living conditions,
the treatment available for physical and mental health care, and how service users are
treated by staff. The specific themes covered include:
• The right to an adequate standard of living
• The right to the enjoyment of the highest attainable standard of physical and
mental health
• The right to exercise legal capacity and to personal liberty and the security of person
• Freedom from torture or cruel, inhuman or degrading treatment or punishment and
from exploitation, violence, and abuse
• The enjoyment of civil, cultural, economic, political and social rights
distribution to potential respondents. Respondents who
wished to take part were able to submit their completed
questionnaire directly and anonymously to us
electronically. After a coding comparison process between
ND, MF, and ST, to ensure consistency, responses were
categorised into themes by use of an open coding
method—ie, the thematic codes were generated directly
See Online for webappendix
1665
Series
Panel 3: Most common human rights violations as
described by respondents, sorted by descending frequency
• Exclusion, marginalisation, and discrimination in the
community
• Denial or restriction of employment rights and
opportunities
• Physical abuse/violence
• Inability to access effective mental health services
• Sexual abuse/violence
• Arbitrary detention
• Denial of opportunities for marriage/right to found a family
• Lack of means to enable people to live independently in
the community
• Denial of access to general health/medical services
• Financial exploitation
Panel 4: Environments in which human rights violations
are most likely to take place, as described by respondents,
sorted by descending frequency
•
•
•
•
•
•
•
•
General community settings in everyday life
Home and family settings
The workplace or potential workplace
Psychiatric institutions and mental health services
Hospitals and health-care services
Prisons, police, and the legal system
Government and official services
Schools and the education sector
from the responses, as opposed to attempting to fit
responses into pre-existing themes or codes.
All respondents were current or former users of mental
health services, and identified themselves as having a
mental or psychosocial disability. 17 respondents were
female (33⋅3%), 32 were male (62⋅7%), and two were
unspecified (3⋅9%), and the median age was 41⋅0 years
with a range of 18–71 years. 31 respondents (60⋅8%), two
unspecified (3⋅9%), were members of organisations of
people with mental and psychosocial disabilities. All
respondents were literate, and most were involved in
advocacy around mental health issues. As such, one
limitation of our consultation is that it captures the
expertise and opinions of people already knowledgeable
about issues of mental health and human rights.
Violations of human rights
To explore the lived-out reality of rights and their violation
in countries with low and middle incomes, we first asked
respondents to give their personal definition of human
rights. Although there was some variability in the
responses, several broad themes emerged. Human rights
were seen by respondents to be “inherent entitlements”
which “no one can take [away]”. In addition to meeting
basic needs (eg, health, food, education, and employment)
1666
and guaranteeing basic freedoms (eg freedom from
discrimination, freedom of expression), respondents
believed that human rights allow a person to “live a
decent life in society”, and have a life that is “harmonious
and happy”. Respondents further noted that human rights
involves the freedom to participate in community life
while being able to live independently. By contrast with
alienation, marginalisation, and denied opportunities,
human rights confer “full recognition of a sense of being
human” with “mutual respect of our human dignity”.
In the context of disability, according to one respondent
from Nepal, human rights are “that which says that all
are equal despite their disabilities and that [everyone]
should be treated the same without discrimination”.
Another respondent from Jordan said that “the most
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
rights violations that respondents described from their
own experience are shown in panel 3.
Restriction of civil, cultural, economic, political,
and social rights
The stigma and misconceptions associated with mental
and psychosocial disabilities often result in people being
ostracised from their community. Pervasive stigma and
discrimination affects a person’s ability to earn an
income, lift themselves out of poverty, and gain access to
treatment and support to integrate or reintegrate into
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 farreaching consequences. Respondents reported that discrimination at all stages of the employment process was
one of the main kinds of human rights violation that takes
place, both in terms of pervasiveness and impact (panel 4).
Difficulties begin at the stage of finding work, even when
the person is well qualified. A respondent from Ghana
reported that “even though I’m trained as an auto
mechanic, I find it difficult to get jobs because I’m deemed
to be ‘insane’ and not in the right frame of mind to do any
meaningful work”. Even when a person has a job, the
discrimination continues. A respondent from Belize
reported that “we [people with mental and psychosocial
disabilities] tend to be underpaid and overworked. We are
considered unprofessional, dangerous and incapable…
Our years of experience and performance are totally
disregarded because we always receive entry-level pay and
do not get benefits that others do”.
According to a previous report,2 unemployment rates
of up to 90% are not uncommon among people with
mental and psychosocial disabilities—a far higher rate
compared with people with other types of disabilities
and people without disabilities. Discrimination in
employment contributes to poverty, with some studies
showing that mental and psychosocial disabilities are
twice as frequent among people in the lowest income
www.thelancet.com Vol 378 November 5, 2011
Series
groups compared with people in the highest income
groups.1,3 31 respondents (60⋅8%) said that having a
mental and psychosocial disability adversely affected
their ability to find or maintain a job, and 28 respondents
(54⋅9%) said that their disability contributed to their or
their family’s poverty. A common theme was the need to
hide mental and psychosocial disabilities from employers.
One respondent from Kenya said that “one has to lie or
deny having a mental illness in order to be considered for
employment. When employed one has to hide the illness
and blame it on any other more ‘appropriate illness’ that
is socially acceptable or risk termination”.
Additionally, many people with mental and psychosocial
disabilities do not have access to social security benefits
or health insurance, which often leads to difficulties in
reintegrating into society. When social security is available,
which tends to be limited to middle-income, rather than
low-income countries, it is often structured in a way that
creates a disincentive for recovery, financial independence,
and workplace participation.4 This tends to perpetuate
patterns of unemployment and dependence.1,5–8
As reviewed in WHO’s Mental Health and Development
report, children and adolescents with mental and
psychosocial disabilities (including intellectual disabilities) face disproportionate barriers in accessing their
right to inclusive education.1 Poverty-related constraints
mean they are usually the first to be deprived of the
possibility of going to school.1 In many low-income and
middle-income countries, children and adolescents with
mental or psychosocial disabilities are institutionalised in
facilities that do not offer any kind of education.9,10 If they
are able to go to school, children in many countries are
sent to segregated or so-called special schools that offer
low-quality education, rather than being included in
mainstream education with tailored support.9,11 Failure to
provide appropriate support can result in poor academic
performance, school failure, and high drop-out rates
compared with other children and adolescents.12
People with mental and psychosocial disabilities are
also restricted from exercising many civil rights.13,14 In
many low-income and middle-income countries, people
with mental and psychosocial disabilities are denied the
right to marry and have children.13,15 Marriage legislation
in a number of these countries states that being of
“unsound mind” or having a long-term mental health
condition can be grounds for annulment or divorce.1
Legislation in other countries with low and middle
incomes prohibits people with mental or psychosocial
disabilities from filing for divorce because these decisions
are made for them by their guardian. Their parental
rights are often also terminated.16
Lack of access to mental health services
In many low-income and middle-income countries,
people do not have access to basic mental health care.
The problems associated with affordability and access to
mental health services in these countries is one of the
www.thelancet.com Vol 378 November 5, 2011
few issues to have received attention in the literature.7 At
the heart of the issue is the dearth of funding and services
provided by governments in many low-income and
middle-income countries. Mental health services are
non-existent in many places. One respondent from Belize
said that his country “does not have enough trained
[professionals] in [mental health] areas to serve the entire
population. It took me 15 years to meet a psychiatrist”.
Even when mental health services are available, they are
often inaccessible.6,17 Consistent with previous studies,18
12 respondents (23⋅5%) noted that services were
disproportionately concentrated in major cities, which
can be many hours away.18 One Jordanian respondent
who lived 3 hours away from the nearest services said that
“it is costly financially and physically to get to the services”.
