Select Committee on European Union Minutes of Evidence

Supplementary written evidence by Professor Graham Thornicroft, Institute of Psychiatry, King's College London

1.  INTRODUCTIONIt is now beyond doubt that widespread discrimination adds to the disability of people with mental illness. The basic problem is this: many people with mental illness are subjected to systematic disadvantages in most areas of their lives. These forms of social exclusion occur at home, at work, in personal life, in social activities, in healthcare, and in the media.


  What is stigma? The concept of stigma is necessary to develop an understanding of experiences of social exclusion, but it is not sufficient to grasp the whole picture, nor to know what practical steps need to be taken to promote social inclusion. Stigma is best seen as three related problems:
—  The problem of knowledge: Ignorance
—  The problem of attitudes: Prejudice
—  The problem of behaviour: Discrimination

  2.1  Ignorance: strong evidence is presented here that most people have little knowledge about mental illnesses, and much of this information is factually incorrect. There is a pressing need to convey more useful information, for example about how to recognise the features of mental illness and where to get help, both to the whole population and to specific groups such as teenagers.

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  2.2  Prejudice: fear, anxiety and avoidance are common feelings both for people who do not have mental illness (when reacting to those who have), and for people with mental illness who anticipate rejection and discrimination and therefore impose upon themselves a form of "self-stigma".

  2.3  Discrimination: the scientific evidence and the strong message from service users and their advocates are clear that discrimination blights life for many people with mental illness, making marriage, childcare, work, and a normal social life much more difficult. Actions are needed to specifically redress the social exclusion of people with mental illness, and to use the legal measures intended to support all disabled people (such as the UK Disability Discrimination Act) for physical and mental disabilities on the basis of parity.


  Empowerment has been described as the opposite of self-stigmatisation. Policy makers can therefore provide specific financial support for ways in which individuals with mental illness can empower themselves or be empowered include the following:

    —  Participating in formulating care plans and crisis plans.

    —  Using cognitive-behavioral therapy to reverse negative self-stigma.

    —  Running regular assessments of consumer satisfaction with services.

    —  Creating user-led and user-run services.

    —  Developing peer support worker roles in mainstream mental health care.

    —  Advocating for employers to give positive credit for experience of mental health illness.

    —  Taking part in treatment and service evaluation and research.


  A series of changes are necessary to assist individual people with mental illness and their carers and family members:
Develop new ways to offer diagnosesMental health staff
Have information packages for family members that explain causes, nature and treatments of different types of mental illness Mental health staff, consumer and families
Actively provide factual information against popular myths Mental health staff
Develop and rehearse accounts of mental illness experiences which do not alienate other people Mental health staff and consumer groups


  For some people with mental illness, allowance needs to be made at work for their personal requirements (1-3). In parallel with the modifications made for people with physical disabilities, people with mental illness-related disabilities may need what are called "reasonable adjustments" in relation to the anti-discrimination laws. In practice this can include the following measures:

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    —  for people with concentration problems, having a quieter work place with fewer distractions rather than a noisy open plan office, with a rest area for breaks;

    —  more or more frequent supervision than usual to give feedback and guidance on job performance;

    —  allow a person to use headphones to block out distracting noise;

    —  flexibility in work hours so that they can attend their healthcare appointments, or work when not impaired by medication;

    —  provide an external job coach for counselling and support, and to mediate between employee and employer;

    —  buddy/mentor scheme to provide on-site orientation, and assistance;

    —  clear person specifications, job descriptions and task assignments to assist people who find ambiguity or uncertainty hard to cope with;

    —  for people likely to become unwell for prolonged periods it may be necessary to make contract modifications to specifically allow whatever sickness leave they need;

    —  a more gradual induction phase, for example with more time to complete tasks, for those who return to work after a prolonged absence, or who may have some cognitive impairment;

    —  improved disability awareness in the workplace to reduce stigma and to underpin all other accommodations;

    —  reallocation of marginal job functions which are disturbing to an individual; and

    —  allow use of accrued paid and unpaid leave for periods of illness.


  In local communities or health and social care economies these initiatives are needed to promote the social inclusion of people with mental illness:
Introduction supported work schemesMental health services with specialist independent sector providers
Psychological treatments to improve cognition, self-esteem and confident Mental health and general health services
Health and social care explicitly give credit to applicants with a history of mental illness when hiring staff Health and social care agencies
Provision of reasonable adjustments/accommodations at work Mental health providers engaging with employers and business confederations

Inform employers of their legal obligations under disability laws Employers' confederations
Deliver and evaluate the widespread implementation of targeted interventions with targeted groups including school children, police and healthcare staff Education, Police and Health commissioning and providing authorities
Provide accurate data on mental illness recovery rates to mental health practitioners Professional training and accreditation organisations
Implementation of measures to support care plans negotiated between staff and consumers Mental health provider organisations and consumer groups


