[Historical aspects of ethics in psychiatry : From the end of humanitarianism up to the Human Rights Convention]. / Historisches zur Ethik in der Psychiatrie : Vom Ende der Humanität zur Menschenrechtskonvention.

The establishment of academic psychiatry was completed around 1900. Simultaneously, in view of the societal crisis phenomenon the professional self-concept of the psychiatrist was shifted to a self-image, according to which psychiatry had to place its expertise at the service of the people and the country. This was particularly expressed in World War I in the brutal dealing with the so-called war neurotics. In association with the so-called death by starvation of ca. 70,000 institution inmates, in the post-war period Karl Bonhoeffer debated a transformation of the term humanitarianism. The worst consequence of the rejection of humanitarian thoughts are the murders of invalids under National Socialism; however, legitimization of such crimes by alluding to collective ethics, as attempted by Karl Brandt, seems to be less than convincing. The reform of psychiatry initiated in the 1960s and the United Nations Convention on the Rights of Persons with Disabilities, which came into force in 2008, have achieved prerequisites for a supportive psychiatry with reduced coercion, whereby many questions also in the legal and social systems must still be clarified.

[Psychiatry without coercion-Exclude the coercion or the patients?] / Psychiatrie ohne Zwang ­ den Zwang ausschließen oder Patient:innen?

BACKGROUND: With reference to the United Nations Convention on the Rights of Persons with Disabilities (UN CRPD), a fundamental change in psychiatric care in Germany was proposed in 2019 by Zinkler and von Peter, supported by a legal perspective from Kammeier, which has since led to controversial debates. Essentially, the aim is not only to reduce coercion in psychiatry to a minimum, but also to fundamentally exclude it in a psychiatry that only provides care. The function as an agent of social control is to be returned from psychiatry to state institutions. Psychiatric hospitals will only admit patients with their consent; patients who refuse therapy will not be admitted regardless of their capacity for self-determination and will remain untreated or, if they have committed a criminal offence or threaten to commit a criminal offence, they will be taken into custody or imprisoned in accordance with the legal regulations applicable to all people. There they will receive psychiatric care if they so wish. AIM OF THE PAPER: The paper outlines the background of this concept, including international sources, traces the discussion in German specialist literature and takes a critical look at it. RESULTS: The criticism is primarily directed against the fact that responsibility for a relevant proportion of psychiatric patients would be handed over to the police and judiciary and that, as a result, two realities of care would be established that would considerably differ in terms of quality. CONCLUSION: Arguments are put forward in favor of retaining the function of social control and considerations are suggested as to how caring coercion can be largely minimized.

The influence of the convention on the rights of persons with disabilities on the European court of human rights in the area of mental health law: Divergence and unexplored potential.

This article explores how the European Court of Human Rights has applied the norms of the UN Convention on the Rights of Persons with Disabilities (CRPD) in the area of mental health law. The European Court was initially receptive to the CRPD, including the UN Committee on the Rights of Persons with Disabilities' call for a repeal of legislation permitting involuntary psychiatric hospitalisation, but later distanced itself from it. The CRPD has nevertheless influenced how the European Court approached (a) involuntary hospitalisation, (b) separating detention from treatment, (c) restraints and other forms of ill-treatment in institutions, and (d) disability-neutral detention based on disability. Despite the two treaty bodies' different jurisprudential methodology and their different assumptions about the role of medical and legal professionals, the CRPD can continue to influence the European Court in areas such as less restrictive alternatives to coercive treatment, the relevance of capacity, and the importance of personal integrity for mental health treatment.

Israeli social workers' recommendations on residential settings for individuals with intellectual disabilities.

BACKGROUND: People with intellectual disabilities have the right to live in the community. As social workers have an important role in decisions regarding residential settings, this study examined their recommendations regarding residential living arrangements of individuals with intellectual disabilities. METHOD: Using a factorial survey approach 174 social workers were presented with true-to-life vignettes and asked to provide their recommendations regarding housing in community apartments, hostels (large group homes) and meonot (large institutions). RESULTS: Higher likelihood of recommending housing in a community apartment was associated with mild intellectual disability, lack of daily support needs, no sexual abuse history, and stated preference for a community apartment. Social workers' experience in working in a specific residential setting was associated with recommending it. CONCLUSIONS: Ongoing training on rights-based ethics and the importance of community inclusion should be provided to social workers. Further, community alternatives should be made available to all individuals with disabilities.

The United Nations Convention on the Rights of Persons with Disabilities and Social Work: Evidence for Impact?