These accessibility problems inhibit a large part of the
population from having proper access to mental health
services because they cannot afford the journey, the
transportation systems are too unreliable, or the
opportunity costs involved are too high.19
In most countries with low and middle incomes, the
absence of community-based mental health care means
there is a disproportionate reliance on psychiatric
institutions as the main provider of mental health
services.20 Not only does this discourage access to services
and hinder a person’s ability to live and participate in
their own community, but these institutions are often
associated with gross human rights violations (panel 4).
Abuses in residential facilities and places of
detention
Many previous reports have documented the poor
physical conditions in many facilities accessed by people
with mental and psychosocial disabilities.1,21–23 Although
this usually refers to substandard living conditions in
residential mental health facilities and psychiatric
hospitals, it is important to recognise that poor conditions
and infrastructure are also prevalent in prisons, nursing
homes, halfway houses, and facilities for traditional or
spiritual healing.24
The absence, or denial, of the basic necessities of living
(including adequate shelter, food, and sanitary facilities)
is itself a violation of a person’s fundamental human
rights. Several previous reports and responses from
respondents have documented living conditions in
residential facilities that are inhuman and degrading
because of problems such as overcrowding, outbreaks of
preventable diseases caused by unsanitary conditions,
poor physical infrastructures, hypocaloric food, and
pervasive tobacco smoke.23,25,26 Deficiencies in the built
environment of mental health facilities can impede
effective treatment and recovery,27 which can result in
worsened mental and physical health of service users.1
This is shown by the account of one respondent’s
admission to a psychiatric institution in Zambia: “alas,
the place of my treatment and care turned out to be a
horrible place to live in. It was characterised [by]
1667
Series
Panel 5: Major strategies for improving the human rights
of people with mental and psychosocial disabilities as
identified by respondents, sorted by descending frequency
• Running public-awareness and anti-stigma campaigns,
and providing education about the rights of people with
mental and psychosocial disabilities, as well as about
mental health in general
• Providing better training of mental health professionals,
increased funding for mental health services, and
provision of better mental health services, especially in
the community
• Promoting the empowerment, rehabilitation, and
participation of people with mental and psychosocial
disabilities in their communities
• Implementing effective and humane laws and policies to
protect and promote the human rights of people with
mental and psychosocial disabilities
• Encouraging the formation of, and providing ongoing
support to, organisations of people with mental and
psychosocial disabilities
• Monitoring and assessment of human rights of people
with mental and psychosocial disabilities, and of mental
health services generally
• Integrating mental health into overall health and
development policies
unhygienic living conditions, physical abuse, nakedness,
and lack of enough food. This experience taught me that
mental hospitals are more of a torture chamber causing
more mental anguish and torment than ameliorating the
mental situation of patients…It led to feelings [of ]
worthlessness, helplessness and hopelessness”.
Beyond the human rights violations caused by the poor
conditions in facilities, people with mental and psychosocial disabilities are often subjected to ill-treatment
including physical, mental, and sexual abuse, and neglect.
These are common occurrences in facilities throughout
the world and are well documented in previous reports
and in the responses of respondents.22,25,28
Arbitrary detention takes place in many low-income and
middle-income countries, whereby psychiatric confinement
is ordered without any basis by the justice system or others
in a position of power.21,29 The result is that people are often
locked in hospitals for years without their legal or medical
status being assessed, and subjected to psychiatric
interventions without informed consent.30–32 Seclusion,
isolation, and restraint—used as punishment or coercion—
are another feature of many institutions.5,19,33,34 In many
low-income and middle-income countries, there is an
absence of recovery-oriented treatment,35 with people with
mental and psychosocial disabilities chained to beds or
posts and made immobile for long periods of time.1,36
A further problem is the use of harmful practices often
described as mental health treatments. One such so-called
treatment is unmodified electroconvulsive therapy (ECT),
1668
which is done without anaesthesia or muscle relaxants—a
condemned practice that can constitute torture or illtreatment, but one that continues in several countries
with low and middle incomes.27,31,37 In other contexts,
harmful treatment practices can involve abuse by some
traditional healers and religious practitioners, including
beatings and the use of shackles and chains as purportedly
curative measures.1,5,19,24
Restriction on the exercise of legal capacity
Human rights violations often occur when individuals
are denied their right to exercise their legal capacity. In
many countries, including some with low and middle
incomes, people with mental or psychosocial disabilities
are deprived of their legal right to make decisions, and
the authority is handed to a third person, a guardian. This
guardian—often a family member, a government official,
or a local service provider—can then make decisions on
behalf of the person in areas such as where and with
whom they should live, how their money, property, and
personal affairs should be managed, and other aspects of
their daily lives.16,38 Decisions concerning health care are
also made by guardians, which can result in people being
detained in mental health facilities and treated against
their will. Despite the far-reaching powers that can be
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
right to exercise their legal capacity more generally.1,27
The denial of legal capacity can also mean that a person
is excluded from participation in social and political life,
such as the right to vote or be elected, and to participate
in the development and implementation of laws and
policies that concern them.1,38
Evidence-based strategies to improve human
rights
Such a pervasive pattern of systemic violations of human
rights of people with mental and psychosocial disabilities
requires a range of strong, inclusive, and integrated
strategies to be adopted in response. Unfortunately, there
is a paucity of evidence for the effectiveness of such
strategies in low-income and middle-income countries.
We review the available evidence in conjunction with the
recommended strategies suggested by respondents
(panel 5) and the obligations set out in the CRPD. The
CRPD is an important reference point because of its
authoritative status in both informing and enforcing
strategies to improve rights for people with mental and
psychosocial disabilities.
Overall, there was a very good match between these
three components (the existing evidence, the respondents,
and the CRPD). However, respondents also identified
several specific strategies relating to participation and
empowerment that have not yet been considered. These
strategies emerged as consistent themes from respondents
from a range of different low-income and middle-income
www.thelancet.com Vol 378 November 5, 2011
Series
countries and with different life experiences, and as such
warrant greater attention.
At the outset, it is important to be mindful that the
strategies discussed below should not exist in isolation
from each other, nor can they be seen as a set of
discretionary goals that receive attention by governments
and development stakeholders only when it is
convenient.39 As one respondent from Nepal pointed out,
all strategies “must be interwoven within the overall
planning of national development. The permanent
solution to this problem cannot be imagined outside the
overall development strategy of the government”.
Information, training, and education campaigns
The attitude of society as a whole has an important role
in the way people with mental and psychosocial
disabilities are treated in the community and by mental
health professionals. Respondents stated that ignorance
or false beliefs about people with mental and psychosocial
disabilities is one of the leading reasons that human
rights violations occur—a theme that is substantiated in
previous reports. Studies from low-income and middleincome countries show that people with mental and
psychosocial disabilities are incorrectly perceived to be
violent, dangerous, or unpredictable. Such negative
attitudes are held not only by the general public, but also
by health professionals and policy makers.40–42
A respondent from Georgia said that the prevailing belief
in his country is that “a person with mental disabilities is
not considered as a human being at all”. These perceptions
are associated with greater social distance from people
with mental and psychosocial disabilities.28 According to
one respondent from Nepal: “society perceives [us] as
degraded human beings facing punishment for their
past actions. Wrong beliefs of illness give society an open
social license to discriminate against mentally affected
people. Therefore, people with mental and psychosocial
disabilities experience human rights violations”.
In response, information and education campaigns are
crucial. Article 8 of the CRPD mandates that State Parties
adopt measures to initiate and maintain awareness
campaigns and human rights training to promote a
greater understanding of the “skills, merits and abilities”
of persons with disabilities. Raising awareness among
different stakeholders about government obligations in
relation to the CRPD is also important, and efforts are
being made in this direction (panel 6).
