Introduction
The COVID-19 pandemic has brought the global community to its knees, laying bare severe inequities in societies of all kinds.Footnote 1 By many measures, these inequities arise from social and institutional legacies that have undermined the dignity and worth of certain population groups, including people with psychosocial disabilities. Regrettably, research so far shows that policy responses to COVID-19, such as lockdowns, physical distancing, and the associated breakdown of social connections, have worsened risk factors associated with mental health conditions (Reference Torales, O’Higgins, Castaldelli-Maia and VentriglioTorales et al. 2020; Reference RajkumarRajkumar 2020; Holmes et al. 2020). The pandemic thus represents a significant obstacle for mental health policymakers and advocates committed to upholding Article 12 of the Convention on the Rights of Persons with Disabilities (CRPD), particularly its principles of legal capacity for all and equal recognition before the law.
To overcome this obstacle, however, we caution international actors – including governments, service providers, and researchers – against a temptation that has pervaded mental health policymaking in the last several decades: to overinvest in biomedical interventions at the detriment of social and human rights-oriented services (Reference Chapman, Williams, Hannah and PūrasChapman et al. 2020). In this chapter, we offer insights on how these actors should instead use the pandemic as an opportunity to pivot away from the dominant biomedical paradigm – which often compromises autonomy and opportunities for individual self-determination – in favor of one based on human rights. By integrating human rights norms, reforming international mental health practice, and moving past unduly coercive practices, this paradigm shift will serve to uphold Article 12 and its promises for people with psychosocial disabilities around the world.
This chapter proceeds in two parts. First, we discuss current practices in international mental health care, calling attention to the fact that the biomedical status quo often results in coercive and asymmetrical patient–provider relationships, stigma, and an arbitrary hierarchization of fundamental rights. Second, we argue that framing the mental health consequences of the pandemic as a crisis of individual conditions, as opposed to one of communal responsibility, will constitute a missed opportunity to make the changes needed to achieve the aims of Article 12. We thus call for human rights-oriented change within and beyond international mental health services. Within international mental health care, stakeholders should seek to bolster innovative forms of support and care, including through remote ways of providing services, dismantling untherapeutic environments, and reconceptualizing universal healthcare coverage. Beyond, they should look to align their actions more closely with international law and the CRPD more specifically, while addressing social determinants that threaten mental health.
1 The Biomedical Paradigm, COVID-19, and Curtailing Article 12
Research on how to address the mental health consequences of the pandemic is still underway. Yet, a consensus may already be coalescing around the idea that nations should focus their investments on biomedical advances and interventions. In an already widely cited position paper in Lancet Psychiatry, for instance, Emily A. Holmes and her colleagues emphasize the need to study the neurotoxic effects of COVID-19, including through “building pathology and molecular neuroscience networks to enable brain and other tissue to be collected at autopsy and examined for viral infection and damage” (Holmes et al. 2020). They also push for the “discovery, evaluation, and refinement of mechanistically driven interventions to address the psychological, social, and neuroscientific aspects of this pandemic” (Holmes et al. 2020).
Holmes and her colleagues, along with the broader mental health academic community, have not ignored how the pandemic has exacerbated certain social determinants associated with mental illness, to be sure (Holmes et al. 2020; Reference Galea, Merchant and LurieGalea, Merchant, & Lurie 2020; Reference GhebreyesusGhebreyesus 2020; Reference Khoo and LantosKhoo & Lantos 2020; United Nations 2020). They recognize that by upending employment, educational, and social support systems, the pandemic has worsened pre-existing vulnerabilities for many population groups, including people with intellectual and developmental disabilities; marginalized groups like incarcerated people, the homeless, and refugees; and lower-income, majority-minority, and Indigenous communities. We agree with this aspect of the analysis and we hope and hope that competing biomedical priorities will not crowd it out. Unfortunately, prevailing practices in international mental health care render us doubtful that this hope will be realized.
The history of medicine is a narrative of great progress, achievement, and breakthrough. But it is also one of expansive human rights violations, illustrated by practices that have subjugated, harmed, and even killed vulnerable individuals receiving care (Reference PūrasPūras 2017). Perhaps unsurprisingly, the history of psychiatric and mental health care has followed a similar course. Stakeholders calling for the prioritization of widespread mental health treatment have successfully argued for a conceptual model that frames mental health conditions in biomedical terms (The Lancet 2011). What has emerged is a policy orientation that focuses on the development of neuroscience and pharmaceutical treatment options that, like other medical treatments, result in narrow and often immediately measurable outcomes.