The United Nations Convention on the Rights of Persons with Disabilities (hereafter CRPD) has provided a radical imperative for the reform of mental health and capacity legislation around the world. The interpretation of the CRPD has been controversial, ranging from the complete abolition of detention, forcible treatment, and substitute decision-making to accepting that elements of these measures need to be retained based on non-discriminatory criteria, additional safeguards, and a comprehensive shift towards supported decision-making. While the potential effects of the CRPD on mental health social work and social work generally are considerable given their shared commitment towards social justice, to date there has been no review of research evidence exploring their relationship. In addressing this knowledge gap, this study held a preliminary discussion with practitioners and academics at the European Association of Social Work Mental Health Special Interest Group in Amsterdam 2022, followed by a scoping literature review on the question: What impact, if any, has the CRPD had on social work practice? The review produced four main findings: impact on legislation; positive impact on practice; limited impact on practice; and impact on social work education and research. In sum, while there were some positive indications of social work and mental health social work practice being influenced by the CRPD, these were scant. Barriers to change included tendencies among some social workers to practise substitute decision-making, in part related to resourcing and policy contexts, and understandings of disability aligned to individualised/medical rather than social perspectives. The results indicate that legal reform on its own is insufficient to impact social work practice, and that realising the potential of the CRPD will necessitate good quality training, as well as improving social workers' knowledge of the human rights of people with mental impairment.

The #Rights4metoo Scale: a tool to monitor compliance with the convention on the rights of persons with disabilities / La escala #YoTambién Tengo Derechos: Una herramienta para monitorizar la convención sobre los derechos de las personas con discapacidad

There is a lack of psychometrically validated tools to evaluate the extent to which people with intellectual disability (ID) truly exercise their rights in all areas of their lives. The aim of this article is to provide evidence about the usefulness and reliability of the pilot version of the #Rights4MeToo Scale, an instrument based on the Quality of Life Supports Model. The scale can be self-reported by people with ID or hetero-reported by family members or professionals. First, through a qualitative study with self-advocates with ID, we provide evidence about the need and usefulness of this tool to understand and monitor compliance with the Convention on Rights of Persons with Disabilities (CRPD). Next, we present preliminary data on the internal consistency of the items that make up the pilot version, analyzing the responses of 1,200 people with ID, family members, and professionals. The #Rights4MeToo Scale will make it possible to conduct national studies on compliance with the CRPD, not to mention international comparative studies when the scale is adapted to the legal and cultural context of other countries. (AU)

Resulta urgente e ineludible contar con herramientas, con adecuadas evidencias de validez y fiabilidad, que permitan evaluar hasta qué punto las personas con discapacidad intelectual (DI) verdaderamente ejercen sus derechos en todos los ámbitos de su vida. El objetivo de este artículo consiste en proporcionar evidencias acerca de la utilidad y la fiabilidad de la versión preliminar de la escala #YoTambién Tengo Derechos, un instrumento diseñado a partir del Modelo de Calidad de Vida y Apoyos. La escala puede ser autoinformada por personas con DI o heteroinformada por familiares o profesionales. Por un lado, mediante un estudio cualitativo con autogestores con DI se proporcionan evidencias acerca de la necesidad y la utilidad de esta herramienta para conocer y monitorizar el cumplimiento de la Convención. Por otro lado, presentamos datos preliminares de la consistencia interna de los ítems, analizando las respuestas de 1.200 personas con DI, familiares y profesionales. La escala #YoTambién Tengo Derechos permitirá llevar a cabo estudios nacionales sobre el cumplimiento de la Convención sobre los Derechos de las Personas con Discapacidad y, con su adaptación al contexto legal y cultural de otros países, estudios comparativos internacionales. (AU)

Crime and victimization outcomes following civil rights limits to the use of compulsory treatment.

Community treatment orders (CTOs) have been associated with reduced crime/victimization-risk. Australia's ratification of the U.N. Convention on the Rights of Persons with Disabilities (CRPD) enabled patient-rights-advocacy to limit CTO-assignment to persons lacking decision-making-capacity. This effort was accompanied by a 15% reduction in CTO-utilization. Has this change affected crime/victimization-involvements of patients with schizophrenia-diagnoses? In Victoria Australia, the study considers crime/victimization-involvement among three patient-groups recruited with the same sampling-algorithm in the decade before (2000-2009, N = 14,711) and after (2010-2019, N = 10,702) CRPD-ratification. Each group is its own-control. Each group's positive-outcome across decades would be "no increase" in crime/victimization-involvement or in the ratio of the group's incident-rates to the State's. Following CRPD-ratification, first-hospitalized-patients with at least one CTO-assignment doubled their involvement in major crime-perpetrations (from 13% to 27%), non-CTO-hospitalized-patients almost doubled (from 10% to 18%), and 11% of outpatients were involved when none were before. Overall, a third (34%) were victimized-by-major-crime up from 28%, with 25% of outpatients experiencing victimization when none had before. Increases were most evident in major-crimes, led by assaults/abductions. Capacity-constraints on compulsory-treatment are associated with increases in crime/victimization-involvement, a transfer of responsibility for patients with schizophrenia-diagnoses from the mental-health-system to the criminal-justice-system, validation of dangerousness stereotypes, and growing negative family impact.