A large proportion of respondents saw education
campaigns as a necessary precondition for reform. For
example, one respondent from Nepal said that although
a multifaceted approach is needed, “at the basic level,
nothing can be done without the awareness in people,
so [the] government must invest amply to spread
such awareness”.
Such campaigns have already been used widely to
advance public understanding on mental health, reduce
stigma and discrimination, and promote human rights
www.thelancet.com Vol 378 November 5, 2011
Panel 6: Raising awareness of the UN Convention on the
Rights of Persons with Disabilities (CRPD): the
International Diploma on Mental Health Law
In 2008, the Indian Law Society in Pune, India, in
collaboration with WHO, set up the International Diploma in
Mental Health Law and Human Rights. The Diploma aims to
build capacity in countries to promote the rights of persons
with mental disabilities in line with the CRPD and other
international human rights standards.
Participants on the course include government officials,
people with mental and psychosocial disabilities, families,
health professionals, lawyers, human rights defenders, and
social workers. The aim of the diploma is to equip national
actors with the skills needed to be able to advocate for
human rights and influence national reform efforts.
in high-income countries.40 However, there are few
examples of such campaigns in low-income and middleincome countries, and fewer assessments of their
effectiveness.43 The available evidence suggests that
campaigns lead to improved public knowledge about
mental health conditions, increased awareness of mental
health services and effective treatment, knowledge about
mental health and attitudes towards people with mental
and psychosocial disabilities, and increased demand for,
and use of, community-based mental health services.44–47
Several factors have been shown to improve the
effectiveness of information campaigns. People with
mental and psychosocial disabilities, their families, and
carers should have an active role in identifying priority
areas to be addressed by campaigns, and be involved in
their design, delivery, and assessment.48 Research to
understand the characteristics of the recipients of
information campaigns makes it more likely that the
messages will be targeted, and the use of appropriate
media channels improves the likelihood of effectively
engaging specific groups. The testimony of people with
mental and psychosocial disabilities themselves has been
identified to be a very significant factor in reducing
stigmatising attitudes.49 Finally, information campaigns
should be conducted on a long-term, routine basis.48
Many respondents noted that people with authority
(including health professionals, government ministers,
and officials) are the most resistant groups when it
comes to improving the human rights of people with
mental and psychosocial disabilities. Previous reports
have also emphasised that negative attitudes towards
people with mental and psychosocial disabilities are
frequent among mental health professionals.34,50,51 Such
attitudes must be addressed through the specific training
and education of people acting on behalf of the state or
with other social authority so that all sections of society
are aware of the rights of people with mental and
psychosocial disabilities. This view was summarised by
a respondent from Sri Lanka: “the whole society needs
1669
Series
to become aware of mental [and psychosocial disabilities].
From the President to the ordinary voter, people must
become aware—especially [people] from government
organisations, temples, schools, transport services, [and
the] police”.
Provision of services in the community
As already discussed, low-income and middle-income
countries face several challenges in relation to access to
mental health care. Psychosocial care and rehabilitation
services and essential medicines are often unavailable,
inaccessible, or unaffordable, which further constrains
treatment and recovery, often with cross-generational
consequences.6,7,52,53
In the limited number of low-income and middleincome countries where budgets for mental health
services exist, most expenditure goes on psychiatric
hospitals or other forms of custodial care associated with
violations of human rights,6,54 rather than on communitybased services. An important response to this is the need
for low-income and middle-income countries to provide
mental health and other services in the community to
improve both access and quality of services and promote
independent living in society in accordance with articles
19 and 25 of the CRPD. Providing better mental health
service is necessarily contingent on providing better
training for mental health professionals, a view echoed
by many respondents. It also entails equipping primary
health-care providers with skills in evidence-based mental
health treatment and care. As a respondent from Kenya
noted, “mental and physical health exist as separate
entities”, and “other physicians and nurses…have no
training or information on mental health. Existing
medical personnel need to be trained continuously on
mental health issues so that they can…handle both issues
as well as put into place referral systems”.
When mental health services are available and
adequately staffed by trained professionals in primary
and community settings they are known to be more
acceptable, accessible, and affordable, and produce better
health and mental health outcomes. As a Jordanian
respondent noted: “the clinic where I get my medications
and therapy sessions is close to my house and my
workplace. It’s in a strategic place where anybody can get
to it within [the city]”. Despite this evidence, no country in
the world has yet managed to effectively provide services
in the community nationwide.1,17,55
However, simply providing mental health services in
the community is not sufficient. A broad set of services
or programmes are needed to enable people to attain and
maintain maximum independence and full inclusion in
society in line with the CRPD. Habilitation and rehabilitation services, including vocational and life-skills
development but also in-home, residential, personal
assistance and other community-support services, are
vital to achieving independence and inclusion. Social and
health-care services need to adopt a holistic approach to
1670
meet the multiple needs of people with mental and
psychosocial disabilities. Strong links are needed with
other sectors to ensure that people have access to housing,
education, and employment.1,17
Employment schemes, in which people with mental
and psychosocial disabilities undertake paid work with
ongoing support and training, have been consistently
shown in studies in low-income and middle-income
countries to result in higher employment rates, better
wages, more hours of employment per month, and better
mental health.1,56–58 Additionally, income generation
programmes and social grants have been shown to
benefit people with mental and psychosocial disabilities,
their families, and communities, but are absent in many
countries with low and middle incomes.1,6,59
Successful community inclusion also relies on making
educational opportunities available and accessible to
children with mental and psychosocial disabilities, and
ensuring that barriers preventing their attendance at
schools are removed. Once in the educational system,
school-based mental health programmes can prevent
the onset or worsening of mental health conditions into
adulthood, and help to maximise the number of people
completing education, which improves opportunities
for employment.1
Empowerment of people with mental and
psychosocial disabilities
As already discussed (panel 3), marginalisation, exclusion,
and discrimination against people with mental and
psychosocial disabilities were seen by respondents as the
most common human rights violations. One respondent
from Sri Lanka noted that: “social discrepancy is high.
The human rights of those who are unable to do anything
are violated more”. Accordingly, empowering people with
mental and psychosocial disabilities both individually and
collectively is one of the key strategies for change (panel 5).
The participation of people with disabilities as equal
members of society in all aspects of living is one of the
fundamental principles that underpins the entire CRPD.
At the individual level, efforts need to focus on ensuring
that people with mental and psychosocial disabilities are
able to exercise their legal capacity in line with article 12
of the CRPD. By contrast with traditional but rightsrestricting models of plenary guardianship, the CRPD
requires that State Parties recognise the right of people
with disabilities to enjoy legal capacity on an equal basis
with others in all aspects of life. Additionally, the CRPD
puts forward a supported decision-making model. This
model enables people to retain their legal capacity and at
the same time choose to receive support in exercising
this right when they desire it and when it is needed.60,61
The person remains at the centre of decision making on
issues that affect him or her, and when necessary, support
can be on-hand to explain relevant issues and interpret
and communicate the signs and preferences of the
individual.62 Types of support might include advocates, a
www.thelancet.com Vol 378 November 5, 2011
Series
personal ombudsperson, community services, personal
assistants, peer supports, and advance planning.63
Public and collective participation can be encouraged
by establishing or strengthening organisations of people
with mental and psychosocial disabilities. In most lowincome and middle-income countries, there are few
organisations made up of and run by such people.1 The
resultant lack of social support creates a sense of isolation
and powerlessness for many people. A respondent from
Belize commented that “[people with mental and psychosocial disabilities] are vulnerable and are still camouflaged
in the community; they are not a strong and united
group”, while a respondent from Egypt commented that
“they cannot defend themselves and they cannot speak
out for themselves out loud”.