At the same time, however, this orientation has led to problematic practices that may continue unabated, even once the pandemic is under control. First, it has led to coercive treatment practices that undermine service users’ rights to autonomy, capacity, and dignity protected under Article 12 of the CRPD. Providers have also become gatekeepers of the well-being of people with psychosocial disabilities, legally entrusted to assess legal capacity and administer treatment without consent, frequently in violent and degrading circumstances. Second, asymmetrical power relationships between providers and patients, often fueled by paternalistic attitudes carried by conventional psychiatry adherents, have served to contribute to the stigma associated with psychosocial disabilities. Third, mental health services have tended to prioritize certain rights (e.g., treatment and access to care) while neglecting others (e.g., autonomy, liberty, family and community care). In the next sections, we explore each of these problems in more detail.
1.1 Coercion and Power Asymmetries
In international mental health care, coercive practices like forced treatment and substituted decision-making have contributed to what Natalie Drew and her colleagues have called “an unresolved global practice” (Reference Drew, Funk and TangDrew et al. 2011). Medical experts generally agree that, as compared to other health care settings, coercion happens most often in mental health care. This widespread reliance on coercion is due in part to the traditional psychiatric view that providers should determine the direction of treatment. Under this understanding, decision-making, priority-setting, and the organization of care often fall in the hands of mental health care specialists and occur in settings that are isolated from the lives of service users. As a result, providers unilaterally decide what is best for people diagnosed with mental health conditions, which jeopardizes the ability of service users to participate in their treatment course.
Coercion in mental health care takes on different forms, including treatment pressures (e.g., incentives and sanctions), interpersonal leverage, threats, and the legally sanctioned use of force to make a person accept treatment (Reference SzmuklerSzmukler 2015). Treatment over objection – the most drastic of these measures – frequently necessitates the use of behavioral controls, “including different forms of restraint (mechanical, physical or pharmacological), forcible seclusion in confined spaces, treatment by administration of medication without the person’s consent and restrictive conditions imposed as part of treatment and supervision in the community” (Reference Sashidharan, Mezzina and PūrasSashidharan, Mezzina, & Pūras 2019). Coercive practices also occur in several types of settings, notably inpatient psychiatric institutions, where there can be “an absence of recovery-oriented treatment, with people with mental and psychosocial disabilities chained to beds or posts and made immobile for long periods of time” (Reference Drew, Funk and TangDrew et al. 2011). These practices also occur in non-clinical and punitive settings, such as jails, prisons, and other detention facilities, which raises the risk of having abusive practices left unchecked by clinical, legal, and democratically accountable oversight mechanisms.
From a human rights standpoint, undue coercion is problematic for multiple reasons. Most basically, the etiology and phenomenology of mental illness remain a subject of much scholarly attention and debate. The biological processes behind mental health conditions are also poorly understood. Yet, coercive practices like forced medicalization and pharmaceutical interventions often transpire under the guise of evidence-based practice, even though available evidence showing their clinical benefits is debatable (D’Lima 2017; Reference Luciano, Sampogna and Del VecchioLuciano et al. 2014; Reference Sailas and FentonSailas & Fenton 2000; Reference WrightWright 2003). If anything, research has shown that coercive practices can adversely impact quality of life for people with psychosocial disabilities, leaving many traumatized and disempowered (Reference Corrigan, Markowitz, Watson, Rowan and KubiakCorrigan et al. 2003; Reference Kallert, Glöckner and SchützwohlKallert, Glöckner, & Schützwohl 2008; Reference Paksarian, Mojtabai and KotovPaksarian et al. 2014).
What is more, people with mental health conditions often have to confront power asymmetries with their providers, leaving them at the mercy of paternalistic decision-making. The former United Nations Special Rapporteur on the right to health has included these forms of asymmetries as part of a “global burden of obstacles” to promoting human rights-based mental health policies and practices (UN Human Rights Council 2017; Reference PūrasPūras 2017). Power asymmetries between providers and service users weaken therapeutic relationships and dissuade “people from seeking further treatment thus increasing the risk of non-adherence and involuntary treatment, particularly those with long-term mental health problems” (Reference Sashidharan, Mezzina and PūrasSashidharan, Mezzina, & Pūras 2019). Given the positive influence that the social sciences, humanities, and other disciplines (e.g., community and social psychiatry) have had on conventional psychiatry throughout the twentieth century, we would hope that this kind of show of power would become a thing of the past (Reference BrackenBracken 2014; Reference Priebe, Burns and CraigPriebe, Burns, & Craig 2013). But the use of paternalistic and coercive practices persists, revealing one of many paradoxes in mental health practice, and one of the central barriers to fulfilling Article 12’s commitment to promoting autonomy and self-determination for people with psychosocial disabilities.
