Mental Health Advocacy – World Mental Healthcare Association

Mental Health Advocacy: Ethical Code, Rights & Duties

1. Introduction and applicability

In India, a wide range of legislation is associated with the rights, duties, and responsibilities of mental health professionals (MHPs) and advocates. The Indian Constitution—in conjunction with human rights-related parliamentary laws, the Mental Health Care Act (MHCA) of 2017, and several international conventions and codes of ethics—oversees and guides mental health advocacy into adopting an ethical course of action and fulfilling the highest ideals of psychology.

However, there is no standing statutory “Code of Practice” (CoP) to supplement the Mental Health Care Act and make the legal terminologies more comprehensible and the legal provisions more efficiently executable, for the benefit of the stakeholders involved in addressing mental health issues in India. Because of this shortcoming, the World Mental Health Association (WMHA) attempts to pen down, in a systematic manner, the rights and responsibilities enjoyed by the various stakeholders and a code of ethics sets down guidelines and best practices to follow for integrity and professionalism in the fields of psychology and psychiatry, respectively.

The ethical code of academic, professional, and personal conduct set forth is broadly intended for activities associated with mental health rights, mental health care and treatment, and mental health services across a broad spectrum of private and public mental health advocates in a variety of contexts. Areas covered include (but are not limited to) clinical and counseling practice of psychology; scientific research, educational practices, and professional training related to psychology; conventional and unconventional treatment interventions in psychiatry; mental health-related administration; mental health establishments; organizational consulting; psychiatric assessments, program designs, and evaluation; and rights of mental health professionals, advocates, and activists. The ethical code and its corresponding legal provisions also apply to activities conducted over conventional, unconventional, in-person, or electronic transmissions.

The prescribed non-statutory CoP is intended to provide guidance for mental health law makers, MHPs, advocates, and patients—in the interests of the general public as well as the professional community related to the disciplines of psychology and psychiatry in India. It serves to safeguard the autonomy and rights of patients seeking mental healthcare treatment and services and protect mental health practitioners from the uncomfortable repercussions of unintended mistakes. As such, it does not form the basis of civil liability and the public is not directly affected by this protocol.

Nonetheless, the prescribed ethics code intends to establish a higher standard of conduct that supplements law and MHPs and other mental health advocates practicing within the territorial jurisdiction of India must meet the higher ethical standards during the execution of their duties and responsibilities. In situations of conflict, the enshrined rights of mental health advocates are committed to protect them and resolve conflicts in a responsible manner in keeping with the basic principles of human rights. However, a lack of understanding or misunderstanding of these fundamental standards of mental health advocacy cannot be treated as a defense to a charge of unethical professional conduct in any field of practice.

2. Who can provide mental health services?

In India, the legal provisions for the right to mental health and mental health care treatment and services involve a large number of stakeholders who operate under the directives of the Constitution of India, parliamentary laws, the Central Government, and the state governments. The terms of diagnosis and mental health treatment and services provided by Mental Health Professionals (MHPs) are subjected to the controlled supervision of policy makers, central and state mental health authorities, courts, judges and magistrates, municipal corporations, medical officers, and licensed mental health establishments.

According to the MHCA, the following MHPs can render mental health care treatment and services in India:

Licensed psychiatrist
Licensed clinical psychologist
Licensed psychiatric social worker
Licensed human rights worker
Licensed mental health nurse
Medical professionals registered in central or state medical register
Mental health professionals registered in central or state medical register
Licensed mental health establishments
Licensed medical or non-governmental or non-profit establishments

3. Responsibilities of mental health professionals

Desai, Nimesh G. Desai opens his editorial essay, Responsibility of psychiatrists: Need for pragmatic idealism, in the journal Psychiatry with the statement: The etymological basis of ‘responsibility’ is to do with the ‘ability to respond’. He was drawing from the landmark code of ethics set down by Paul Chodoff and supplemented by Richard S. Lazarus that lays down the professional responsibilities of psychiatrists, psychologists, and other similar mental health professionals. The fundamental principles in this seminal protocol include:

The responsibility of competence or the need to master their task
The responsibility of ethical behavior or to police medical ranks
The responsibility of accountability or to be accountable to the public; and
The responsibility of advocacy or to be advocates for the mentally ill persons

Multiple codes of ethics exist across the world. Mostly, these are based on the universal dimensions of medical ethics, with minimal customization to suit the legal prescriptions of the countries these protocols are operating in. However, it is widely recommended and desired that mental-health professional duties and responsibilities should be openly tailored to the “need” of the hour and the respective requirements of the actors in a given situation. With the emergence of mental health as a fundamental right and the increasing acceptance of mental health as a scientific discipline that alleviates psychological distress and human suffering—the responsibilities of mental health professionals are greater and more inescapable than ever.