In fact, the lack of independent organisations of people
with mental and psychosocial disabilities was seen by
some respondents as a principal reason that human
rights violations occur. This is consistent with respondents’
view that the establishment of such organisations would
be a crucial way of promoting acceptance and positive
change in attitudes. Empowering people with mental and
psychosocial disabilities to self-organise and advocate for
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 are given a collective political
voice to influence and lobby for policy and legislative
reform.65–67 One respondent from Tajikistan said that
belonging to such an organisation “[has] made my life
more positive and useful despite the huge stigma and
discrimination I experienced before and a bit now. The
positive side is that I can understand users and their
feelings so that…we [can] help each other”.
States have an obligation, under article 29 of the CRPD,
to “promote actively an environment in which persons
with disabilities can effectively and fully participate in the
conduct of public affairs, without discrimination and on
an equal basis with others”. This can be achieved by
encouraging people’s participation in or forming of
NGOs and political parties. The participation of people
with mental and psychosocial disabilities is a key strategy
to ensure that their personal experience and knowledge
drives reform and that laws, policies, and services are
acceptable, address their needs, and respect their human
rights in accordance with article 4 of the CRPD.1,68,69 Such
steps must be carried out together with a dismantling of
overarching legal barriers such as restrictions on the
exercise of legal capacity, which prevents people from
joining associations and exercising their political rights.
A systematic review on the effect of involving people
with mental and psychosocial disabilities in the training
of mental health service providers and in the assessment
of mental health services found that involvement
improved service users’ quality of life and social
functioning and resulted in trainees having a more
positive attitude towards people with mental and
www.thelancet.com Vol 378 November 5, 2011
Panel 7: Key UN and regional human rights instruments
UN instruments
• Convention on the Rights of Persons with Disabilities
• International Covenant on Economic, Social and
Cultural Rights
• International Covenant on Civil and Political Rights
• Convention Against Torture and Other Cruel, Inhuman
or Degrading Treatment or Punishment and its
Optional Protocol
Regional instruments
• African Charter on Human and Peoples’ Rights
• American Convention on Human Rights
• Additional Protocol to the American Convention on
Human Rights in the area of Economic, Social, and
Cultural Rights
• Inter-American Convention on the Elimination of All
Forms of Discrimination Against Persons with Disabilities
• European Convention for the Protection of Human Rights
and Fundamental Freedom
• European Convention for the Prevention of Torture and
Inhuman or Degrading Treatment or Punishment
psychosocial disabilities.1,68,70 Participation also leads to
assessments that are more likely to address people’s
requirements and concerns.71,72 Additional benefits
include the development of more relevant outcome
indicators, a better quality of information obtained from
service recipients, and practical change strategies to
improve services.73 Despite these benefits there is little
evidence of countries involving people with mental and
psychosocial disabilities in service assessment.71
Law and policy reform
Law and policy reform is a key strategy identified in
previous reports and by respondents to promote human
rights. Well formulated policies and laws can promote the
development of accessible services in the community,
stimulate advocacy and education campaigns, and
establish legal and oversight mechanisms to prevent
human rights violations.1,74–77 Mental health policies and
laws in low-income and middle-income countries are
absent in many cases, and where they exist they fail to
incorporate current international human rights and best
practice standards, in some cases actively violating human
rights.1,6,78–80 In reference to legislation specifically, one
respondent from Nepal said that “[our] laws are
discriminatory. They encourage the authorit[ies] to
imprison and then [ forcibly] start treatment on mentally
affected persons”. It is therefore crucial that policies and
laws are introduced in line with international human
rights standards including the CRPD and other
instruments (panel 7). This requires the active involvement of people with mental and psychosocial disabilities
in the policy-making process. Historically, the development
1671
Series
of policies and laws has excluded people with mental and
psychosocial disabilities, which has meant that their
needs have not been adequately addressed.
There are opportunities to codify human rights
standards and proscribe violations and discrimination
not only in specific mental health policy and legislation,
but also in laws and policies on anti-discrimination,
general health, disability, employment, social welfare,
education, housing, and other areas. However, wellformulated policies and laws are of no use if they are not
put into effect. Indeed, respondents highlighted lack of
enforcement as a significant reason why human rights
violations occur, and that government commitment
is essential in order to establish mechanisms for
implementation and monitoring.
Establishment of legal and oversight mechanisms
The establishment of legal and oversight mechanisms to
protect the rights of people with mental and psychosocial
disabilities is mandated under articles 13–16 of the CRPD.
In many low-income and middle-income countries, there
is no well-defined independent judicial procedure or
mechanism that can be accessed by people admitted
involuntarily to mental health facilities to contest their
detention.37,81–83
In addition to judicial review mechanisms, regular
visits by independent bodies to mental health facilities
and other places of detention to inspect the conditions in
which residents live is crucial to prevent abuses and
ensure that fundamental rights are being respected. One
respondent from Georgia said that “specific cases of the
violation of patients’ rights should be highlighted.
Regular monitoring of human rights observance [must]
be carried out at psychiatric institutions”. Such
monitoring mechanisms are required by the CRPD and
the Optional Protocol of the UN Convention Against
Torture. This role can be undertaken by a dedicated
independent visiting committee or integrated into the
functions of existing monitoring mechanisms and
organisations such as national human rights institutions,
national ombudsperson offices, or NGOs.
Complaints mechanisms also need to be established
and made accessible to persons with mental and
psychosocial disabilities. Part of the reason why violations
continue unabated is that they are unreported. Legal
mechanisms therefore need to be in place to enable and
encourage people with mental and psychosocial
disabilities, their family members, friends, and advocates
to report any human rights violations freely and securely.
Examples of successful legal action
Legal remedies are being undertaken by local NGOs and
disabled people’s organisations. For example, Action for
Mental Illness (ACMI) is an Indian NGO that, in addition
to its other advocacy activities, has undertaken litigation
representing the needs and rights of people with mental
and psychosocial disabilities at provincial and national
1672
levels. In its ongoing litigation in the High Court of
Karnataka, ACMI’s actions have successfully led to
legislative and policy reforms, including setting
minimum standards for hospitals and nursing homes,
converting a state psychiatric hospital to an open-ward
system (ie, where patients are free to move around the
ward without their movements being restrained in any
form or manner), and establishing a budget for mental
health in the state. ACMI also continues to lobby for
mental health legislation to be made consistent with the
CRPD, and runs legal literacy workshops for people with
mental and psychosocial disabilities and their families.84
However, in many countries legal remedies are absent,
and in the absence of effective regulatory and oversight
mechanisms within the domestic sphere, many people
in low-income and middle-income countries have relied
on international and regional human rights systems and
organisations for justice and redress. Although the
jurisprudence of these bodies is in its infancy, the African
Court on Human and People’s Rights30 and the InterAmerican Court on Human Rights33 have all ruled on
matters related to the rights of people with mental and
psychosocial disabilities. The European Court of Human
Rights has a more developed case-law on rights issues,29,85
and the European Committee on Social Rights has
decided on two collective complaints concerning the
education of children with intellectual disabilities.86,87 The
European Committee for the Prevention of Torture also
visits all places of detention—including psychiatric
institutions—within member states, and reports its
findings and recommendations.88
International NGOs also have a crucial role in oversight
and redress. The Mental Disability Advocacy Center
(MDAC), for example, has been successful in strategic
litigation at international and national levels that has
brought about legislative reform. In the case of
Shtukaturov v Russia, the European Court of Human
Rights found that Russia had violated several rights of
the European Convention on Human Rights, which
subsequently led to the Russian Constitutional Court
striking down three provisions about capacity and
consent relating to people with mental and psychosocial
disabilities in Russian domestic law that the MDAC
argued were unconstitutional.89
However, although such international mechanisms can
be effective for facilitating reform and empowering the
people and groups involved, they should not be the
primary method for addressing human rights violations.
Oversight mechanisms, judicial review, and access to
legal remedies in domestic law must be available to
people with mental and psychosocial disabilities on an
equal and accessible basis.