1.2 Stigma and Abnormalizing the Normal
Stigma represents another persistent obstacle to protecting equal rights and legal capacity for people with mental health conditions (Randall 2010; Reference McDaidMcDaid 2008). Conventional psychiatry adherents have long held that people with psychosocial disabilities are “ill” and thus unable to participate fully in social, political, or economic pursuits. This labeling, exacerbated by the biomedical model’s flawed equivalence between mental health conditions and physical illnesses, has contributed to perceptions of incapacity, preventing individuals with psychosocial disabilities from integrating into society and enjoying decision-making capacity (Reference Sashidharan, Mezzina and PūrasSashidharan, Mezzina, & Pūras 2019). And yet, as international systems prepare for the predicted rising tide of mental health issues caused by the pandemic, we fear that certain behavioral reactions like stress and anxiety will be over-pathologized, a response that may only serve to marginalize further those in need. That risk is particularly salient in areas of the world that continue to use colonial-era psychiatric asylums, as coercive interventions perpetuate the impression that people with mental health conditions are unpredictable and dangerous (Reference Mascayano, Armijo and YangMascayano, Armijo, & Yang 2015).
Furthermore, overestimating the prevalence of mental illness through the pathologization of certain behaviors and emotional reactions will provide a biased picture of the pandemic’s impact. This approach will blur the line between people who need clinical attention and those whose conditions may attenuate through non-clinical interventions. The kind of “mass pathologization” might force vulnerable people into traditional mental health care systems, even if they stand to derive more benefit from employment, educational, and social support systems (Reference Horwitz and WakefieldHorwitz & Wakefield 2007). The latter issue in particular might have the perverse distributional effect of burdening already weakened healthcare systems while simultaneously reinforcing a system that has a history of perpetuating stigma.
1.3 The Arbitrary Hierarchization of Fundamental Rights
International mental health care has also tended to uphold certain fundamental rights while undermining others. For example, although mental health systems offer care to people in need, it may come at the cost of other rights (e.g., informed consent), particularly when it occurs under conditions of coercion. For many, this arbitrary prioritization of rights can cause harm. It also undercuts a bedrock principle of Article 12 – that is, the ability of people with disabilities to “[fend] off others purporting to make decisions for us” (Reference QuinnQuinn 2011). Person-centered mental health care is thus necessary to protect the autonomy and dignity of individuals with psychosocial disabilities, and it serves as an ethical orientation that aligns with the CRPD.
One of the authors here has already observed that this problematic phenomenon runs in parallel to the human rights travesties that have occurred in some orphanages and other types of residential institutions in Central and Eastern Europe (UN Human Rights Council 2015). These orphanages came into being during an era of charity and paternalism, when the state was expected to take over the upbringing of children who grow up in at-risk families, so to provide essential needs like nutrition and shelter. But evidence started to emerge showing that institutionalized children often had at least one parent from whom they had suffered separation, and that massive institutionalization of children did more harm than good. The orphanage system’s choice to prioritize one set of rights (e.g., nutrition and shelter) over others (e.g., living in family and community) meant overlooking the right to a supportive family environment. This failure caused many institutionalized children irreparable physical and mental health harm.
2 Changing Paradigms
In light of the pandemic, international systems must look for opportunities to redefine how to care for people with psychosocial disabilities within and beyond mental health services. In so doing, they should aim to put people with psychosocial disabilities “at the center of the discourse” (United Nations Enable). This orientation will fulfill the obligation under Article 12 “to take appropriate measures to provide access by persons with disabilities to the support they may require in exercising their legal capacity.”
