Counselling Psychology Quarterly
Vol. 22, No. 1, March 2009, 77–84
Mental health as a human right in the context of recovery after
disaster and conflict
MPH Candidate, Harvard School of Public Health, NGO Representative of the
International Union of Psychological Science to the United Nations, Harvard University,
Boston, Massachusett, USA
(Received 21 December 2008; final version received 3 January 2009)
Natural disaster and armed conflict can have a profound impact on the
mental health and psychosocial well-being of the affected population.
Furthermore, mental health problems contribute significantly to the global
burden of disability, especially in low-resource countries. Several interna-
tional human rights conventions affirm the obligation of state governments
to protect, promote and fulfill the right to health, including mental health.
However, the right to mental health has not received adequate attention
from national and international institutions and organizations. Mental
health is still not a priority on the global agenda and is often neglected in
recovery and development efforts after disaster or conflict. Individuals
involved in the mental health field may benefit from familiarity with
relevant human rights documents and guidelines which can inform
research, practice and advocacy efforts.
Keywords: human rights; mental health; psychosocial; conflict; war;
disaster; humanitarian; recovery; development
Mental health in the context of disaster and conflict
Natural disasters and armed conflict can have severe and long-lasting effects not only
on physical health, but also on mental health and psychosocial well-being (Norris
et al., 2002; Solomon & Green, 1992). Research suggests that more than one third of
adult and child (Norris et al., 2002; Vernberg, Silverman, La Greca, & Prinstein,
1996) disaster victims suffer from PTSD after disaster. In the aftermath of such
events, the risk increases for developing problems such as substance abuse, anxiety,
depression, adjustment disorders, interpersonal problems, suicide, vocational
difficulties, long-term physiological changes, and subsequent physical health
problems (Norris et al., 2002). These risks affect individuals and communities
including those not directly involved in the disaster or armed conflict.
In the case of armed conflict, such risks do not only affect combatants but also
communities and civilians. Compared with 14% of all deaths occurring among
civilians in World War II, the proportion of civilian deaths has reached 90% in
several wars during the 1990s (Garfield & Neugut, 2000). This high rate likely reflects
the increased proportion of intra-state conflicts such as civil wars, as opposed to
ISSN 0951–5070 print/ISSN 1469–3674 online
ß 2009 Taylor & Francis
conflicts between nation states (World Bank, 2008). After incidences of violence and
conflict, the affected population often suffers from lasting psychological trauma and
mental health problems (Roberts, 2008; Slim, 2008). Both adults and children,
especially those who have committed or suffered atrocities, can experience chronic
psychological problems such as PTSD, depression, anxiety, substance use problems
and suicidality (Summerfield, 2000; Betancourt et al., 2008). Individuals who were
involved in armed forces or victims of sexual violence may also have difficulty
re-adjusting to post-conflict life and may experience rejection or stigmatization by
their communities (Betancourt et al., 2008). In low resource countries, natural
disasters can cause or exacerbate armed conflict, resulting in complex emergencies
(Inter-Agency Standing Committee [IASC], 2007).
Mental health and psychosocial problems can be very debilitating, as they disrupt
essential areas of vocational, family and community functioning (American
Psychiatric Association, 1994). Depression was the fourth leading contributor to
the global burden of disease (in Disability Adjusted Life Years, DALYs) in 2000 and
is projected to reach second place in 2020 (World Health Organization [WHO],
2008). The costs of mental health problems can not only be measured in suffering
and reduced quality of life among affected communities but also in economic terms.
Mental illness can stifle long-term social and economic development, resulting in
decreased work productivity or job loss, reduced educational attainment, physical
illness, increased medical service utilization, incarceration or homelessness (Kartha
et al., 2005; Kessler et al., 2008). Mental and behavioral disorders are estimated to
account for over 30% of all years lived with disability, and this number is expected to
increase (World Health Organization, 2003). Lack of access to effective intervention
can worsen the problem, particularly in low-resource countries which are already
disproportionately affected by disaster and conflict. WHO asserts that mental health
is the ‘‘foundation for well-being and effective functioning’’ and that there is ‘‘no
health without mental health’’ (Prince et al., 2007; World Health Organization,
2008). The right to health, including mental health is a fundamental human right, an
assertion found in several human rights documents and conventions (Office of the
High Commissioner for Human Rights [OHCHR], 2008a).