Conclusions
People with mental and psychosocial disabilities in
low-income and middle-income countries continue to
experience a wide range of human rights violations,
www.thelancet.com Vol 378 November 5, 2011
Series
including the inability to access adequate mental health
services in a safe, therapeutic, and affordable setting.
Rights violations also include being subjected to stigma
and discrimination in the community, particularly in
relation to employment, and being denied the opportunity
to exercise legal capacity and civil, social, and political
rights. Abuse, and inhumane and degrading treatment,
are also sadly still commonplace.
Because the spectrum of violations against people
with mental and psychosocial disabilities is so wide, the
realisation of these rights depends on various entities
including the public and private sector, groups of
professionals, political and judicial bodies, and society
as a whole. As the CRPD makes clear, preventing
human rights violations and promoting a rightscompliant society for people with mental and
psychosocial disabilities needs the cooperative
participation of all stakeholders. This begins with
educating all parts of society, including all sectors of
government, health and mental health professionals,
the media, and of course people with mental and
psychosocial disabilities and their families about mental
health and human rights.
The CRPD and other international human rights
standards require states and the international community
to empower people with mental and psychosocial
disabilities, their organisations, and civil society. Civil
society must be enlisted as advocates and agents for
change, holding governments accountable for meeting
their obligations with regard to human rights. To rectify
this historic and ongoing neglect and mistreatment, it is
essential to create clear benchmarks or indicators of
tangible progress, with rigorous monitoring and assessment at the state and international level. Additionally,
more research must be devoted to examining the
effectiveness of strategies to prevent violations and
promote the rights of people with mental and psychosocial
disabilities. This research must be informed by the
expertise, knowledge, and opinions of people with mental
and psychosocial disabilities. However, lack of research
cannot be an excuse for complacency: sufficient evidence
exists to spur governments, civil society, and other
development stakeholders into taking action to end
violations and promote the rights of people with mental
and psychosocial disabilities.
Contributors
ND, MF, ST, and BS were involved in the conception of this article and
the design of the consultation methodology. ND, MF, ST, JL, EC, and SK
were involved in the data collection process. ND, MF, SP, and OL did the
review of the literature. ND, MF, ST, LG, and BS did the qualitative data
analysis and interpretation. All authors were involved in the drafting,
revision, and finalisation of the article.
Conflicts of interest
We declare that we have no conflicts of interest.
Acknowledgments
We thank all the people with mental and psychosocial disabilities and
their organisations who provided their expertise and opinion on issues
related to mental health and human rights. We also acknowledge a
www.thelancet.com Vol 378 November 5, 2011
number of people for their help and support in the development of this
article: Albert Maramis, Anita Marini, BasicNeeds Sri Lanka,
Charlene Sunkel, Dan Taylor, Daniel Rivera, George-Tudor Florea,
Jan-Paul Kwasik, Manana Sharashidze, Moody Zaki, Patricia Robertson,
Sarah Skeen, and Shadi Jaber.
References
1
Funk M, Drew N, Freeman M, Faydi E, WHO. Mental health and
development: targeting people with mental health conditions as a
vulnerable group. World Health Organization, 2010. http://www.
who.int/mental_health/policy/mhtargeting/en/index.html
(accessed Feb 1, 2011).
2
Harnois G, Gabriel P, WHO, ILO. Mental health and work: impact,
issues, and good practices. International Labour Organization.
http://www.ilo.org/skills/what/pubs/lang--en/docName-WCMS_108152/index.htm (accessed Feb 12, 2011).
3
Patel V, Araya R, de Lima M, Ludermir A, Todd C. Women, poverty
and common mental disorders in four restructuring societies.
Soc Sci Med 1999; 49: 1461–71.
4
Knapp M, Funk M, Curran C, Prince M, Grigg M, McDaid D.
Economic barriers to better mental health practice and policy.
Health Policy Plan 2006; 21: 157–70.
5
Santegoeds J. Another world is possible! Europe’s and Africa’s
common goals: the high needs of active social inclusion and
support of users and survivors of psychiatry. Stichting Mind Rights,
2007. http://www.mindrights.nl/report_wsf_2007_nairobi_kenya.
htm (accessed Feb 12, 2011).
6
WHO. Mental health atlas: 2005. World Health Organization, 2005.
http://whqlibdoc.who.int/publications/2005/924156296X_eng.pdf
(accessed Feb 12, 2011).
7
Saxena S, Thornicroft G, Knapp M, Whiteford H. Resources for
mental health: scarcity, inequity, and inefficiency. Lancet 2007;
370: 878–89.
8
WHO. Mental health systems in selected low- and middle-income
countries: a WHO-AIMS cross-national analysis. World Health
Organization, 2009. http://www.who.int/mental_health/evidence/
who_aims_report_final.pdf (accessed June 8, 2011).
9
Open Society Mental Health Initiative. Access to education and
employment for people with intellectual disabilities: an overview
of the situation in central and eastern Europe. Open Society Mental
Health Initiative, 2006. http://www.osmhi.org/contentpics/202/
MHIReportEdEmp3Oct.pdf (accessed Feb 12, 2011).
10 Mental Disability Rights International, Asociación Pro Derechos
Humanos. Human rights and mental health in Peru. Mental
Disability Rights International, 2004. http://www.mdri.org/PDFs/
reports/Peru%20Report%20-%20Eng%20-%20Final.pdf (accessed
Feb 12, 2011).
11 UNICEF Innocenti Research Centre. Children and disability in
transition in CEE/CIS and Baltic states. United Nations Children’s
Fund, 2005. http://www.unicef.org/ceecis/Disability-eng.pdf
(accessed Feb 13, 2011).
12 Patel V, Flisher AJ, Nikapota A, Malhotra S. Promoting child and
adolescent mental health in low and middle income countries.
J Child Psychol Psychiatry 2008; 49: 313–34.
13 Menon DK, Peshawaria R, Ganguli R. Public policy issues in
disability rehabilitation in developing countries of south-east Asia.
Asia Pacific Disability Rehabilitation Journal, 2002. http://www.aifo.
it/english/resources/online/apdrj/selread102/menon.doc (accessed
Feb 14, 2011).
14 Sharma S. Human rights of mental patients in India: a global
perspective. Curr Opin Psychiatry 2003; 16: 547–51.
15 Raye KL. Violence, women and mental disability. Mental Disability
Rights International, 1999. http://www.handicap-international.fr/
bibliographie-handicap/4PolitiqueHandicap/groupes_particuliers/
Femmes_Genre/violence.doc (accessed Feb 12, 2011).
16 Mental Disability Advocacy Center. Guardianship and human
rights in Russia: analysis of law, policy and practice. Mental
Disability Advocacy Center, 2007. http://www.mdac.info/
documents/Russia%20report_comprehensive_English.pdf
(accessed Feb 14, 2011).
17 WHO, World Organization of Family Doctors. Integrating mental
health into primary care: a global perspective. World Health
Organization, 2008. http://whqlibdoc.who.int/publications/2008/
9789241563680_eng.pdf (accessed Feb 12, 2011).
1673
Series
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
1674
Kigozi F, Ssebunnya J, Kizza D, Cooper S, Ndyanabangi S. An
overview of Uganda’s mental health care system: results from an
assessment using the World Health Organization’s assessment
instrument for mental health systems (WHO-AIMS).
Int J Ment Health Syst 2010; 4: 1.
Read UM, Adiibokah E, Nyame S. Local suffering and the global
discourse of mental health and human rights: an ethnographic
study of responses to mental illness in rural Ghana. Global Health
2009; 5: 13.
Saraceno B, van Ommeren M, Batniji R, et al. Barriers to
improvement of mental health services in low-income and
middle-income countries. Lancet 2007; 370: 1164–74.