2.1 Within Mental Health Services
2.1.1 Expanding Access to Remote Forms of Care
Given the mass isolation caused by the pandemic, offering remote forms of mental health care must become a priority for countries across the world. The delivery of such care can occur via videoconferencing, internet forums, phone applications, text messaging, and emails (Reference Zhou, Snoswell and HardingZhou et al. 2020). A robust tele-mental health care infrastructure would ideally ensure that service users – particularly the most vulnerable – can access care under their own terms and from the comfort of their homes or other dedicated care facilities. Research has already shown that such care will assist people with mental health conditions to “maintain psychological well-being and cope with acute and post-acute health requirements more favorably” (Reference Zhou, Snoswell and HardingZhou et al. 2020). Moreover, as John Torous and Til Wykes have explained, “digital health platforms could be important developments from this pandemic, but the most enduring will be investment in the people, process, and support to ensure telehealth cycles of interest are not tied to disasters but rather improve care every day” (Torous, & Wykes 2020).
Several countries (e.g., the Netherlands, Sweden, and the United States) have facilitated the widespread use of tele-mental health care services through the lifting of legal and regulatory barriers (Reference Wind, Rijkeboer, Andersson and RiperWind et al. 2020; Torous & Wykes 2020). In the United States, for example, the Coronavirus Aid, Relief, and Economic Security Act helped expand insurance coverage for people with mental health conditions who required immediate tele-behavioral health services (P.L. 116–136). Nevertheless, most countries lack the resources or the will to develop the technological and policy infrastructure necessary to deploy remote mental health care services at scale (Reference Ohannessian, Duong and OdoneOhannessian, Duong, & Odone 2020). For example, despite being one of the countries hardest hit by the pandemic, Italy did not include telehealth as an essential health care service covered by the Servizio sanitario nazionale, the country’s universal healthcare system (Reference Ohannessian, Duong and OdoneOhannessian, Duong, & Odone 2020). Furthermore, access to the Internet is often stratified across racial and economic lines, resulting in what many call the “Digital Divide” (Reference Van Dijk and RösslerVan Dijk 2017; Reference FairlieFairlie 2004). Addressing these gaps through best practices and laws that ensure access and the protection of service users’ privacy will not only make countries more resilient to future crises. It will also offer an alternative, less restrictive avenue of support for people with psychosocial disabilities, bolstering their ability to readily access care. An expansion of the scope of mental health care services beyond those traditionally offered in clinical settings is a necessary step forward in addressing the pandemic and fulfilling the aims of Article 12.
2.1.2 Dismantling Untherapeutic Environments
International mental health care policymakers must also take accountability for the gaps in care in non-clinical settings, such as carceral institutions and immigration detention centers. As the pandemic continues to unfold, this obligation becomes all the more urgent because places of detention house a disproportionate amount of people with mental illness (Reference Liebrenz, Bhugra, Buadze and SchleiferLiebrenz et al. 2020). These places are also “epicenters for infectious diseases because of the higher background prevalence of infection, the higher levels of risk factors for infection, the unavoidable close contact in often overcrowded, poorly ventilated, and unsanitary facilities, and the poor access to health-care services relative to that in community settings” (Reference Kinner, Young and SnowKinner et al. 2020).
In times of crisis like the current pandemic, these issues coalesce in making places of detention inhumane. One part of the problem involves the heightened risk of preventable death caused by the high rates of infection and the lack of adequate clinical infrastructure. In the United States, estimates suggest that around 108,000 inmates had contracted COVID-19 as of August 2020, and almost 900 had already died due to complications associated with the virus (The Marshall Project 2020). Similarly eerie numbers were captured in the United Kingdom, where epidemiologists predicted that the pandemic could cause more than 800 preventable deaths in the country’s prison system (Institute of Epidemiology and Health Care 2020). Another part of the problem is that individuals feel unsafe in institutional settings, leading them to experience unrest and outrage. In Mexico, for instance, a riot broke out in an immigration detention center over fears that overcrowding and unsanitary conditions would expose the detained population to infection. This incident left one person dead and others severely injured (The Associated Press 2020).
One of the authors here has already argued for the diversion of people with mental illness away from the criminal legal system (Reference Barsky, Cucolo and SistiBarsky, Cucolo, & Sisti 2020). The idea underlying of this argument is that non-clinical institutional settings like jails and prisons lack the resources, expertise, and accountability mechanisms necessary to respond to the needs of people with mental illness, resorting reflexively and discriminatorily to drastic and punitive practices like solitary confinement. The pandemic has magnified the need to both eliminate unduly punitive practices and dismantle untherapeutic environments (UN Human Rights Council 2018). Indeed, if people with mental health conditions cannot receive minimally appropriate attention in these kinds of settings, opportunities for rehabilitation and self-determination are rendered impossible. This result is repugnant to the principles of Article 12.