The Quality of Life Supports Model as a Vehicle for Implementing Rights.

The Quality of Life Supports Model (QOLSM) is emerging as a new framework that is applicable to people with disabilities in general, but specially to people with intellectual and developmental disabilities (IDD). The aim of this conceptual paper is twofold. Firstly, it aims to show the overlap between the QOLSM and the Convention on the Rights of People with Disabilities (CRPD), highlighting how the former can be used to address many of the goals and rights embedded in the latter. Secondly, the article seeks to illustrate the connection between these two frameworks and highlight the importance of acknowledging and measuring the rights of people with IDD. Therefore, we posit that the new #Rights4MeToo scale is ideal for: (a) providing accessible means and opportunities for people with IDD to identify and communicate their needs regarding their rights; (b) enhancing the supports and services that families and professionals provide to them; and (c) guiding organizations and policies to identify strengths and needs in relation to rights and quality of life. We also discuss future research needs and summarize the main findings of this article, highlighting its implications for practice and research.

The United Nations convention on the rights of persons with disabilities, neuroscience, and criminal legal capacity.

The United Nations Convention on the Rights of Persons with Disabilities requires states parties to 'recognize that persons with disabilities enjoy legal capacity on an equal basis with others in all aspects of life.' This mandate has sparked debate about the interpretation of legal capacity, including within the criminal context as applied to the retrogressively named 'insanity defense.' Yet, under-examined are two questions: First, what defenses should defendants with psychosocial disabilities be able to invoke during criminal prosecutions? Second, what kind of evidence is consistent with, on the one hand, determining a defendant's decision-making capacity to establish culpability and, on the other hand, the right to equal recognition before the law? Developments in neuroscience offer a unique prism to grapple with these issues. We argue that neuroscientific evidence of impaired decision-making, insofar as it presents valid and interpretable diagnostic information, can be a useful tool for influencing judicial decision-making and outcomes in criminal court. In doing so, we oppose the argument espoused by significant members of the global disability rights community that bioscientific evidence of psychosocial disability should be inadmissible to negate criminal responsibility. Such a position risks more defendants being punished harshly, sentenced to death, and placed in solitary confinement.

Human rights promotion and the 'Geneva impasse' in mental healthcare: scoping review.

BACKGROUND: The World Psychiatric Association recently emphasised that the protection of human rights in mental healthcare was a 'central concern'. This paper examines recent literature on human rights and mental healthcare. AIMS: To (a) outline how international human rights law distinguishes between the protection and promotion of human rights; and (b) explore the literature on promoting human rights in mental healthcare which avoids what has been termed the 'Geneva impasse' between those who argue that compulsory care and treatment can never comply with human rights law and those who argue that they can if certain conditions are met. METHOD: The following doctrinal methodology was used: (a) identification and detailed analysis of international human rights conventions and commentaries; (b) identification of key literature on human rights and mental healthcare; and (c) critical analysis of key issues emerging from the literature. RESULTS: Much of the literature on human rights and mental healthcare focuses on whether restrictions on compulsory care are required to meet the requirements of United Nations Conventions. There is an emerging literature identifying measures to promote the right to the enjoyment of the highest attainable standard of mental health. CONCLUSIONS: There has been a focus on protecting the rights to liberty and equality before the law for mental health patients. The nascent literature on promoting human rights in mental healthcare could mark a way forward beyond the 'Geneva impasse' that has dominated public debate in recent years.

Mental capacity-why look for a paradigm shift?

Challenges to the legitimacy of mental capacity over the past 10 years have been spearheaded by the Committee on the Rights of Persons with Disabilities, the treaty body for the UN Convention on the Rights of Persons with Disabilities (CRPD). This challenge has been asserted to have produced a 'paradigm shift'. In this article, we examine why that interpretation has had such limited traction in the legal policy arena, and whether it should have traction. We also analyse whether the Committee has subtly but importantly shifted its position. We then develop an argument that the true goal, compatible with the CRPD, is the satisfactory determination of whether a person has or lacks mental capacity to make or take a relevant decision. Our article contextualises multi-disciplinary, research-informed guidelines designed as a contribution to satisfactory determination. While our article is based upon the position in England and Wales, we suggest that our conclusions are of wider application.