The responsibilities of mental health professionals can be categorized under professional, legal, ethical, and social labels. These have been elaborated on below:

I. Professional responsibilities

The foremost fundamental professional obligation in mental health, like any other field, is professional competence. A mental health professional should have the mandatory academic qualifications and professional skills to provide help to people suffering from mental health conditions. The MHP should obey the existing protocols of the profession, avoid conflicts of interest, and put the interests of clients ahead of their own interests and profit motives. He/she must also advance his/her professional competence to cater to the growing demands of mental health cases.

However, psychiatry or mental health, as a discipline and profession, is often plagued by ambiguity when it comes to its frameworks of approach and practice, namely:

A. “Unscientific” Profession

There are misplaced and fallacious notions around the psychiatric and psychological professions, deeming them unscientific or lacking in empirical rigor. The alleged “safe” and “experimental” course of practice, the soft nature of the skills considered desirable for MHPs, and the lack of substantial penalty for unprofessional conduct challenge the complacency of the professionals. Especially in developing or developed countries—wherein the awareness about mental health is relatively in its infancy—most professional barriers arise from an absence of classification of mental health disorders, de-prioritization of mental health, and the imposition of western-oriented mental health systems in totally different cultural milieu. As such, these countries witness unscientific mental health treatment practices that fuel regressive and fatal ideologies around mental health. These include mislabelling of mental health symptoms, stigma, dangerous treatment methodologies, and debilitating use of pharmaceuticals.

B. “Unprescribed” Practice

Research, treatment, and services related to mental health are relatively new and, as such, most developing and developed countries lack adequate framework for such practices. With the field undergoing rapid advancements in theory and practice, technological advancements, and a wide range of disciplinary interfaces—signaling out a career path and carrying it forward with significant professional advancement can be a daunting task. The channels and the tools via which a person can become a mental health professional and adequately carry out his/her responsibilities are scarce. There is also a lack of uniform standards for obtaining and meeting the requisite qualifications, as well as the near–absence of monitoring of standards. This is further aggravated by lack of a research agenda, insufficient data and feedback on treatment methods and prognosis, and paucity of skilled resources and psychiatric infrastructure.

There are also no proper guidelines for the implementation of effective and sustainable community health care programs. Even the programs offered are based on western models and most of the MHPs involved are ‘imported’ from western countries and decidedly unfamiliar with the values, language and culture of the immigrant countries. Moreover mental health treatment in economically weak nations are expensive and, hence, a novelty. This actually widens the gap in treatment and encourages unscientific and mislabelled diagnostic practices.

C. Lack of Identity in Mental Health Practitioners

The myth of ambiguity around the profession of mental health sometimes makes it difficult for MHPs (especially in developing and under-developed countries) to project and assert their appropriate identities.

Owing to deprioritization of mental health or inadequate acceptance of the field as a full-time scientific profession—most psychiatrists and psychologists sometimes harbor issues about their individual and/or group identity vis-a-vis other medical specialties. As a 2006 study elaborates: “the perceived, and often externally attributed, ‘non-scientific’ or ‘non-medical’ nature of their work often leads psychiatrists to internal doubts and, sometimes, negative attitudes towards their own profession.” Besides, the alleged “non-effectiveness” of the treatment methods and misplaced sense of therapeutic nihilism often compel psychiatrists and other mental health professionals almost apologetic about and limited in their profession.

II. Legal Responsibilities

Similar to any other individual or professional, adherence to law is a chief responsibility of MHPs. The legal provisions in India that govern the mental health profession demand that an MHP should be professionally competent enough to execute the responsibilities of the profession as per the law. It clearly defines that an MHP should neither “discharge any duty or perform any function that is not authorized by the MHCA or other medical legislatures” nor “recommend any medicine or treatment not authorized by the field of his profession”. It also holds supreme sway over the processes of therapeutic practice, issues of confidentiality and accountability, and the relationship between the mental health service provider and the consumer.

The legal responsibilities of MHPs are further subdivided into laws with direct influence on human rights issues or mental health issues. Because the sweep of mental health issues is rather broad, the legal responsibilities of MHPs also impact ‘indirectly related’ mental health issues associated with disabilities, marriage and dowry, etc. Nonetheless, when it comes to developing and under-developed countries, the legal provisions guaranteeing mental health rights, treatment, and responsibilities are scattered and inadequate.