2.1.3 Humanizing Universal Health Coverage and Access
As part of its 2030 Agenda for Sustainable Development, the World Health Organization (WHO) has made it a priority to “achieve universal health coverage and access to quality health care” (UN General Assembly 2015). But, in the wake of the pandemic, achieving “physical and mental health and well-being,” as the WHO has set out to do, will involve more than health care coverage and access (UN General Assembly 2015). To achieve this goal, and to overcome the mental health challenges caused by the pandemic, international mental health care systems must adopt a person-centered, human rights-based understanding of universal health care that eschews a narrow biomedical conceptualization of health. Strengthening global mental health systems based on principles of legal capacity, self-determination, nondiscrimination, and participation is vital for people with mental health conditions, as they are particularly at risk of coming into prolonged and repeated contact with such systems throughout their lives.
One facet of this expansive understanding of universal health coverage will involve research on the critical role played by what the CRPD defines under Article 27 as the right to work and employment – that is, “the opportunity to gain a living by work freely chosen or accepted in a labour market and work environment that is open, inclusive and accessible.” According to recent research from Bangladesh and India, several suicides have occurred due to work deprivation and other forms of economic distress (Reference Bhuiyan, Sakib, Pakpour, Griffiths and MamunBhuiyan et al. 2020; Reference Dsouza, Quadros, Hyderabadwala and MamunDsouza et al. 2020). These troubling events corroborate past research that has found that “economic recession, unemployment, and poverty are strongly associated with severe psychological comorbidities such as suicidal behaviors” (Reference Bhuiyan, Sakib, Pakpour, Griffiths and MamunBhuiyan et al. 2020). Thus, if global mental health systems are to prevent increased incidences of mental illness and suicide, they must look beyond clinical interventions and into preventive economic relief programs, which can help protect people who lose their income and are otherwise in financially precarious positions. A corollary benefit of this proposal also centers on ensuring that people with psychosocial disabilities can “control their own financial affairs,” which is an objective of Article 12.
A critical assessment of how mental health systems have responded to the needs of homeless people and others who have lesser or no means for self-determination is also necessary. For a long time, researchers have recognized that homelessness is a risk factor for mental illness (Reference Bassuk, Rubin and LauriatBassuk, Rubin, & Lauriat 1984). Plus, as Jack Tsai and Michal Wilson have warned, people experiencing homelessness are particularly at risk of COVID-19 exposure because many “congregate in living settings – be it formal (i.e., shelters or halfway houses) or informal (i.e., encampments or abandoned buildings) – and might not have regular access to basic hygiene supplies or showering facilities” (Reference Tsai and WilsonTsai & Wilson 2020). Global mental health stakeholders must, therefore, take account of the need to offer sheltering services, where the priority is both to offer basic living services and to connect people with needed community-based services.
2.2 Beyond Mental Health Services
The pandemic has exacerbated certain social determinants (e.g., inequality and discrimination) that contribute to mental illness (Reference Compton and ShimCompton & Shim 2015). Rolling back this damage will require ingenuity and creativity on the part of global mental health stakeholders. But, doing so will require that governments design social policy and invest in services beyond mental health care that aim to maximize the improvement of social determinants that contribute to mental health conditions. No one-size-fits-all solution exists, to be sure. But certain human rights principles, including those enunciated in Article 12 and other provisions in the CRPD, can serve as guideposts as countries continue to coordinate with global mental health stakeholders in setting up an infrastructure capable of weathering the pandemic. Two of the authors here have contributed to producing a set of critical elements for rights-based supports for crisis response, setting an important starting point for how human rights standards can translate into operational elements at the practical level (Reference Stastny, Lovell and HannahStastny et al. 2020). What follows is thus less of a formula and more of an evidence-based exercise in understanding how services beyond mental health care can help people with mental illness cope with the pandemic.