Mental health and human rights
Several documents have been drafted by international as well as regional bodies,
affirming the human rights of people with regard to mental health. Examples of these
include the International Covenant on Economic, Social, and Cultural Rights
(ICESCR), The Convention on the Rights of the Child (CRC), and the Convention
on the Rights of Persons with Disabilities (CRPD).
International Covenant on Economic, Social, and Cultural Rights
The ‘‘International Covenant on Economic, Social, and Cultural Rights’’ (ICESCR)
was opened for signatures in 1966 and has been ratified by 159 United Nations
member states as of December of 2008 (OHCHR, 2008a). Article 12 of the ICESCR
asserts the ‘‘right of everyone to the enjoyment of the highest attainable standard of
physical and mental health’’. General Comment 14 was drafted by the Committee on
Economic, Social, and Cultural Rights (CESCR) in 2000, providing concrete
78 I. Weissbecker
guidance for interpreting the right to health in Article 12 of the ICESCR (Committee
on Economic Social and Cultural Rights, 2000; Gruskin & Tarantola, 2005). The
comment notes that the right to health does not only encompass the right to health
care, but also adequate socio-economic conditions necessary for health such as food,
water and housing (Committee on Economic Social and Cultural Rights, 2000).
General Comment 14 also outlines that ‘‘health facilities, goods and services’’ should
be available, accessible, acceptable and of good quality. It further defines healthcare
to include ‘‘preventive, curative, rehabilitative health services and health education;
regular screening programs; appropriate treatment of prevalent diseases, illnesses,
injuries and disabilities, preferably at community level; the provision of essential
drugs; and appropriate mental health treatment and care’’ (Committee on Economic
Social and Cultural Rights, 2000).
Convention on Rights of the Child
The Convention on the Rights of the Child (CRC) was opened for signatures in 1989
and has been ratified by 193 UN member states as of December 2008 (OHCHR,
2008a). The CRC specifies the rights of children and adolescents to development, to
be protected from physical and mental abuse and to have their views respected
(OHCHR, 2008b). It further recognizes that children with mental disabilities have
the right ‘‘to enjoy a full and decent life in conditions that ensure dignity, promote
self-reliance, and facilitate the child’s active participation in the community’’ and
recognizes the right of every child to a ‘‘standard of living adequate for the child’s
physical, mental, spiritual, moral, and social development.’’
Convention on the Rights of Persons with Disabilities
The relatively recent Convention on the Rights of Persons with Disabilities (CRPD)
was opened for signatures in March of 2007 and has been ratified by 45 UN member
states as of December, 2008 (OHCHR, 2008a). This document specifically includes
individuals with mental illness, stating that ‘‘persons with disabilities include those
who have long-term physical, mental, intellectual, or sensory impairments which in
interaction with various barriers may hinder their full and effective participation in
society on an equal basis with others’’ (Leonardi et al., 2006; OHCHR, 2008b). This
convention recognizes that individuals with disabilities should be free from
‘‘exploitation, violence, and abuse’’ and that those individuals need special
protection and safety in situations of armed conflicts or humanitarian emergencies
(OHCHR, 2008b). The importance of raising awareness and combating stigma and
stereotypes of individuals with disability is also emphasized. Furthermore, the
convention notes that member states should collect disaggregated (i.e., separated)
data on individuals with disabilities, disseminate this data, and identify and address
barriers to the realization of rights of persons with disabilities (OHCHR, 2008b).
