how Estonia is using a WHO tool to tackle stigma and promote human rights in mental health services

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Ingrained stigma and a fixed mindset about how people with mental disorders should be treated are two of the greatest challenges to mental health reform in the WHO European Region. But now, more and more countries are seeing changes at the local level that are transforming the way people receive and provide mental health support.

Estonia is one of these countries. Since 2020, Estonia has been using the WHO QualityRights Toolkit to transform its mental health and social care services. To date, the Estonian National Social Insurance Board (ENSIB) has assessed more than 30 institutions, ranging from assisted living facilities to retirement homes for people with severe psychosocial and intellectual disabilities.

“When we talk about transforming services, we are talking about transforming relationships,” says Cláudia Braga, a WHO QualityRights trainer with more than a decade of service transformation experience in her home country of Brazil. . “You have to consider people with psychosocial disabilities as citizens and you want to promote services based on their right to freedom.

Braga is one of 3 trainers who were in Tallinn in September to refresh Estonian experts’ knowledge of the QualityRights Toolkit, a suite of tools developed by WHO to assess and improve the quality of care in health care facilities. mental health and social protection.

These assessments aim to determine whether facilities adequately support the recovery of people with mental disorders, while protecting their fundamental human rights – such as the right to make decisions about their own lives, to have a job, to get married and have a family. These rights are too often denied because of stigma.

According to Cärolyn-Angelika Liblik, service coordinator at ENSIB, mental health and social care have historically been built around the “out of sight, out of mind” state of mind. People with mental disorders tend to be pushed for life into institutions – which are often separate from communities – where they are forgotten.

Through interviews, document reviews, and observations, trainers typically determine the extent to which these facilities provide their users with a good standard of living, good physical and mental health care, and opportunities to make decisions. regarding their care and to live independently.

They also check whether service users are free from violence, torture or abuse (including seclusion and restraint), all of which violate the UN Convention on the Rights of Persons with Disabilities, ratified in Estonia in 2012 They then make recommendations on how the facility can improve the situation for service users.

Providing mental health care while protecting human rights

In Estonia, as in many countries in the European Region, long-term care facilities remain the main form of care for people with intellectual and psychosocial disabilities.

In 2018, the WHO conducted assessments of 75 long-term care facilities in 25 countries, including Estonia, and found them “well below standard”. The rights of people staying in these establishments were often violated. For example, staff did not tell users why they were receiving particular treatments and even physically coerced them into administering drugs.

These episodes often occur when a client is experiencing a mental health crisis, but they can also occur when staff apply a general solution (such as locking all of the client’s doors at night) to a particular case (a patient who may want escape during a mental health crisis).

“But people aren’t in the middle of a crisis all the time,” says Simon Vasseur-Bacle, clinical psychologist and QualityRights trainer at the WHO Collaborating Center for Mental Health Research and Training in Lille, France. . It advises staff to think creatively about how to apply particular solutions in particular cases, while involving service users themselves – together with their families and other professionals – in determining what they want, both in times of crisis and in normal life.

Make mental health the person, not the disease

One problem is that staff at these facilities may view assessors like Liblik as an intrusive presence, potentially adding more work to an environment that is already understaffed. In their QualityRights training workshop in Estonia, however, Vasseur-Bacle and Braga emphasized that service transformation is not about adding more work, but about creatively using existing resources – human and otherwise – to deliver services. centered on the person, not the disease.

They also believe that in most cases staff are more than willing to change when given the opportunity. “In my experience, people want to transform services,” says Braga. “They want to work in a good department. We all want to go home and tell people that that day we were able to help a user, for example, to go to a specific supermarket to buy pasta. When we use the QualityRights Toolkit, we are able to motivate people to think about it. »

In many cases, this change in mindset is triggered by the assessment process itself, if not by the many follow-up visits that help departments implement the recommendations they make.

Ultimately, Liblik hopes service providers will understand that she and her team are here to make life better for service users. “I wouldn’t be here and I wouldn’t work at the Social Insurance Fund if I didn’t want to change the world,” she says.

Although ENSIB has so far been the only institution to implement QualityRights assessments in Estonia, they hope this will change. Part of the reason they asked WHO to hold the training in Tallinn in September was to recruit others to join their assessments, including family members of service users and service providers themselves.

Many participants pledged to improve their knowledge of the toolkit and to engage in assessments in the future. As one participant said: “These 2 days have been like a revelation. I am convinced that change and development are possible. I am very curious to see how this will develop in Estonia.

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