Specialist care - Dignity and mental health care
This section of the Dignity in care guide was written by Alison Faulkner.
You feel better in yourself when people treat you with kindness and compassion.
In this section:
Dignity and mental health care in practice
- Treat people with respect – as individuals and fellow human beings. Avoid labelling people because of their diagnosis or their association with any other group.
- Provide person-centred care and support – place the individual and their needs, preferences and aspirations at the centre of care. An ethos of person-centred care upholds the dignity both of people using services and of staff.
- Promote good practice in safeguarding – focus on prevention and make proportionate, person centred responses to abuse.
- Adopt a recovery approach to mental health – in particular, help people sustain their personal identity and self-respect, which are both closely associated with the concept of dignity.
- Promote good communication – this demonstrates respect and maintains an individual’s dignity. Good communication means enabling both professionals and service users to communicate. Professionals may be trained in the relevant attitudes and communication skills, but services users may need support with communication, particularly if they lack capacity.
- Tackle discrimination – through individual and local community initiatives, national programmes, policy and legislative measures.
- Engage service users from black and minority ethnic groups – take active steps to engage people and ensure their views are recorded in their care plan.
- Adopt a human rights-based approach to mental health care – ensure that people’s human rights are protected at a time when their capacity, autonomy, choice and control may be compromised under mental health legislation. Where someone has been deprived of their liberty under the Mental Health Act, offer them support to deal with any related trauma.
- Preserve autonomy, choice, control and independence – provide person-centred care and enable people to state their needs and preferences in advance of loss of capacity. Methods you can use include advance statements, crisis cards and life story resources for people with dementia.
- Improve the quality of care in inpatient settings – provide patient-centred care that is individualised, comprehensive and continuous; a range of therapeutic resources; a relaxed and secure atmosphere. See for example the Sainsbury Centre for Mental Health (2006).
- Promote a positive organisational ethos – from the top, encourage an ethos of respect and dignity (Carter, 2009). Include taking a person-centred approach to care and a zero tolerance of abuse.
- Provide training, clinical supervision and support – adopt measures to enable staff to examine their own attitudes and to feel supported in their role. This will encourage them to treat others with respect.
- Address environmental risks to dignity – provide single sex wards, privacy in personal care and use of bathroom facilities, clean facilities, adequate space and appropriate staffing levels.
What others are doing – ideas you could use
- Promote recovery-focused services
- Engage and empower people with dementia
- Collect users’ views on dignity in care
- Raise awareness of dignity issues
- Take a holistic approach to improving dignity on the ward
- Support Dignity Action Day
- Provide same sex accommodation
- Use training and information resources
These practice examples are self-reported and have not been evaluated.
Key points from policy and research
- Adults with mental health problems are one of the most socially excluded groups in society (Social Exclusion Unit, 2004).
- Self-respect and self-esteem is central to maintaining mental health and wellbeing (Warner, 2011).
- Current government policy on mental health enshrines the concept of dignity within a strategy based on outcomes. (Department of Health, 2011)
- The Human Rights Insight Project showed that vulnerable groups see being treated with dignity and respect as the single most relevant factor when dealing with workers in the NHS or social services, compared with other principles of human rights (Ministry of Justice, 2008).
- Respecting an individual’s identity and protecting their dignity will help to promote recovery, whereas acts that violate dignity and fail to respect an individual and their story can lead to further damage (Jacobson 2009; Kogstad 2009; Warner 2011).
- People in mental health units are less likely to report that staff treat them with dignity and respect than those in primary and secondary care (Ipsos MORI, 2005/6).
- Environmental issues that can threaten dignity in acute wards include overcrowding, poor staffing (levels and quality), the use of mixed sex wards and impoverished or unclean environments (Curtice and Exworthy, 2010).
- Dignity in mental health settings is supported by person centred care, improving inpatient experiences for black and minority ethnic communities, good communication, human rights and safeguarding.
Dignity and mental health care - Policy and research in more detailOpen
People with mental health problems are too often shunned and discriminated against, even in those places which are supposed to be therapeutic and caring. Yet being treated with kindness and respect by staff can make all the difference to someone's wellbeing and esteem, and hasten recovery.Paul Farmer, Chief Executive, Mind (The Guardian, 15 August 2007)
The government's Dignity in Care campaign was extended to people with mental health problems in August 2007, nine months after it was launched to influence the care of older people in health and social care settings.
SCIE defines dignity as: ‘A state, quality or manner worthy of esteem or respect; and (by extension) self-respect.’ This is significant in the mental health context, because of the central role self-respect and self-esteem play in maintaining mental health and wellbeing. Little of the research into dignity has been carried out in mental health settings but nonetheless much of it considers threats to dignity, such as stigma and discrimination, institutional treatment and human rights. These core themes have implications for the dignity, identity, self-respect and self-esteem of individuals with mental health problems.