III. Social responsibilities

The responsibility of advocacy associated with MHPs poses them to be advocates for the mentally ill persons. This does not simply extend to the general non–medical public, but also to mental health professionals themselves. More often, the social responsibilities in the psych–profession include mental health awareness and addressal of issues related to:

Society’s unreal expectations that all mental health professionals should be free of any ailment, mental or physical
The MHP’s own misplaced grandiose belief that the ability to understand human behavior gives them the capacity to overcome any problem with total equanimity
The lack of adequate in-depth acceptance of the concept of mental health by mental health professionals themselves

IV. Ethical Responsibilities

In recent years, the ethical responsibilities of MHPs have been centered on the changing demands of mental health services, shifting social contexts of such service delivery, and recognition for well–regulated codes of professional ethics. Such responsibilities determine how ethically an MHP conducts his profession and handles issues like conflict resolution, confidentiality, rights and dignity of patients, etc. There are also provisions for the MHPs themselves to monitor, review, and update the standards of ethical practice

While MHPs face the same challenges as any other medical professional, most of the time, appropriating an acknowledgement for the ethical responsibility inherent in the profession is an extremely difficult task. Especially in developing and under-developed countries, such difficulties are amplified by:

A lack of clear ethical guidelines
Consistent implementation of ethical protocols
Unprofessional attitudes of professionals involved
Limited assertion of ethical rights by the consumers

4. Ethics of Conduct

I. Ethics

Ethics is a branch of moral philosophy that involves defending, systematizing, and recommending concepts of right and wrong behavior. Applied ethics in the medical profession is referred to as “medical ethics” and it is associated with ethical concerns around the clinical practice of medicine and related scientific research.

Medical ethics in psychiatry concerns itself with the clinical practice and academic research in the disciplines of psychology and psychiatry. In India, the psychiatric code of ethics is followed by not just mental health professionals (MHPs) but also other stakeholders such as law makers, governmental and non-governmental organizations, mental health establishments, and acting medical officers.

The seven pillars of Medical Ethics include:

Non-Maleficence
Beneficence
Health Maximization
Efficiency
Respect for Autonomy
Justice
Proportionality

II. What are the types of relationships MHPs experience throughout the tenure of their profession?

During the tenure of profession, MHPs are often involved in the following types of relationships:

MHP–profession relationship

Psychiatrist–patient relationship
Doctor–doctor relationship
MHP–medical bodies relationship
MHP–Governmental bodies relationship
MHP–legal bodies relationship

III. Code of Ethics for Psychiatrists

a. Respect for Humanity and Dignity

The psychiatrist should, at all times, respect the right to life and dignity and humanity of individuals with mental illness.

b. Appropriate Assessment

The psychiatrist should, at all times, to the greatest extent possible, conduct evidence-based, objective assessments of people with mental illness.

c. Commitment to the Best Interests of Individuals with Mental Illness

The psychiatrist should, at all times, cooperate with the general public and other specialists to provide psychiatric treatment and comprehensive support that give priority to the best interests of individuals with mental illness.

d. Respect for the Right of Self-determination of Individuals with Mental Illness

While providing treatment or support, the psychiatrist, at all times, should endeavor to establish valid, fully informed consent with individuals with mental illness, based on the provision of appropriate and sufficient information.

e. Confidentiality

The psychiatrist should, at all times, uphold certain standards of confidentiality about diagnosis information, treatment plans, and other matters that relate to people with mental illness.

f. Nonmaleficence

The psychiatrist should, at all times, strive to avoid actions that may cause harm to people with mental illness, their families, and their friends.

g. Prohibition of Abuse and Exploitation

The psychiatrist must, at all times, never abuse their expertise or position, and shall not exploit people with mental illness in any manner whatsoever.

h. Cultivation of Personal Character and Maintenance of Abilities

The psychiatrist must, at all times, always strive to cultivate their personal character, maintain integrity, and acquire the most up-to-date knowledge and techniques—both in their own fields of specialties and related domains.

i. Mutual Duty to Colleagues

The psychiatrist must, at all times, hold psychiatrist colleagues in great esteem and cooperate in interactions related to research, practice, etc. However, she/he must not tolerate unethical behavior or practice or drop in standards of medical ethics associated with colleagues and contribute to addressing the situation.

j. Adherence to Principles of Research Ethics

When conducting clinical research, the psychiatrist should observe the ethical

principles codified in the rules governing ethics in research.

k. Contribution to Society

The psychiatrist should, at all times, carry out appropriate mental health and welfare education and awareness activities, and shall contribute to the enhancement of mental health and welfare services.

l. Duty to Laws and Institutions

The psychiatrist, at all times, should observe all applicable laws, and shall work toward the improvement of the legal environment and relevant institutions related to mental health issues, treatment, and services.