Applicable regional human rights documents have been drafted on regional levels as
well. An example is the ‘‘African (Banjul) Charter on Human and Peoples’ Rights’’
(1981) which is supervised by the African Commission on Human and People’s
Counselling Psychology Quarterly 79
Rights (WHO, 2005). This document contains articles on civil, political, economic,
social and cultural rights and affirms the right for ‘‘all to enjoy the best attainable
state of physical and mental health’’ and for the disabled to have the ‘‘right to special
measures of protection in keeping with their physical or moral needs’’ (WHO, 2005).
Human rights standards
Several major human rights standards are applicable to mental health and have been
used to interpret what specifically is meant by principles outlined in international
conventions such as the ICESCR (WHO, 2005). Most notably, the ‘‘UN Principles
for the Protection of Persons with Mental Illness and the Improvement of Mental
Health Care’’ (MI Principles) outline minimum human rights standards for the
practice of mental health (United Nations General Assembly, 1991). These principles
apply to persons with mental disorders, regardless of whether or not they are
institutionalized. The MI Principles recognize that every person with a mental
disorder ‘‘shall have the right to live and work, as far as possible, in the community’’
(United Nations General Assembly, 1991). However, the MI Principles have been
criticized for not being effective enough. Compared to international human rights
conventions, the principles are not legally binding and do not provide any form of
international monitoring or reporting (Harding, 2003).
Technical standards that have been adopted by different international agencies can
also guide interpretation of human rights conventions (WHO, 2005). The
Declaration of Caracas (1990) was initiated by the Pan American Health
Organization (PAHO) and adopted as a resolution by various legislators, mental
health professionals and organizations (WHO, 2005). This declaration emphasizes
that mental health services should be community-based and that ‘‘resources, care
and treatment for persons with mental disorders must safeguard their dignity and
human rights, provide rational and appropriate treatment, and strive to maintain
persons with mental disorders in their communities’’ (WHO, 2005). The declaration
also states that mental health legislation must ‘‘safeguard the human rights of
persons with mental disorders, and services should be organized so as to provide for
enforcement of those rights’’ (WHO, 2005). The WHO developed technical standards
outlined in the Mental Health Care Law: Ten Basic Principles (WHO, 1996a), which
further interpret the MI Principles and can guide countries in developing mental
health legislation. Additionally, WHO developed Guidelines for the Promotion of
Human Rights of Persons with Mental Disorders (WHO, 1996b) which also interpret
the MI principles and can help evaluate human rights conditions in institutions.
Those guidelines outline principles for the promotion of mental health and
prevention of mental disorders, which should include access to basic mental health
care as well as ‘‘mental health assessments in accordance with internationally
accepted principles’’ (WHO, 2005, 1996b).
United Nations member states who have ratified international human rights
conventions such as the ICESCR, the CRC and the CRPD are obligated to
respect, promote, and fulfill the right to mental health, which includes the
implementation of domestic mental health law and policy as well as the provision
80 I. Weissbecker
of technical, administrative, and budgetary resources (e.g., Committee on
Economic Social and Cultural Rights, 2000). However, the right to mental
health has not received adequate attention from the international community,
governments, or international donors (Brendan, 2006). Mental health is still not a
priority on the global agenda and is often neglected in recovery and development
efforts after disaster or conflict.
Mental health as a human right after disaster and conflict
Mental health and human rights have often been framed in the context of human
rights violations committed against individuals who are suffering from mental illness
(e.g., Dhanda & Narayan, 2007; Yamin & Rosenthal 2005). While this is an
important aspect, the issue of health including mental health in the context of human
rights has much broader implications (Gruskin & Tarantola, 2005; Hannum, 1992).