The Right to Sexuality, Reproductive Health, and Found a Family for People with Intellectual Disability: A Systematic Review.

Although sexuality, reproductive health, and starting a family are human rights that should be guaranteed for all citizens, they are still taboo issues for people with intellectual disability (ID), and even more so for women with ID. This paper systematically reviews the current qualitative and quantitative evidence on the rights of people with ID in regard to Articles 23 (right to home and family) and 25 (health, specifically sexual and reproductive health) of the Convention on the Rights of Persons with Disabilities (CRPD). A systematic review of the current literature, following PRISMA 2020, was carried out in ERIC, PsychInfo, Scopus, PubMed, ProQuest, and Web of Science. In all, 151 articles were included for review. The studies were categorized into six themes: attitudes, intimate relationships, sexual and reproductive health, sexuality and sex education, pregnancy, and parenthood. There are still many barriers that prevent people with ID from fully exercising their right to sexuality, reproductive health, and parenthood, most notably communicative and attitudinal barriers. These findings underline the need to continue advancing the rights of people with ID, relying on Schalock and Verdurgo's eight-dimensional quality of life model as the ideal conceptual framework for translating such abstract concepts into practice and policy.

Can the World Health Organisation's 'QualityRights' initiative help reduce coercive practices in psychiatry in Ireland?

The treatment of mental illness is undergoing a paradigm shift, moving away from involuntary treatments towards rights-based, patient-centred care. However, rates of seclusion and restraint in Ireland are on the rise. The World Health Organisation's QualityRights initiative aims to remove coercion from the practice of mental health care, in order to concord with the Convention on the Rights of Persons with Disabilities. The QualityRights initiative has recently published a training programme, with eight modules designed to be delivered as workshops. Conducting these workshops may reduce coercive practices, and four of the modules may be of particular relevance for Ireland. The 'Supported decision-making and advance planning' and the 'Legal capacity and the right to decide' modules highlight the need to implement the Assisted Decision-Making (Capacity) Act, 2015, while the 'Freedom from coercion, violence and abuse' and 'Strategies to end seclusion and restraint' modules describe practical alternatives to some current involuntary treatments.

The Voluntary Sterilisation Act: Best Interests, Caregivers, and Disability Rights.

How can caregivers' interests be balanced with disability rights in decisions about whether to sterilise an intellectually disabled person? This question is considered in the context of Singapore, a commonwealth country that lacks a test case. Singapore has a lesser-known history of eugenics, and has struck an uneasy compromise between communitarian values and obligations under the United Nations Convention on the Rights of Persons with Disabilities (CRPD) in recent years. This article provides an overview of Singaporean law under the Voluntary Sterilisation Act 1974 and the Mental Capacity Act 2008, and compares this with the law in Canada, England and Wales, and Australia. This article also situates the CRPD in the context of Singapore's dualist view of international law and communitarian approach to disability policy. It argues that CRPD rights to bodily integrity can be presumptively upheld in best interests determinations on sterilisation, while caregivers' interests can be accommodated in a relational understanding of best interests. A decisional framework along these lines is proposed.

Psychiatric advance directives and consent to electroconvulsive therapy (ECT) in Australia: A legislative review and suggestions for the future.

Psychiatric Advance Directives (PADs) have been adopted in many jurisdictions around the world and in most Australian states and territories. They are seen as a less restrictive and patient-centered approach to the provision of mental health care. Electroconvulsive therapy (ECT) is a restricted treatment in most jurisdictions in Australia and across the world. This paper explores the history, regulation and use of ECT and PADs and the intersections between them. It provides an overview of the legislative framework in each Australian state and territory and explores some of the issues which have arisen such as complexity of the regulatory framework, making PADs binding for refusing and consenting to ECT, involving treating teams in how PADs are made, using restrictive interventions to implement PADs, and the role of the Tribunal. While PADs are often framed as an important legal tool for allowing patients to refuse psychiatric treatment (especially ECT), the paper emphasizes that they can also be an innovative way for people to consent to psychiatric treatment in advance and an empowering option to access mental health care. It then makes some suggestions for future reform.

Sixteen Years since the Convention on the Rights of Persons with Disabilities: What Have We Learned since Then?

