Mental health provision needs to move with the times, with a rights-based community approach
Mental health services lack the resources needed to provide respectable and sufficient care for its users, often operating on entrenched biological models of care and outdated legal and regulatory frameworks. Fighting against this mould are community-based mental health systems which offer alternatives to the "coercive" psychiatric models.
Tucked away on a quiet street in Switzerland’s capital, Soteria Berne looks like just another family home. Walking past the cream-coloured property, one would not immediately think services for those suffering from psychosis such as schizophrenia are treated here, and that is the point.
It is the kind of community-based mental health care approach lauded in a sweeping report of the sector by the World Health Organization (WHO), which recommends a basket of reforms to address failures in the current systems, including more person-centred alternatives to traditional hospital-based treatment.
“Mental health is still so stigmatised, and this leads to an investment in psychiatric hospitals which isolate people away from society and their communities,” explained Dr Michelle Funk, Unit head in WHO’s department of mental and substance use and the report’s co-lead writer.
According to Funk, governments everywhere spend less than two per cent of their budgets on mental health and most costs are on psychiatric hospitals that detach patients from society, based on outdated beliefs that they are “dangerous”, “lazy”, “unintelligent” and need to “be protected from normal life because they are unable to function in society.”
Hidden from public scrutiny, many people in these institutions are often over prescribed drugs and experience violence, abuse and neglect. They are often subject to “physical, mechanical and chemical restraint, or are put into seclusion which leads to physical and mental harm and sometimes even death,” Funk added.
Against this landscape, the recent 300-page report, Guidance on community mental health services: Promoting person-centred and rights-based approaches, is both damning and a source of hope.
It highlights the need to exclude coercive practices such as seclusion and restraint, while emphasising the importance of social factors such as housing, education, employment and social protection.
Covid-19 has shone a light on the broken mental health system, bringing to the forefront “the damaging effects of institutions, lack of cohesive social networks, isolation and marginalisation experienced as well as the fragmented and fragile nature of many mental health systems and services.”
Community mental health space tucked in Berne. Highlighted as a successful example of good practice in the WHO report, Soteria Berne offers a different kind of care for people with mental health difficulties. Located in a former “simple hotel”, the 10-bedroom house offers a space for treatments that differ significantly from the city’s other psychiatric inpatient and outpatient services.
For over 35 years, patients aged between 16 and 40 with psychoses, particularly schizophrenic episodes, are offered alternative treatment in this live-in acute crisis service centre.
“Daily life in Soteria Berne is similar to a group of young people living together in a quite big house with a garden,” Dr Walter Gekle, head physician of Soteria Berne said.
“Everything in and around the house is organised together and the focus is on sharing moments of real interpersonal contact in order to provide a holding and containing relationship between users and staff members. By this, acute psychotic episodes can be lived through together.”
Despite being the smallest registered hospital in Switzerland, there are no semblances of a hospital. There are “no alarm lights, no closed doors, every user has their own room and nobody enters without knocking on the door and we have a cat in the house,” Gekle explained. In addition, the therapeutic appointments with doctors and psychologists are held close-by but off the premises.
Soteria, in Greek mythology, was the goddess of safety and protection, and the services provided promise a “low-key, relaxing, low-stimulus, home-like and ‘normal’ environment to produce as little stress as possible.”
The anti-psychiatry model first championed in the 1970s, was founded by psychiatrist Loren Mosher in the United States. Today there are over 15 Soteria projects, mostly in Germany but also found in Japan, the United Kingdom and the Netherlands.
By placing individuals in everyday, low-stimulus contexts, the hope is to normalise the context surrounding mental health, whilst respecting the “stress- vulnerability paradigm of psychosis,” Gekle explained.
Evaluations have also proven that this system is working, as “symptoms improvement equals that of traditional treatment settings and the psychosocial functioning is slightly better, compared to traditional settings,” Gekle said.
Most importantly, there are no forms of coercion, Gekle told Geneva Solutions, explaining that every decision is based on informed consent including when the user chooses to receive their treatment or end it.
Holistic approach to mental health systems. Soteria’s no stigma, no discrimination approach is one of about two dozen such models praised in the report, which asks for a global rethinking of mental health. Positioned as a “guidance” document, it also offers extensive blueprints and recommendations on reforming current mental health systems whilst promoting community-based mental health services that Funk says:
do not use coercive practices such as seclusion and restraint;
do not accept any form of physical, verbal, psychological or sexual abuse;
respect people’s choices and decisions about their treatment, care and support;
provide directly or facilitate access to support with housing, education, professional opportunities, and relationships with family members;
explicitly promote community inclusion, participation & empowerment.
These community-based services occur in different forms across the globe but all commonly strive to offer the rights-based approach to mental health care that Funk advocates for.
Such models of mental health services include Atmiyata in India, Centro de Atenção Psicosocial (CAPS) in Brazil and Tupu Ake in New Zealand, are said to be run by '“experts by experience or peers” bringing in the users’ perspectives.
As another example, Zimbabwe’s Friendship Bench is “an actual wooden bench, being placed in front of some of the healthcare facilities and building on local resources in local communities in Harare, Zimbabwe,” said Dr Fahmy Hanna also working in the WHO’s department of mental and substance use.
“People can come and sit on the bench and receive the problem-solving intervention which is evidence-based,” he added.
“From Zimbabwe’s Friendship Bench to India’s Atmiyata Gujarat, these alternatives rely heavily on individuals with ‘lived experience’ to deliver low-cost effective support for people with mental health conditions,” Funk explained.
These wide ranging services provide real alternatives to biomedical care which relies almost exclusively on diagnosis, medication and symptom reduction.
“Mental health systems and services should include a more holistic approach that considers all aspects of a person’s life… This means a move towards more balanced, person-centred and recovery-oriented practices that respect their will and preferences in treatment, implementing alternatives to coercion, and promoting people’s right to participation and community inclusion,” Funk urged.