Studies that have defined the aspects of dignity (Woolhead et al, 2004; Griffin-Heslin, 2005) are useful in helping us to think about dignity and mental health. They point to the central role of the ‘self’ in considerations of respect and dignity of identity, and of an individual’s rights and autonomy – all of which can be compromised in the provision of the mental health care. The themes of autonomy and human rights take on particular significance in mental health, because of the potential for compromising an individual’s human rights through the use of the Mental Health Act (1983).
Since 2007, dignity has featured in the performance management of local services. The five-year strategy for improving health services, ‘NHS 2010-2015: From good to great’, included a statement of patients' rights contained in the NHS Constitution. These include: 'You have the right to be treated with dignity and respect, in accordance with your human rights'. The NHS Operating Framework for 2010/11 (Department of Health, 2009) set priorities and performance indicators for the NHS; a 'patient and user reported measure of respect and dignity in their treatment' is among the “vital signs” listed for local action’.
Current government policy on mental health, ‘No health without mental health’ (HMG/DH, 2011) enshrines the concept of dignity within a strategy based on outcomes. The guiding principles for the strategy are freedom, fairness and responsibility.
The policy states that people with mental health problems should be able to plan their own route to recovery supported by professional staff who place them and their families and carers at the centre:
listening to what they want, giving them information, involving them in planning and decision-making, treating them with dignity and respect, and enabling them to have choice and control over their lives and the services they receive.HMG/DH, 2011, para 2.3
The strategy goes on to state:
Those who provide support will respect the human rights of each individual. They will respect their privacy and dignity and ensure that support is sensitive to their particular needs.HMG/DH, 2011, para 3.34
The National Dementia Strategy (DH, 2009), provides a framework for improving relevant health and social services, stating that: ‘Recent reports and research have highlighted the shortcomings in the current provision of dementia services in the UK’. The Old Age Faculty of the Royal College of Psychiatrists, in its response to a consultation on the human rights of older people in healthcare, highlighted the following issues:
- The abusive infringement of human rights experienced by older people in care homes. This report stressed that this situation would be totally unacceptable in the care of children and that the elderly remain amongst our least protected individuals.
- There continue to be concerns raised over the privacy and dignity of care in hospitals and residential care homes.
- Older people with mental health problems are excluded from certain categories of care home even when these would best meet the person’s needs.
- Many older people have no alternative but to enter a care home because the local authority does not have the financial resource to fund the care that would enable them to remain in their own homes as they would choose.
- If older people suffer from dementia and other forms of mental disorder their condition will deny them the opportunity to voice their opinions and they may have no other advocate.
Dignity and human rights
Dignity has been enshrined in international human rights since the UN Declaration of Human Rights in 1948. See legal section on Human Rights in this guide.
The UN Convention on the Rights of Persons with Disabilities (2006) constituted a significant commitment to a human rights framework for people with disabilities. It set out a number of guiding principles, including ‘respect for inherent dignity, individual autonomy including the freedom to make one’s own choices’. It was ratified by the UK Government in 2009. The Convention establishes internationally recognised benchmarks for disabled people’s rights in all areas of life, and includes the right not to be discriminated against. Dignity is the only principle specifically mentioned in the Statement of Purpose (Curtice and Exworthy 2010).
The Mental Health Act (1983; amended 2007) is significant in this context, because it sets out the conditions under which the compulsory detention and treatment of people with mental disorders is permitted. See key legislation in the legal section of this Guide.
The introduction of Supervised Community Treatment in the 2007 amendments to the Mental Health Act led to considerable dissent. Some groups believe this form of treatment constitutes a violation of human rights. Pilgrim (2007) discusses the campaigning activities of the Alliance of Mental Health Charities, professional groups and service users formed in opposition to the Government’s proposals to reform the Mental Health Act in the 1990s. Pilgrim concludes that the 1983 Act was adapted to suit the government’s interests regarding social control, so reinforcing the efficiency of risk management. The Alliance did not attain its goal of a legal right to assessment, care and treatment in order to help reduce the use of compulsory powers.
The Code of Practice for the Mental Health Act (DH, 2008) suggests that the use of the Act should be underpinned by a number of guiding principles, one of which is the ‘respect principle’:
People taking decisions under the Act must recognise and respect the diverse needs, values and circumstances of each patient, including their race, religion, culture, gender, age, sexual orientation and any disability. They must consider the patient’s views, wishes and feelings (whether expressed at the time or in advance), so far as they are reasonably ascertainable, and follow those wishes wherever practicable and consistent with the purpose of the decision. There must be no unlawful discrimination.(DH, 2008, para 1.4, page 5)
The Code of Practice further states that any intervention requiring control or restraint must be used in a way that ‘minimises any risk to the patient’s health and safety and that causes the minimum interference to their privacy and dignity, while being consistent with the need to protect the patient and other people’.