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  In terms of national policy, a series of changes are necessary which span governmental ministries, the non-governmental and independent sector, along with service user and professional groups. This is a vision of a long-term attack upon individual and systemic discrimination through a co-ordinated, multi-sectoral programme of action to promote the social inclusion of people with mental illness.
Use a social model of disability that refers to human rights, social inclusion and citizenship Governments and non governmental organisations (NGOs) to change core concepts
Apply the anti-discrimination laws to give parity to people with physical and mental disabilities Parliament and government
Inform all employers of their legal obligations under these laws Ministry of Employment or equivalent
Interpret anti-discrimination laws in relation to mental illness Judiciary and legal profession
Establish service user speakers' bureaux to offer content to news stories and features on mental illness NGOs and other national level service user groups
Provide and evaluate media watch response units to press for balanced coverage Statutory funding for NGOs to provide media watch teams
Share between countries the experience of disability discrimination acts Legislators, lawyers, advocates and consumer groups
Understand and implement international legal obligations under binding declarations and covenants NGOs to communicate legal obligations of all stakeholders, and health and social care inspection agencies to audit how far these obligations are respected in practice
Audit compliance with codes of good practice in providing insurance Associations of Insurers with Service User organisations and mental health NGOs
Providing economic incentives rather than disincentives to disabled people ready to return to work Employment Ministries to introduce new and flexible arrangements for disabled people to work with no risk to their income
Change law to allow people with a history of mental illness to serve on juries with a presumption of competence Justice Ministries to amend the law relating to jury service


  What action is necessary which is best done at the international level? Such contributions, so far removed from the everyday lives of people, may be hardly noticeable unless they are very sharply focussed and coherent. Setting international standards for national polices can be one useful intervention. For example the World Health Organisation (WHO) has published standards to guide countries in producing or revising mental health laws (4). This covers advice on:

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    —  access to care;

    —  confidentiality;

    —  assessments of competence and capacity;

    —  involuntary treatment;

    —  consent;

    —  physical treatments;

    —  seclusion;

    —  restraint;

    —  privacy of communications;

    —  appeals against detention; and

    —  review procedures for compulsory detention (4).

  Such guidelines are needed. At present 25 per cent of countries worldwide do not have legislation related to mental health treatment, and for those that do, half of these enacted its law over 15 years ago. Generally lower income countries are more likely to have older legislation.

  In the European Union anti discrimination laws are now mandatory under the Article 13 Directive. Such laws must make illegal all discrimination in the workplace on grounds that include disability. They must also set up institutions to enforce these laws. The time is therefore right is share experience between different countries on how successful such laws have been to reduce discrimination against people with mental illness, and to understand more clearly what is required both for new legislation elsewhere, and for amendments to existing laws that fall short of their original intentions.

  International organisation, such as the WHO can also contribute towards better care and less discrimination by indicating the need for national mental health policies, and by giving guidance on their content. In 2005, for example, only 62 per cent of countries in the world had a mental health policy (5). In Europe Health Ministers have signed a Mental Health Declaration and Action Plan which set the following priorities:

    —  foster awareness of mental illness;

    —  tackle stigma, discrimination and inequality;

    —  provide comprehensive, integrated care systems;

    —  support a competent, effective workforce; and

    —  recognise the experience and knowledge of services users and carers(6-8).


  People with mental illnesses in many countries are treated in ways which prevent them from exercising many of their basic human rights. It is hardly an exaggeration to say that we can estimate the value attached to people in this category quite precisely from seeing how much or how little attention is paid to ensuring that they are treated in fully humane ways.

        "All persons have the right to the best available mental heath care, which shall be part of the health and social care system."— United Nations. UN Resolution 46/119 on the Protection of Persons with Mental Illness and the Improvement of Mental Health Care, adopted by the General Assembly on 17 December 1991. New York: United Nations; 1991.

  The primary source of international human rights within the United Nations (UN) is the Universal Declaration of Human Rights (UDHR), which refers to civil, political, economic, social and cultural rights. Civil and political rights, such as the right to liberty, to a fair trial, and to vote, are set out in an internationally binding treaty, the International Covenant on Civil and Political Rights (ICCPR), which has not been ratified by only seven nations including China (9). Economic, social and cultural rights, such as the rights to an adequate standard of living, the highest attainable standard of physical and mental health, and to education, are described in a second binding treaty, the International Covenant on Economic, Social and Cultural Rights (ICESCR), which has not been ratified by the USA.

  The UN High Commissioner for Human Rights (OHCHR) reports to the UN General Assembly on the implementation of the rights protected by these human rights treaties. Countries which have ratified these binding treaties are then obliged under international law to guarantee to every person on their territory, without discrimination, all the rights enshrined in both.