The right to health includes the right to mental health, which encompasses
preventative efforts as well as availability, accessibility, acceptability, and quality of
mental health goods and services (Committee on Economic Social and Cultural
Efforts towards reconciliation, psychosocial recovery, and counselling for
perpetrators and victims of violence have been outlined as integral elements of
post-conflict reconstruction, along with the efforts of re-establishing security, legal
systems, good governance and social and economic well-being (Barnett et al., 2007;
Center for Strategic and International Studies and the Army of the United States of
America, 2002). However, it has been pointed out that very few multi-lateral and US
institutions prioritize or engage in such activities (Barnett et al., 2007). Mental health
legislation is often absent in developing countries, and does not receive adequate
attention in human development efforts (Lancet Global Mental Health Group, 2007;
WHO, 2008). Globally, the proportion of Disability Adjusted Life Years (DALYs)
attributable to mental disorders is about 11.5%, while the median proportion of the
health budget allocated to mental health is only 3.8% (WHO, 2008). This gap is even
wider in countries affected by disaster and conflict, which typically experience a
greater burden of mental health problems, and a lower or non-existent budget
allocation for improving mental health (WHO, 2008). Mental health remains one of
the most under-funded areas of health care, especially in low-resource settings
(IASC, 2007; Lancet Global Mental Health Group, 2007). As a result, it is estimated
that 75% of individuals with mental health problems in low income countries have
no access to mental health services (WHO, 2008).
Vulnerable populations are likely to be affected the most. Individuals with lower
resources, which includes groups such as refugees as well as women, children, the
elderly, the disabled and those with pre-existing mental health or substance use
problems, are especially vulnerable to poor health outcomes after disaster or conflict.
They are more likely to show severe and persistent stress reactions and are less likely
to recover socioeconomically (Galea, Nandi, & Vlahov, 2005; Norris et al., 2002).
The prevalence of acute and chronic psychological impairment following disasters is
likely to be higher among communities with higher losses and low resources (Norris
et al., 2002). Adequate mechanisms for evaluation, culturally informed intervention
and follow-up regarding mental health problems in such countries, however, are
often lacking (Saraceno et al., 2007).
Counselling Psychology Quarterly 81
Currently, best practices and guidelines are emerging, that can assist governments
and organizations in addressing mental health issues from a public health perspective
in low resource settings affected by conflict or disaster. The Inter-agency Standing
Committee (IASC) Guidelines on Mental Health and Psychosocial Support in
Emergency Settings for example, offer practical advice for protecting and promoting
mental health and psychosocial well-being, including aspects of coordination,
monitoring and evaluation, human rights, human resources, community mobiliza-
tion, health services, and education (IASC, 2007). Furthermore, the World Health
Organization has recently launched the mental health Gap Action Programme
(mhGAP) which outlines ways in which mental health problems can be effectively
addressed in low- and middle-income countries (WHO, 2008). Recommendations
include cost-effective interventions at the community level and integration of mental
health care into primary health care services (Betancourt et al., 2008; Bolton et al.,
2007; WHO, 2008). Further research and evaluation efforts are still needed to
elaborate on best practices, ethical principles, monitoring and evaluation, and issues
of accountability when addressing mental health and psychosocial needs in affected
communities. However, existing documents and guidelines can aid governments and
organizations in promoting, protecting, and fulfilling the right to health, including
mental health, in countries that have been affected by disaster and armed conflict.
Natural disasters, armed conflict, and complex emergencies can have profound and
enduring effects on mental health and psychosocial well-being, which can
significantly impact social and economic development and recovery efforts. The
right to health, including mental health, has been affirmed in various international
human rights documents and guidelines. However, mental health is often not given a
high priority by the international community, including UN member states, and
international donors, who attend to competing needs and agendas (Lancet Global
Mental Health Group, 2007). Specific guidelines exist for helping governments and
NGOs in promoting and protecting mental health and psychosocial well-being after
disaster and conflict. Protecting, promoting, and fulfilling the right to mental health
requires a comprehensive approach that includes legislation, policy, programming,
monitoring, and evaluation activities to be undertaken various national and
international stakeholders. Individuals working in the mental health field may
benefit from familiarity with international human rights law and relevant
recommendations in order to guide programming research, and advocacy efforts
aimed at aiding those affected by disaster and conflict.
Declaration of interest: The author reports no conflicts of interest. The author alone is
responsible for the content and writing of the paper.
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