Amnesty International. Bulgaria: arbitrary detention and
ill-treatment of people with mental disabilities. Amnesty
International, 2002. https://www.amnesty.org/en/library/asset/
EUR15/008/2002/en/f388a832-d7fd-11dd-9df8-936c90684588/
eur150082002en.pdf (accessed Feb 15, 2011).
Gostin L. “Old” and “new” institutions for persons with mental
illness: treatment, punishment or preventive confinement?
Public Health 2008; 122: 906–13.
Disability Rights International, Comisión Méxicana de Defensa
y Promoción de los Derechos Humanos. Abandoned and
disappeared: Mexico’s segregation and abuse of children and
adults with disabilities. Disability Rights International, 2010.
http://www.disabilityrightsintl.org/wordpress/wp-content/
uploads/Mex-Report-English-Nov30-finalpdf.pdf (accessed
Feb 12, 2011).
Ae-Ngibise K, Cooper S, Adiibokah E, et al. “Whether you like it
or not people with mental problems are going to go to them”:
a qualitative exploration into the widespread use of traditional
and faith healers in the provision of mental health care in Ghana.
Int Rev Psychiatry 2010; 22: 558–67.
Anas AA. Exposed: inside Ghana’s “Mad House”. Myjoyonline.com
2009. http://news.myjoyonline.com/news/200912/39569.asp
(accessed Feb 12, 2011).
Primanita A. Doctors to inspect overcrowded shelters where
mentally ill patients are dying. Jakarta Globe, 2009. http://www.
thejakartaglobe.com/jakarta/doctors-to-inspect-overcrowdedshelters-where-mentally-ill-patients-are-dying/276720 (accessed
Feb 12, 2011).
European Committee for the Prevention of Torture and Inhuman
or Degrading Treatment or Punishment. Report to the Turkish
Government on the visit to Turkey carried out by the European
Committee for the Prevention of Torture and Inhuman or Degrading
Treatment or Punishment (CPT). CPT/Inf 2006; 30.
Lamichhane J. Nepal’s victims of ignorance. guardian.co.uk 2010;
http://www.guardian.co.uk/commentisfree/2010/oct/07/
mental-health-provision-nepal (accessed Feb 14, 2011).
European Court of Human Rights. Factsheet: mental health.
European Court of Human Rights, 2011. http://www.echr.coe.int/
NR/rdonlyres/4F36D680-0FA4-4124-98CE-A20FB9E754FC/0/
FICHES_Sant%C3%A9_mentale_EN.pdf (accessed Feb 15, 2011).
Purohit and Moore v The Gambia. African Court on Human
and People’s Rights. 241/2001. 2001.
UN General Assembly. Interim report of the Special Rapporteur
on torture and other cruel, inhuman or degrading treatment or
punishment. United Nations, 2008; A/63/175. http://daccess-dds-ny.
un.org/doc/UNDOC/GEN/N08/440/75/PDF/N0844075.
pdf?OpenElement (accessed Feb 13, 2011).
Viana Acosta v Uruguay 110/1981. UN HRC, UN Doc Supp N 40
(A/39/40) 169. 1984.
Ximenes-Lopes v Brazil. Inter-American Court of Human Rights.
Series C No 149. Judgment of July 4, 2006.
Ahern L, Rosenthal E. Torment not treatment: Serbia’s segregation
and abuse of children and adults with disabilities. Mental
Disability Rights International, 2007. http://www.mdri.org/PDFs/
reports/Serbia-rep-english.pdf (accessed Feb 13, 2011).
Roberts H. A way forward for mental health care in Ghana? Lancet
2001; 357: 1859.
Ahern L, Rosenthal E. Hidden suffering: Romania’s segregation
and abuse of infants and children with disabilities. Mental
Disability Rights International, 2009. http://www.mdri.org/PDFs/
reports/romania-May%209%20final_with%20photos.pdf (accessed
Feb 13, 2011).
37
38
39
40
41
42
43
44
45
46
47
48
49
50
51
52
53
54
55
56
57
58
59
WHO. WHO resource book on mental health, human rights and
legislation. World Health Organization, 2005. http://www.who.
int/mental_health/policy/resource_book_MHLeg.pdf (accessed
Feb 13, 2011).
European Union Agency for Fundamental Rights. The right to
political participation of persons with mental health problems and
persons with intellectual disabilities. European Union Agency for
Fundamental Rights, 2010. http://fra.europa.eu/fraWebsite/
attachments/Report-vote-disability_EN.pdf (accessed
Feb 12, 2011).
Skeen S, Kleintjes S, Lund C, et al. “Mental health is everybody’s
business”: roles for an intersectoral approach in South Africa.
Int Rev Psychiatry 2010; 22: 611–23.
Kermode M, Bowen K, Arole S, Pathare S, Jorm AF. Attitudes to
people with mental disorders: a mental health literacy survey in a
rural area of Maharashtra, India. Soc Psychiatry Psychiatr Epidemiol
2009; 44: 1087–96.
Adewuya AO, Makanjuola ROA. Social distance towards people
with mental illness in southwestern Nigeria. Aust N Z J Psychiatry
2008; 42: 389–95.
Hugo CJ, Boshoff DEL, Traut A, Zungu-Dirwayi N, Stein DJ.
Community attitudes toward and knowledge of mental illness in
South Africa. Soc Psychiatry Psychiatr Epidemiol 2003; 38: 715–19.
Thornicroft G, Rose D, Kassam A, Sartorius N. Stigma: ignorance,
prejudice or discrimination? Br J Psychiatry 2007; 190: 192–93.
Angermeyer MC, Dietrich S. Public beliefs about and attitudes
towards people with mental illness: a review of population studies.
Acta Psychiatr Scand 2006; 113: 163–79.
Kakuma R, Kleintjes S, Lund C, Drew N, Green A, Flisher A.
Mental health stigma: what is being done to raise awareness
and reduce stigma in South Africa? Afr J Psychiatry 2010; 13: 116–24.
Stuart H. Fighting the stigma caused by mental disorders: past
perspectives, present activities, and future directions.
World Psychiatry 2008; 7: 185–88.
Eaton J, Agomoh AO. Developing mental health services in Nigeria.
Soc Psychiatry Psychiatr Epidemiol 2008; 43: 552–58.
Sartorius N. Short-lived campaigns are not enough. Nature 2010;
468: 163–65.
Pinfold V, Thornicroft G, Huxley P, Farmer P. Active ingredients in
anti-stigma programmes in mental health. Int Rev Psychiatry 2005;
17: 123–31.
Kapungwe A, Cooper S, Mwanza J, et al. Mental illness: stigma
and discrimination in Zambia. Afr J Psychiatry 2010; 13: 192–203.
Nordt C, Rössler W, Lauber C. Attitudes of mental health
professionals toward people with schizophrenia and major
depression. Schizophr Bull 2006; 32: 709–14.
WHO. Mental health, poverty and development. World Health
Organization, 2009. http://www.who.int/nmh/publications/
discussion_paper_en.pdf (accessed Feb 13, 2011).
Saxena S, Sharan P, Saraceno B. Budget and financing of mental
health services: baseline information on 89 countries from WHO’s
project atlas. J Ment Health Policy Econ 2003; 6: 135–143.
Raja S, Wood SK, de Menil V, Mannarath SC. Mapping mental
health finances in Ghana, Uganda, Sri Lanka, India and Lao PDR.
Int J Ment Health Syst 2010; 4: 11.
Taylor TL, Killaspy H, Wright C, et al. A systematic review of the
international published literature relating to quality of institutional
care for people with longer term mental health problems.
BMC Psychiatry 2009; 9: 55.
Twamley EW, Jeste DV, Lehman AF. Vocational rehabilitation in
schizophrenia and other psychotic disorders: a literature review and
meta-analysis of randomized controlled trials. J Nerv Ment Dis 2003;
191: 515–23.
