Dignity in mental health care: the conceptual connections between sense of dignity, stigma and self-stigma among people with mental disorder diagnoses

Exactly what is dignity? The concept is contemplated in sociology, theology, law, health care, pedagogy, philosophy, psychology and psychiatry (1)(2)(3)(4)(5)(6), with different disciplines contributing their specific valuable perspectives and understandings, making the phenomenon multi-faceted and not easy to pin-down. Dignity, understood as an attribute of every human being, is described as an unquestionable and inviolable value deriving from being human, forming the basis of equality for all people (7). Dignity, considered ontologically, describes a person regardless of the situation the person finds herself in and it cannot be shattered. From this perspective, dignity is inherent to every human being, emphasizing that no person should be treated as a means to an end or as a commodity (8,9). Dignity is also an important part of human rights (10). Here, we would like to focus on the concept of dignity from the perspective of mental health, psychiatry and psychology. Within these fields dignity is described as a practical and crucial element of effective and ethical mental health care, which is essential for well-being, while threats to dignity can be linked to poorer mental health (11). For instance, among psychiatric inpatients, a diminished sense of dignity was associated with increased clinical severity, reflected by both past suicide attempts and present suicidal thoughts (12).The theory of Public Health assumes that lack of dignity is associated with an increased risk of disease (13). Public health should recognize dignity (and thus a sense of dignity) as one of the core values and an element of human well-being. Respect for dignity should be an important principle guiding health interventions (14 -16). Proposing an ethics framework for public health, Kass (17) emphasized that ethical guidelines for clinical practice, while maintaining the imperative to avoid harm, began explicitly requiring the preservation of patient and research participant dignity. Insufficient recognition of human dignity in healthcare can provoke adverse emotional responsesincluding fear, distrust, denial, anger, hostility, apathy, sadness, and frustration -which, in turn, have an unquestionable impact on patients' overall health (18). The World Health Organization (19) emphasizes its commitment to ensuring that individuals with mental health conditions are able to lead lives characterized by dignity. In this regard, WHO (20) launched various initiatives, which aimed to support countries in developing high-quality mental health services that respected the dignity and autonomy of patients and supported recovery. Therefore, dignity should be considered a fundamental value in psychiatry.If dignity is considered the foundation of humanity, social relationships and well-being (21), it is all the more appropriate to raise this issue among people with mental disorder diagnoses, as they have been and/or may be at risk of discrimination (22), face difficulty getting a job (23), poverty (24), domestic violence (25), sexual abuse (26), involuntary hospitalization (27), stigmatizing attitudes among psychiatrists (28) and clinical psychologists (29). Additionally, the mental health sector can also reinforce stigmatizing views and attitudes toward people with lived experiences of mental disorder diagnoses (30). One such form of discrimination can be diagnostic overshadowing, which occurs when physical symptoms are incorrectly attributed to mental health conditions, leading to missed or inaccurate diagnoses (31). Patients reports suggest that the physical health needs of individuals with mental disorder diagnosis are often not given adequate attention by healthcare providers (32). This is particularly evident in patients with complex presentations, where the coexistence of psychiatric and somatic symptoms frequently leads clinicians to prioritize psychiatric explanations within the differential diagnosis (33). The consequences are increased distress, limited medical treatment, and even death (34,35). Thus, the institutional reality of mental health care may be particularly harmful to the sense of autonomy, respect, and dignity. Some authors emphasize that the mere experience of psychiatric treatment -including contact with a psychiatrist, the use of medications that may cause side effects, and the often inadequate standards of psychiatric hospitalscan be stigmatizing for patients (1). On this account, these experiences are discussed within the context of dignity in psychiatric care (1).In this article, we focus on individuals with mental disorder diagnoses, however, it is important to note that stigmatization or threats to dignity affect other groups as well, including sexual individuals with in and dignity is an attribute of every human being, a sense of dignity can be or in with other people The that experiences of dignity of individuals that a sense of can be particularly when individuals their to for is limited and autonomy is or when they the to of the that the sense of dignity in people with a diagnosis of a mental people with a diagnosis of the of and The that and discrimination can the sense of particularly among people part in the that a diagnosis of and the associated with it it to experience dignity. 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