  The body which monitors implementation of the ICESCR is the Committee on Economic, Social and Cultural Rights (CESCR). In a special report explaining how the ECESCR relates specifically to the rights of people with disabilities, the Committee stated:

        "The obligation of States parties to the Covenant to promote progressive realisation of the relevant rights to the maximum of their available resources clearly requires Governments to do much more than merely abstain from taking measures which might have a negative impact on persons with disabilities. The obligation in the case of such a vulnerable and disadvantaged group is to take positive action to reduce structural disadvantages and to give appropriate preferential treatment to people with disabilities in order to achieve the objectives of full participation and equality within society for all persons with disabilities. This almost invariably means that additional resources will need to be made available for this purpose and that a wide range of specially tailored measures will be required."

  More specifically in relation to mental illness, the UN Principles for the Protection of Persons with Mental Illness and for the Improvement of Mental Health Care were adopted in 1991, and elaborate the basic rights and freedoms of people with mental illness that must be secured if states are to be in full compliance with the ICESCR. The "The Right to Mental Health" is stated in Article 12 of the ICESCR, which provides the right of everyone to the "enjoyment of the highest attainable standard of physical and mental health", and identifies some of the measures states should take "to achieve the full realisation of this right".

  These "Mental Illness Principles" apply to all people with mental illness, and to all people admitted to psychiatric facilities, whether or not they are diagnosed as having a mental illness. They provide criteria for the determination of mental illness, protection of confidentiality, standards of care, the rights of people in mental health facilities, and the provision of resources. Mental Illness Principle 1 lays down the basic foundation upon which nations' obligations towards people with mental illness are built: that "all persons with a mental illness, or who are being treated as such persons, shall be treated with humanity and respect for the inherent dignity of the human person", and "shall have the right to exercise all civil, political, economic, social and cultural rights as recognised in the Universal Declaration of Human Rights, the International Covenant on Economic, Social and Cultural Rights, the International Covenant on Civil and Political Rights and in other relevant instruments". It also provides that "all persons have the right to the best available mental health care". As the United Nations' health agency, the World Health Organisation (WHO) gives substance to the UN's understanding of what is meant by "the best available mental health care" (4;10).

  In addition to these agreements, 46 member states of the Council of Europe are bound or guided by a series of arrangements (11;12). These include the 1950 European Convention on Human Rights and Fundamental Freedoms (ECHR), and the European Committee for the Prevention of Torture and Inhuman or Degrading Treatment or Punishment (CPT). It is now time for EU nations to recognise and to fully implement these obligations (13).

  (1)  Pinfold V, Thornicroft G, Huxley P, Farmer P. Active ingredients in anti-stigma programmes in mental health. International Review of Psychiatry 2005;17(2):123-31.

  (2)  Pinfold V, Huxley P, Thornicroft G, Farmer P, Toulmin H, Graham T. Reducing psychiatric stigma and discrimination: evaluating an educational intervention with the police force in England. Soc Psychiatry Psychiatr Epidemiol 2003 June;38(6):337-44.

  (3)  Pinfold V, Toulmin H, Thornicroft G, Huxley P, Farmer P, Graham T. Reducing psychiatric stigma and discrimination: evaluation of educational interventions in UK secondary schools. Br J Psychiatry 2003;182:342-6.

  (4)  World Health Organisation. WHO Resource Book on Mental Health, Human Rights and Legislation. Geneva: World Health Organisation; 2005.

  (5)  World Health Organisation. Mental Health Atlas 2005. Geneva: World Health Organisation; 2005.

  (6)  World Health Organisation. Mental Health Declaration for Europe. Copenhagen: World Health Organisation; 2005.

  (7)  World Health Organisation. Mental Health Action Plan for Europe. Copenhagen: World Health Organisation; 2005.

  (8)  Thornicroft G, Rose D. Mental health in Europe. BMJ 2005 March 19;330(7492):613-4.

  (9)  United Nations. International Covenant on Civil and Political Rights. Adopted by the UN General Assembly Resolution 2200A (XXI) of 16 December 1966. New York: United Nations

(; 1966.

  (10)  Thornicroft G. Actions Speak Louder: Tackling Discrimination against People with Mental Illness. London: Mental Health Foundation; 2006.

  (11)  Kingdon D, Jones R, Lonnqvist J. Protecting the human rights of people with mental disorder: new recommendations emerging from the Council of Europe. Br J Psychiatry 2004 October;185:277-9.

  (12)  Bindman J, Maingay S, Szmukler G. The Human Rights Act and mental health legislation. Br J Psychiatry 2003 February;182:91-4.

  (13)  Thornicroft G. Shunned: Discrimination against People with Mental Illness. Oxford: Oxford University Press; 2006.

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