BasicNeeds. Mental health and development: a model in practice.
BasicNeeds, 2008. http://www.basicneeds.org/download/PUB%20
-%20Mental%20Health%20and%20Development%20A%20
Model%20in%20Practice.pdf (accessed Feb 1, 2011).
Yip KS. Vocational rehabilitation for persons with mental illness
in the People’s Republic of China. Adm Policy Ment Health 2007;
34: 80–85.
Mitchell D, Harrison M. Studying employment initiatives for people
with mental health problems in developing countries: a research
agenda. Prim Health Care Res Dev 2001; 2: 107–16.
www.thelancet.com Vol 378 November 5, 2011
Series
60
61
62
63
64
65
66
67
68
69
70
71
72
73
74
75
Dhanda A, Narayan T. Mental health and human rights. Lancet
2007; 370: 1197–98.
Dhanda A. Legal capacity in the disability rights convention:
stranglehold of the past or lodestar for the future?
Syracuse Journal of International Law and Commerce 2007; 34: 429–62.
UN. From exclusion to equality: realizing the rights of persons with
disabilities: Handbook for parliamentarians on the Convention of
the Rights of persons with disabilities and its optional protocol.
United Nations, 2007. http://www.un.org/disabilities/documents/
toolaction/ipuhb.pdf (accessed Feb 13, 2011).
IDA CRPD Forum. Principles for the implementation of Article 12.
Psychrights. http://psychrights.org/Countries/UN/
FinalArticle12principles.pdf (accessed Feb 13, 2011).
Fitzsimons S, Fuller R. Empowerment and its implications for clinical
practice in mental health: a review. J Ment Health 2002; 11: 481–99.
WHO Regional Office for Europe. User empowerment in mental
health: a statement by the WHO Regional Office for Europe. World
Health Organization, 2010. http://www.euro.who.int/__data/assets/
pdf_file/0020/113834/E93430.pdf (accessed Feb 13, 2011).
Commission on Social Determinants of Health. Achieving health
equity: from root causes to fair outcomes: interim statement. World
Health Organization, 2007. http://whqlibdoc.who.int/publications/
2007/interim_statement_eng.pdf (accessed Feb 14, 2011).
Israel BA, Checkoway B, Schulz A, Zimmerman M. Health
education and community empowerment: conceptualizing and
measuring perceptions of individual, organizational, and
community control. Health Educ Q 1994; 21: 149–70.
Simpson E, House A. Involving users in the delivery and evaluation
of mental health services: systematic review. BMJ 2002; 325: 1265.
Crawford MJ, Aldridge T, Bhui K, et al. User involvement in the
planning and delivery of mental health services: a cross-sectional
survey of service users and providers. Acta Psychiatr Scand 2003;
107: 410–14.
Heywood M. South Africa’s treatment action campaign: combining
law and social mobilization to realize the right to health.
J Hum Rights Pract 2009; 1: 14–36.
Sweeney A, Wallcraft J. Quality assurance/monitoring of mental
health services by service users and carers. WHO Regional Office
for Europe, 2010. http://www.euro.who.int/__data/assets/
pdf_file/0004/124564/E94375.pdf.pdf (accessed Aug 23, 2011).
Thornicroft G, Tansella M. Growing recognition of the importance
of service user involvement in mental health service planning and
evaluation. Epidemiol Psichiatr Soc 2005; 14: 1–3.
Davidson L, Ridgway P, Schmutte T, O’Connell M. Purposes and
goals. In: Wallcraft J, Schrank B, Amering M, eds. Handbook of
service user involvement in mental health research.
Wiley-Blackwell; 2009.
Rosenthal E, Sundram CJ. The role of international human rights
in national mental health legislation. WHO, 2004. http://www.who.
int/mental_health/policy/international_hr_in_national_
mhlegislation.pdf (accessed Feb 13, 2011).
Funk M, Drew N, Saraceno B, et al. A framework for mental health
policy, legislation and service development: addressing needs and
improving services. Harv Health Pol Rev 2005; 6: 57–69.
www.thelancet.com Vol 378 November 5, 2011
76
77
78
79
80
81
82
83
84
85
86
87
88
89
Funk M, Drew N, Saraceno B. Global perspective on mental
healthpolicy and service development issues: the WHO angle.
World Health Organization, 2007. http://www.euro.who.int/__data/
assets/pdf_file/0007/96451/E89814.pdf (accessed Feb 13, 2011).
Funk M, Gale E, Grigg M, Minoletti A, Yasamy MT. Mental health
promotion: an important component of national mental health
policy. In: Herrman H, Saxena S, Moodie R, eds. Promoting mental
health: concepts, emerging evidence, practice. World Health
Organization, 2005. http://www.who.int/mental_health/evidence/
MH_Promotion_Book.pdf (accessed Feb 13, 2011).
Faydi E, Funk M, Kleintjes S, et al. An assessment of mental
health policy in Ghana, South Africa, Uganda and Zambia.
Health Res Pol Sys 2011; 9: 17.
WHO. Mental health and poverty project policy brief 8: developing
effective mental health policies and plans in Africa—7 key lessons.
World Health Organization, 2009. http://www.who.int/mental_
health/policy/development/MHPB8.pdf (accessed Feb 13, 2011).
WHO. Mental health and poverty project policy brief 7: developing
effective mental health laws in Africa. World Health Organization,
2009. http://www.who.int/mental_health/policy/development/
MHPB7.pdf (accessed Feb 13, 2011).
Trivedi JK, Narang P, Dhyani M. Mental health legislation in South
Asia with special reference to India: shortcomings and solutions.
Mental Health Rev J 2007; 12: 22–30.
Ahern L, Rosenthal E. Behind closed doors: human rights abuses
in the psychiatric facilities, orphanages and rehabilitation centers
of Turkey. Mental Disability Rights International, 2005. http://www.
mdri.org/PDFs/reports/turkey%20final%209-26-05.pdf (accessed
Feb 12, 2011).
Doku V, Ofori-Atta A, Akpalu B, et al. Phase 1. Country report:
a situation analysis of mental health policy development and
implementation in Ghana. Mental Health and Poverty Project,
2008. http://www.leeds.ac.uk/nuffield/documents/mental_health/
gh_mhpp08.pdf (accessed Feb 12, 2011).
National Human Rights Commission, National Institute of Mental
Health and Neuro Sciences. Mental health care and human rights.
National Human Rights Commission, 2008. http://nhrc.nic.in/
Publications/Mental_Health_Care_and_Human_Rights.pdf
(accessed June 8, 2011).
Bartlett P, Lewis O, Thorold O. Mental disability and the European
Convention on Human Rights. Leiden: Brill, 2006.
Autism-Europe v France. Complaint No 13/2002. European
Committee on Social Rights, 2003.
Mental Disability Advocacy Center (MDAC) v Bulgaria. Complaint
No 41/2007. European Committee on Social Rights, 2008.
European Committee for the Prevention of Torture and Inhuman
or Degrading Treatment or Punishment. The CPT in brief. CPT,
2010. http://cpt.coe.int/en/documents/eng-leaflet.pdf (accessed
Feb 14, 2011).
Mental Disability Advocacy Center. Where we work: Russia. Mental
Disability Advocacy Center. http://www.mdac.info/Russia (accessed
Feb 15, 2011).
1675
Comment
The authors are members of the Global Initiative for Emergency and Essential
Surgical Care (GIEESC). DAS participated in a WHO workshop in Mehsana, India, in
August, 2006 (non-funded), and has not received any funding for participation in
any activities related to the subject of this Comment. RAG has received travel and
accommodation payments from WHO for some of his consultant work for WHO.
