Dignity in mental health care: The why, what and how to?
To mark this year’s WMHD, the Mental Health Innovation Network is running a month long series highlighting dignity in four areas of global mental health where dignity is most often compromised and/or redeemed. This week’s subtheme is “Dignity in Health Services”.
Share this blog on social media using the hashtag #WMHD2015 and our Twitter handle (@mhinnovation), and join the conversation by commenting below.
Why dignity is considered a corner stone of mental health care?
People affected by mental disorders are often subjected to discrimination
Many people with mental disorders globally are deprived of their right to be treated as valued individuals. In fact, they are not only marginalized in their communities but they are also subject to wide-ranging forms of human rights violations in treatment facilities. It can still be common in some countries for people to be locked away in small, prison-like cells or to be chained to their beds, unable to move. Processes of involuntary placement, involuntary treatment and long duration of inpatient stay for people with mental disorders impact some of their most fundamental rights, including the right to liberty.
Worldwide, the great majority of mental hospital inpatients are discharged within one year (global median, 80%). However, in certain regions more than 20% of inpatients stay longer than five years. Institutionalization of people in mental hospitals negatively impacts on people’s sense of self-worth and usually leads to negative perception of the society for the long term residents of these institutions.1
Human rights principles are not always implemented in mental health care:
According to WHO’s Mental Health Atlas 2014, only 45 % of countries have developed or updated their policies or plans for mental health in line with international and regional human rights instruments, while only 34% of all countries have updated their law for mental health in line with international and regional human rights instruments.1
Essential services are not equally distributed:
The failure to provide a full range of services and supports to people with mental health conditions leads to increased isolation and exclusion from society. It results in people being discriminated against and denied opportunities in employment and education, despite the fact that these are central to people’s sense of self-worth and mental health and well-being. On average globally, there is less than one mental health worker per 10 000 people. In low and middle-income countries rates fall below 1 per 100 000 people, whereas in high-income countries the rate is 1 per 2000 people. The rate of persons with severe mental disorders, who receive income support or other forms of non-monetary support (e.g. access to employment, educational assistance), is heavily influenced by countries’ income level, with a far higher rate of support seen in high-income countries (520 persons per 100,000 population) compared to lower-income countries (12-14 in low and lower-middle income countries). 1
What do we mean by dignity?
The UK’s Royal College of Nursing provides a useful definition of dignity in relation to nursing care, which can be applied to the health care field more generally: “Dignity is concerned with how people feel, think and behave in relation to the worth or value of themselves and others. To treat someone with dignity is to treat them as being of worth, in a way that is respectful of them as valued individuals.”
The way we conceptualize the term ‘dignity’ is different from classical Roman times, 2500 years back, when the term 'dignitas hominis' was reserved for someone worthy of honor and respect because of the status that he or she had attained, e.g. because of a specific public position.2
The concept of ‘dignity’ has been influenced by religions, philosophies and politics ever since, and it was not until the Universal Declaration of Human rights (UDHR) that the notion of universality of human dignity was enshrined in international law via the statement that “all human beings are born free and equal in dignity and rights”.
As of July 2015, the Convention on the Rights of Persons with Disabilities (CRPD) has 159 states signatories. According to its very first article, the stated purpose of the CRPD is to protect the rights and dignity of persons with disabilities. The CRPD is a unique treaty among other international human rights instruments in that it has an objective that clearly focuses on 'dignity' of a vulnerable population group. The Convention promotes a shifting of views of persons with disabilities from objects of medical treatment, towards viewing them as full members of society, with equal dignity and equal rights.3
What can health care partners do to promote dignity in mental health care?
National and international partners of health care provision must ensure that all laws, policies and practices in mental health care promote dignity and respect for people with mental health conditions on an equal basis with others. Health Care of people with disabilities, including those with mental disabilities, is highlighted in Article 25 of CRPD which requires "health professionals to provide care of the same quality to persons with disabilities as to others, …, raising awareness of the human rights, dignity, autonomy and needs of persons with disabilities through training and the promulgation of ethical standards".
In May 2013, for the first time, 194 WHO Member States endorsed the Mental Health Action Plan 2013-2020 (MHAP) at the 66th World Health Assembly. The MHAP highlights the importance of promoting social justice, equality and dignity for people affected by mental disorders on an equal basis with others to end their marginalization and disenfranchisement in society. The MHAP also highlights the importance of respect for the inherent human dignity when developing policies, plans and services in the area of mental health.
The MHAP mentions explicitly in its vision the importance of equal distribution of opportunities and privileges for people affected by mental disabilities: “The vision of the action plan is a world in which … persons affected by these disorders are able to exercise the full range of human rights and to access high quality, culturally appropriate health and social care in a timely way to promote recovery, in order to attain the highest possible level of health and participate fully in society and at work, free from stigmatization and discrimination.”
The MHAP set a number of global targets to be achieved by the year 2020: Targets 1.1 and 1.2 state respectively that 80% and 50% of countries will have developed or updated their a) policy/plans for mental health and b) law for mental health in line with international and regional human rights instruments.4
How can we assess and improve dignity at the mental health care facility level ?
In 2012, WHO launched its Quality Rights project to support countries to put in place and maintain good quality services that are respectful of the dignity, autonomy and recovery of persons with mental disorders and psychosocial disabilities. Quality Rights aims to improve the quality and human rights conditions in mental health and social care facilities and empower organizations to advocate for the rights of people with mental and psychosocial disabilities. The Quality Rights toolkit is based on the United Nations CRPD, and includes sets of standards and criteria against which the situation in facilities can be assessed. Teams undertaking the assessment determine whether these quality and human rights standards are being met in facilities.5
Acknowledgement: This blog has benefited from comments and inputs from Dan Chisholm, Natalie Drew and Michelle Funk.
WHO. (2015) Mental Health Atlas 2014. Geneva: World Health Organization.
Robert, GA (1951) Health Care Politics and Services: A Social Justice Analysis. New York: Springer Publishing Company.
UN General Assembly. (2007) Convention on the Rights of Persons with Disabilities: resolution / adopted by the General Assembly, A/RES/61/106. [accessed 25 March 2019] WHO.
WHO. (2013) Mental Health Action Plan 2013-2020. Geneva : World Health Organization.Robert, A. G. (1951). Health Care Politics and Services: A Social Justice Analysis. Springer Publishing Company.
WHO. (2012) QualityRights tool kit to assess and improve quality and human rights in mental health and social care facilities. Geneva: World Health Organization.
Image courtesy of Valentina Iemmi. Copyright © 2015 Valentina Iemmi. All rights reserved