One obvious area of concern relates to how countries provide supported decision-making, integration, and community-based services to elderly people. Article 12 espouses a person-centered policy framework, one in which all people should have the ability to care for themselves autonomously and free of unduly coercive constraint (Reference BarskyBarsky 2021). Furthermore, Article 19 of the CRPD recognizes the right of “all persons with disabilities to live in the community” and requires that countries “take effective and appropriate measures to facilitate full enjoyment by persons with disabilities of this right.” But the pandemic has made clear that the institutional model of care for the elderly – namely nursing homes and other senior housing facilities – is a failure and has isolated this vulnerable segment of the population while establishing conditions propitious for mass infection, suffering, and death (Reference Armitage and NellumsArmitage & Nellums 2020). To fulfill the rights to self-determination, independence, and community inclusion, systems of elderly care must change. But who will bear this burden? Governments? Innovators in the private sector? The public? As the pandemic continues to affect communities across the world, and as global mental health stakeholders continue to address not only the current pandemic, but also future crises, these questions will only grow in importance. What is clear, however, is that the status quo has favored practices of isolation and marginalization. These practices are a sure way to short-circuit hope for a more inclusive future.
Another urgent area concerns the development of supportive and preventive services for children, especially those with psychosocial and intellectual disabilities. Article 7 of the CRPD requires that countries “take all necessary measures to ensure the full enjoyment by children with disabilities of all human rights and fundamental freedoms on an equal basis with other children.” But, by upending the provision of social services like schools, which have traditionally operated as “a de facto mental health system for many children and adolescents,” the pandemic has impacted the attainment of developmental milestones. Moreover, as Louise Dalton and her colleagues have stated, rapid COVID-19 spread has required “caring for a predominantly adult patient population, magnifying the invisibility of children’s urgent psychological needs” (Reference Dalton, Rapa and SteinDalton, Rapa, & Stein 2020). Solutions to these problems can only come through initiatives rooted in access (e.g., tele-mental health and online learning platforms), inclusion (e.g., financial packages for economically distressed families and universal education), and non-discrimination (e.g., robust legal protections for children with disabilities).
Evidence also shows that adverse childhood experiences (ACE) contribute to a high prevalence of physical and mental health conditions that can persist through life (Reference Monnat and ChandlerMonnat & Chandler 2015; Reference Schilling, Aseltine and GoreSchilling, Aseltine, & Gore 2007). Starting from infancy, children can suffer from different forms of violence, including emotional abuse and neglect. When such forms of violence reach the level of toxic stress, the brain and body will learn to react to any stressful event in harmful ways. Given research showing a relationship between the pandemic and increased instances of family violence – a phenomenon that may have to do with the stress caused by measures like lockdowns and social distancing – more children will be vulnerable to suffering adverse childhood experiences (Reference Usher, Bhullar, Durkin, Gyamfi and JacksonUsher et al. 2020). But pathologization and medicalization of effects of ACEs and toxic stress would be counterproductive. Instead, we suggest that there should be more investments to promote healthy holistic development and positive parenting, so that children are protected from any forms of violence.
Although important, these issues are far from exhaustive. But the approach we propose here – that is, enhancing social determinants of mental health while promoting human rights principles in tackling problems caused by the pandemic – should apply in all areas of social policy. In the context of global mental health care, this approach is of particular importance. Resorting to a biomedical conception of mental health, as well as the coercive and other problematic practices that have long stemmed from it, will not assist the millions of people whose mental health and well-being have deteriorated because of the pandemic. Turning to the CRPD and other sources of international human rights policy and law will best calibrate policy interventions.
3 Conclusion
The COVID-19 pandemic has created conditions that may very well increase the incidence of mental health conditions in communities across the world. To address this generation-defining challenge, however, international mental health systems need to look beyond a biomedical conception of mental health and toward an orientation predicated on the kinds of human rights principles embedded in Article 12. By humanizing mental health treatment services and investing in policies that prioritize social determinants, this approach will enable the design of interventions that place people – and their well-being – first.
The pandemic – a global catastrophe that has caused the death of millions, and the suffering of millions more – thus represents a moment of reflection and learning for stakeholders committed to upholding Article 12 and the principles it enshrines. In this spirit, we are reminded of what the late Dr. Martin Luther King, Jr. told a crowd in Memphis, Tennessee, at the height of the Civil Rights Movement, the day before his assassination: “that only when it is dark enough can you see the stars.”
The stars here represent a new way of caring for people with psychosocial disabilities, a population group that continues to suffer discrimination, oppression, and subjugation. And only in moments of deep change – like those in which we live at this moment – can an honest, introspective process of reform occur. Now is a time like no other to change paradigms.
Figure 2.1 Risk and protective factors for mental health promotion