Persons with disabilities have historically been subjected to discrimination and exclusion, placing them in dangerous situations of social vulnerability. The Convention on the Rights of Persons with Disabilities, passed on the 13th of December 2006, was an important legislative landmark for valuing the rights of this population group. This study involved a bibliometric analysis of 1024 research articles published in Scopus on the social, workplace, educational, and financial inclusion of persons with disabilities since the Convention. The results show an increase in scientific production, and there is also a great deal of multi-disciplinarity, which has led to important breakthroughs for the all-encompassing inclusion of this section of the population. The most productive journals, authors, institutions, and countries, as well as the international cooperation networks, are presented here. The review concludes by setting out the main themes and trends in the research.

The collaborative development through multidisciplinary and advocate consensus of an accessible notice of rights for people with intellectual disabilities in police custody.

Background People with intellectual disabilities are over-represented in the criminal justice system. The United Nations' Convention on the Rights of Persons with Disabilities (UNCRPD) enshrines a right to equal access to justice for persons with disabilities (Article 13, UNCRPD). Accessible information is a key aspect of exercising this right. Yet, many jurisdictions, including Ireland, are yet to develop accessible information for disabled people who may be arrested. Aims This paper describes the collaborative development through multidisciplinary and advocate consensus of an accessible (Easy -to- Read) Notice of Rights (ERNR) for people with intellectual disabilities in police custody in Ireland. Methods Guidelines developed by Ireland's representative organisation for people with intellectual disabilities and examples of international practice were used to develop a draft ERNR by the primary researcher in partnership with an expert from a representative organisation for people with intellectual disabilities. The ERNR was developed thereafter through two focus groups with a view to achieving consensus with a focus on accessibility, accuracy and layout. This included a multidisciplinary focus group with participants from a representative organisation for people with intellectual disabilities, psychology, speech and language therapy, the police force, public health, forensic psychiatry, mental health, law and, subsequently, a focus group of people with lived experience of intellectual disability. Results Progressive development of the ERNR resulted in incremental improvements in textual accuracy as well as the inclusion of more accessible language and imagery. Originality/value This is the first attempt at developing an easy-to-read document relating to the legal rights of suspects in police custody in Ireland and, accordingly, this procedural innovation promises to assist, not just persons with intellectual disabilities, but also those with limited literacy at the point of arrest. The methodology used in the preparation of the document, employing a focus group to achieve consensus with participation from both multiple disciplines and persons with an intellectual disability, is in harmony with the ethos of the UNCPRD. This methodology may usefully be employed by other member states that have ratified the Convention but have yet to develop accessible version of the legal rights and entitlements that extend to arrested persons under their domestic law.

From Substitute to Supported Decision Making: Practitioner, Community and Service-User Perspectives on Privileging Will and Preferences in Mental Health Care.

Compliance with the Convention on the Rights of Persons with Disabilities (CRPD) requires substitute decision making being abolished and replaced with supported decision making. The current exploratory study involved a series of hui (meetings) with subject matter experts across the spectrum of the mental health care system to identify interventions facilitative of supported decision making; and the prioritisation of those in accordance with their own perspectives. A mixed-methods approach was used to categorise, describe and rank the data. Categories of intervention identified included proactive pre-event planning/post-event debriefing, enabling options and choices, information provision, facilitating conditions and support to make a decision, and education. The category of facilitating conditions and support to make a decision was prioritised by the majority of stakeholders; however, people from Maori, Pasifika, and LGBTQIA+ perspectives, who disproportionally experience inequities and discrimination, prioritised the categories of proactive post-event debriefing/pre-event planning and/or information provision. Similar attributes across categories of intervention detailed the importance of easily and variably accessible options and choices and how these could best be supported in terms of people, place, time, material resources, regular reviews and reflection. Implications of these findings, particularly in terms of the operationalisation of supported decision making in practice, are discussed.

Between the convention and conventional practice: Israeli social workers' recommendations regarding the legal capacity of people with disabilities.

BACKGROUND: Following the convention on the rights of persons with disabilities (CRPD), various countries have recently amended their legal capacity laws with the aim of restricting the use of guardianship and increasing the use of other, less restrictive practices, mainly supported decision making. As social workers have a key role in carrying out these reforms, this study examines how Israeli social workers make legal capacity-related decisions. METHOD: Semi-structured interviews with 27 Israeli social workers. RESULTS: Thematic analysis identified three factors driving social workers' recommendations regarding guardianship and supported decision-making: the person's diagnosis and functioning level, and the presence of a supportive family. A fourth factor, the person's preferences, played a complex and more limited role. CONCLUSIONS: Many changes have yet to be made to fully apply the support paradigm in Israel, since social workers still tend to base their recommendations on factors not fully aligned with the CRPD.