1
2
3
4
Debas HT, Gosselin RA, McCord C, et al, eds. Disease control priorities in
developing countries, 2nd edn. New York: Oxford University Press, 2006:
1245–60.
Gosselin RA, Thind A, Bellardinelli A. Cost/DALY averted in a small hospital in
Sierra Leone: what is the relative contribution of different services?
World J Surg 2006; 30: 505–11.
McCord C, Chowdhury Q. A cost effective small hospital in Bangladesh: what it
can mean for emergency obstetric care. Int J Gynaecol Obstet 2003; 81: 83–92.
Javitt JC. The cost effectiveness of restoring sight. Arch Ophthalmol 1993; 111:
1615.
5
6
7
8
9
10
Parry E. Essential surgery. Trauma Q 1999; 14: 329–33.
Cherian MN, Noel L, Buyanjargal Y, Salik G. Essential emergency surgical
procedures in resource-limited facilities: a WHO workshop in Mongolia.
World Hosp Health Serv 2004; 40: 24–29.
WHO. Integrated management of emergency and essential surgical care,
2003. http://www.who.int/surgery/publications/imeesc (accessed July 17,
2007).
WHO. Surgical care at the district hospital, 2003.http://www.who.int/
surgery/publications/scdh_manual (accessed July 17, 2007).
WHO. Workshop reports. http://www.who.int/surgery/education_training
(accessed July 17, 2007).
WHO. WHO called to return to the Declaration of Alma-Ata. http://www.who.
int/social_determinants/links/events/alma_ata (accessed July 17, 2007).
Mental health and the mass media: room for improvement
The mass media exerts a powerful influence on public
attitudes about mental health. However, the message
that often comes across reinforces negative stereotypes
about people with mental illness: they are strange,
unpredictable, and probably dangerous.1,2 Improvement
of this situation will need effort on the part of both
media and mental health professionals.
Earlier this year, an event in the small university town
of Blacksburg, VA, USA, thrust mental health into the
spotlight of the international media. On April 6, 2007,
a student at Virginia Tech University opened fire in a
dormitory and then a classroom, killing 33 people,
including himself. A deluge of media coverage followed,
much of it focused on issues related to the mental
health of the shooter, Seung-Hui Cho. Several aspects of
this coverage reflect broader themes common in media
coverage of mental health.
“There’s no way you can plan for a psycho and that’s
clearly what we’re dealing with here”, CNN commentator
Jack Cafferty opined hours after the shootings,3 before
the identity of the shooter (as well as information about
his mental health) had been made public. The rush to link
homicide with mental illness is not new4 and indicates
the common misconception that mental illness goes
hand in hand with violence. In fact, most people with
psychiatric disorders are not violent,5 and although mental
illness could have had a role in the Blacksburg rampage,
this broader perspective was often lost in the ensuing
coverage. Some reports gave the opposite impression. A
week after the shootings, the Wall Street Journal reported
that the shootings at Virginia Tech had prompted
business managers to “rethink an array of security issues,
particularly how to identify mentally ill people in their
midst before they harm others or themselves”.6
In the days after the shootings, many media outlets
ran stories on the reaction of the Korean-American
community, members of whom were shocked and
saddened that the killer was one of their own. Some
Published Online
September 4, 2007
DOI:10.1016/S01406736(07)61246-X
AP Photos
The printed journal
includes an image merely
for illustration
Media vehicles, Virginia Tech University
www.thelancet.com Vol 370 September 22, 2007
1015
Comment
feared that the shootings could lead to prejudice against
them among the general public.7 However, few reporters
sought the perspective of mental health consumers,
many of whom presumably had similar fears of being
judged guilty by association. As the discussion in the
news media turned to issues about the rights of people
with mental illness (eg, laws for involuntary psychiatric
commitment, privacy of mental health records, and
restrictions on purchasing firearms), the opinions of
individuals with the most at stake were rarely heard.
Cafferty was hardly alone in using derogatory slang to
refer to the killer. “Psycho penned poison plays” blared a
headline in the New York Post8 days after the shooting.
The Sun, a UK newspaper, variously referred to Cho as a
crazed killer and a maniac.9 Criticism of such language in
this case could be overzealous political correctness, yet it
is worth asking why derogatory labels related to mental
illness still appear in the media, whereas slurs based
on race or physical disabilities are widely regarded as
unacceptable, even in describing perpetrators of serious
crimes.1 The likely answer is that members of the media are
susceptible to the same prejudices and misunderstandings
about mental illness that prevail in the general public.
Despite such shortcomings, the media also have the
power to bring about positive change. Media coverage
of the Asian tsunami in 2004 and Hurricane Katrina
in 2005 brought attention to the psychological effect
of disasters and the paucity of mental health services in
some of the affected areas. Several news and editorial
articles in the Oregonian newspaper in 2005 led to the
closure of a decrepit and overcrowded state psychiatric
hospital, and helped persuade lawmakers to pass bills
funding more community-based mental health services
and to induce insurers to provide equal coverage for
mental and physical illness (and won the Oregonian a
Pulitzer Prize for editorial writing in 2006).
Those of us in the news media have an obligation
to be accurate and fair in all that we cover. For
mental health coverage, accuracy and fairness mean
avoiding stereotypical and stigmatising language, and
seeking the opinions of mental health consumers in
matters that concern them. Journalists seeking guidance
on these points can consult resources compiled by several
governmental, professional, and advocacy organisations,
including: SHIFT, an antistigma campaign sponsored by
the National Institute of Mental Health in England;10 the
US National Institute of Mental Health;11 and the US Dart
Center.12 Mental health professionals and consumers
can help improve coverage of mental health issues by
engaging and educating members of the media. Without
open lines of communication, little will change.
Greg Miller
Science, San Francisco, CA 94110, USA
gmiller@aaas.org
I declare that I have no conflict of interest.
1
2
3
4
5
6
7
8
9
10
11
12
Wahl O. Media madness. Rugters University Press: New Brunswick, NJ, 1995.
Morris G. Mental health issues and the media. New York: Routledge Press,
2006.
CNN transcripts. Deadliest shooting rampage in U.S. history. April 16,
2007. http://transcripts.cnn.com/TRANSCRIPTS/0704/16/sitroom.02.
html (accessed Aug 16, 2007).
Nairn R, Coverdale J. Imputations of madness in print media depiction of a
mass killing. Aust J Commun 2006; 33: 143−61.
Friedman RA. Violence and mental health—how strong is the link?
N Engl J Med 2006; 355: 2064−66.
Hymowitz C. Bosses have to learn how to confront troubled employees.
Wall Street J April 23, 2007: B1.
Steinhauer J. Korean-Americans brace for problems in wake of killings.
New York Times April 19, 2007.
de Kretser l, Sheehy K. Psycho penned poison plays: class horrified by
psycho dad and chainsaw mother. New York Post April 18, 2007.
http://www.nypost.com/seven/04182007/news/nationalnews/psycho_
penned_poison_plays_nationalnews_leela_de_kretser_and_kate_sheehy.
htm (accessed July 2, 2007).
Smith E, Clench J. Maniac put blame on classmates. Sun April 20, 2007.
http://www.thesun.co.uk/article/0,,2-2007180398,00.html (accessed
July 2, 2007).
SHIFT. Media. http://www.shift.org.uk/media.html (accessed Aug 20,
2007).
National Institute of Mental Health. Reporting on suicide:
recommendations for the media. April 20, 2007. http://www.nimh.nih.
gov/suicideresearch/mediasurvivors.cfm (accessed May 15, 2007).
Dart Center for Journalism & Trauma. Resources. http://www.dartcenter.
org/resources/index.html (accessed May 15, 2007).
Nurses and mental health services in developing countries
Published Online
September 4, 2007
DOI:10.1016/S01406736(07)61251-3
1016
Some of the barriers to progress identified...
Purchase answer to see full
attachment