IV. Ethical code of conduct for government bodies

According to the Mental Health Act of 2017, the “appropriate Government” stands—

In relation to a mental health establishment established, owned or controlled by the Central Government or the Administrator of a Union territory having no legislature
In relation to a mental health establishment established, owned or controlled within the territory of a state (a State Government) or a Union territory having legislature (the Government of that Union territory)

The “appropriate Government” should, at the minimum:

Take measures to ensure effective coordination between services provided by concerned ministries and departments dealing with health, law, home affairs, human resources, social justice, employment, education, women and child development, medical education to address issues of mental health care, etc.
Ensure that all provisions of legislation concerning mental health are given wide publicity through public media (including television, radio, print and online media) at regular intervals
Plan, design, fund, and implement appropriate programmes to reduce stigma associated with mental illness
Plan, design, fund, and implement appropriate programmes to reduce incidences of suicide
Provide periodic sensitisation and awareness training on the issues of mental health
Meet internationally accepted guidelines for the number of mental health professionals on the basis of population and quality of mental health services
Train all medical officers and law–enforcement officers in public establishments (like hospitals, jails, etc.) to provide basic and emergency mental healthcare
Include primary, secondary and tertiary healthcare and in all government-run mental health programmes
Provide treatment in a manner that supports persons with mental illness to live in the community and with their families
Provide acute mental healthcare services to all sections of the population (including the destitute, the homeless, and the poverty-stricken) without discrimination or prejudice
Ensure that all government-funded mental health services shall be of equal quality to other general health services and no discrimination be made in quality of services provided to persons with mental illness
Specify the minimum quality standards of mental health services throughout the length and breadth of the country
Ensure that basic and emergency mental healthcare services shall be available at all community health centers and upwards in the public health system run or funded by the Government
register all government -run or -controlled mental health establishments and develop quality and service provision norms for different types of mental health establishments
Make provision of acute mental healthcare services such as outpatient and inpatient services: half-way homes, sheltered accommodation, home-based rehabilitation, hospital– and community– based rehabilitation establishments and services, child mental health services, old age mental health services, etc.
Provide the Essential Drug List and ensure the availability of all medicines on the Essential Drug List, free of cost, to all persons with mental illness at all times at health establishments run or funded by the Government
Ensure the free availability of related and appropriate ayurveda, yoga, unani, siddha, homeopathy or naturopathy systems to all persons with mental illness
Formulate and execute the method, modalities, and procedure for handling mental health cases of prisoners, refugees, foreign detainees, etc.

V. Ethical code of conduct for mental health establishments

According to the Mental Health Act, “mental health establishment” means “any health establishment, including Ayurveda, Yoga and Naturopathy, Unani, Siddha and Homeopathy establishment, by whatever name called, either wholly or partly, meant for the care of persons with mental illness, established, owned, controlled or maintained by the appropriate Government, local authority, trust, whether private or public, corporation, co-operative society, organization or any other entity or person, where persons with mental illness are admitted and reside at, or kept in, for care, treatment, convalescence and rehabilitation, either temporarily or otherwise; and includes any general hospital or general nursing home established or maintained by the appropriate Government, local authority, trust, whether private or public, corporation, co-operative society, organization or any other entity or person; but does not include a family residential place where a person with mental illness resides with his relatives or friends”.

The code of conduct for such mental health establishments in the public health system mandates that that all government-run mental health establishments should:

Be registered under the Clinical Establishments (Registration and Regulation) Act, 2010 or any other state law that acknowledges health centers
Display the certificate of registration in a conspicuous place in the mental health establishment in such manner so as to be visible to everyone visiting the mental health establishment
Be under the supervision of a medical officer, a practicing psychiatrist, and other MHPs
Be under the supervision of a “local authority” including “a Municipal Corporation or Municipal Council, or Zilla Parishad, or Nagar Panchayat, or Panchayat”, etc.
Fulfill the standards of services and facilities laid down by the MH Act
Fulfill the provisions of maintenance of records and case reporting as specified by the MH Act regulations and other data and privacy acts

VI. Ethical code of conduct in telemedicine

In recent years, India has witnessed a technological revolution and this is accompanied by a burst of telemedicine services. Telemedicine services in the country come under the combined jurisdiction of the Ministry of Health and Family Welfare and the Department of Information Technology.

The ethical code of conduct for telemedicine professionals involves:

Providing e-Education and e-Healthcare delivery along the terms and conditions outlined in the Mental Healthcare Act of 2017
Achieving high quality electronic mental health services for all Indians through the cost-effective programs
Setting up a public electronic health record
Ensuring safe data transmission and storage during telemedicine practices
Extending telemedicine practices to the fields of traditional medicine
Providing a variety of web-based services such as tele-education, telemedicine, online-decision support, online counseling, interactive advisory services, e-governance services, etc.
Connecting medical colleges, medical learning centers, specialty hospitals, mobile medical specialists, and rural mobile units/clinics on an online portal