“The pain of severe depression is quite unimaginable to those who have not suffered it, and it kills in many instances because its anguish can no longer be borne. The prevention of many suicides will continue to be hindered until there is a general awareness of the nature of this pain.”
The concept of ‘Dignity’ originated three centuries ago. By the 21st century, human dignity is considered to be central in human bioethics and is grouped into human and social dignity. Human and social dignity must be complementary in health delivery as envisaged in the 1948 United Nations Universal Declaration of Human Rights. The World Dignity Project grouped dignity into three groups; human dignity (external) that covers physical care and respect for the individual; self-dignity (internal) that covers the feeling of empowerment in the treatment process; and universal dignity that covers how society treats those with mental illness. Dignity in mental health means having the hope, value and worth of oneself, one’s family, immediate community and also the country. Dignity also means freedom from being labeled, stigmatised or marginalised.
The theme ‘Dignity in Mental Health’ for World Mental Health Day 2015 is a significant leap from last year’s ‘Living with Schizophrenia’, which specifically focused on the struggles of schizophrenia patients, the availability of treatment processes and the achievements. This year’s theme encompasses the core elements of fighting mental health stigma and the promotion of better mental health itself.
The major stakeholders in mental health services are the mental health professionals, patients and their caregivers (as the primary service users), and the community at large. All of these parties have important roles to play with regards to dignity in mental health.
Achieving dignity among mental health service users will only be a dream without properly trained mental health professionals to deliver adequate evidence-based treatments and interventions. However, constraints on human resources and limited governmental budget on mental health services usually restrict the amount of training that can be provided and the number of mental health workers who could be trained. This is where the concept of ‘skill-mix’ and ‘task-shifting’ comes in handy. In skill-mix, groups of mental health professionals with different set of skills and roles combine to offer help to each patient they see. In task-shifting, activities previously held by specific mental health professionals are transferred to other health workers or the community to be applied at other kinds of platforms. Mental health professionals delivering the service must also be compassionate while handling the service users so that the engagement and rapport is sustainable. Good communication in interpersonal relation is pivotal as there is a significant relationship between the ability of a professional to listen with the amount of respect a patient feels. Patients and caregivers will feel appreciated when handled by mental health professionals who are caring and appreciative of the needs and concerns of their service users. The patient’s self-worth also improves when those delivering the service applies a patient-centred approach, where patient’s autonomy is given due consideration. This approach demands the provision of adequate information regarding the treatment process by the professionals to the patients, and encourages the patients to be involved in the decision-making process. On another note, dignity in mental health among mental health professionals means being open-minded in considering new ideas and receiving constructive criticism from other mental health professionals and also those from other medical specialties. Mutual respect is a two-way relationship which could open more doors and ideas when solving complex issues pertaining to the patients and their caregivers. Synthesis and collaboration is better than antithesis and confrontation, be it when dealing with those suffering from mental health issues or professionals from other medical or non-medical groups.
A person suffering from mental illness is a human being. This individual yearns to be considered and addressed as an individual with his or her own characteristics and personality. Promoting dignity in mental health among the service users means doing away with labels such as ‘patient’ or ‘client’. These individuals all present to the mental health services with names and they should be addressed appropriately. Improper labels such as ‘psycho, psych patient, the disturbed one’ etc., that are commonly heard during discussions or referrals even among medical staff must be banned and thrown away from the mind of any self-respecting individual. People with mental health issues need to be given proper and adequate access to assessment and treatment opportunities. It is sad to know that even in developed countries such as the United States and European countries, around 50% – 60% of people suffering from mental illness were not granted proper access to mental health services while in countries like China, this percentage had climbed close to 90%. This is why mental health services must be integrated with primary care and public healthcare services. This integration will definitely open more channels for access and promote early detection and treatment, thus offering better prognosis. At this period of time, the treatment of mentally ill individuals is not only confined to the provision of medication to get them well. Psychosocial rehabilitation is an important component of ‘management’ which would not only assist with remission but also with the recovery process. Recovery in mental health means “living a satisfying, hopeful and contributing life, even when there are ongoing limitations caused by mental health problems and illnesses”. Recovery-oriented practice is based on promoting dignity and respect. It recognises the possibility of recovery and wellness, while at the same time maximising self-determination and self-management of the illness and mental health. It also helps families to understand and support their affected loved ones.
Too often, we as mental health providers are guilty of propelling the stigmatisation of this condition and effectively, robbing these individuals of their inherent right to dignity. We look at an individual in the ward, suffering from severe schizophrenia for instance, we have conditioned and automatically slap a societal-imposed limit within our minds to “perceive” and “view” them in the most clichéd of stereotypes. We equate these individuals’ respective self-worth and abilities to their mental diagnoses and treat them as such – mentally incapable, dysfunctional and a nuisance to the society. We forget that there is another part of these individuals, a positive part which just like any other, deserves to be respected, and are dignified in their own way.
When I was at Woodbridge Hospital, Singapore for a Conference on Mental Health last year, the Head of Departments told me something profoundly amazing. The philosophy in that hospital is to focus on that part of the individual which is sane, sociable, which is kind, which is intelligent. They weren’t focusing on the psychosis. They weren’t ignoring the schizophrenic fantasies. They were focused on something else. And I thought, “Wow! You guys have understood!.” If you focus on somebody’s faults – the fact that they sometimes act in a dysfunctional way or they speak in hallucinatory ways or they behave in a violent manner to themselves or others…if you focused on that, then you make this person into someone or make this dysfunction a whole of them, rather than just a part of them. How about focusing on the rest of the time when they are perfectly – I won’t say normal because being normal is stigmatising the so-called abnormal – when they are fully functioning individuals and able to flow in the society without any problems or reactions from other people.
This is such an important psychology to see. I was so pleased that at least somebody is getting the message.
In life, it is what you water, what you focus on, is what grows in life. If we could only accord these individuals and respect them as such, you see things most people will never notice. You see their exquisite beauty. You see the grass becomes so beautiful, rocks, features in there which you never noticed before. You see just the bark on the trees. The tessellated texture becomes exquisite.
Of course that’s a great test. It is easy to see the beauty in the hillside. But to see such beauty in these people bearing these psychiatric diagnoses is more of a tough ask. But to these patients, this is an amazing change; they feel that someone is respecting them. It is a strange experience for them to have someone who looks at them and sees something beautiful and good that they too start to change the way they look at themselves.
If I can see something in them, and they respect me for being honest and truthful, then they think maybe that such beauty does exist in them; and they start looking for it themselves. The schizophrenic patient starts to see another part of their being. The beautiful part. When that starts to grow and prosper, you find that when these patients get discharged, they are healed. The reason, the sickness, the pain and whatever it was that led them to the ward, is now gone. It’s amazing what happens.
When you have a sickness, say a cancer, many of them forget that most of their body hasn’t got cancer. That there are still other parts of them – focusing on these other aspects give the patients incredible strength, incredible fitness and power. You can harness that power, the power of the positive side of the illness; the power of the positive side of someone’s behavior. I think many people can understand how that alone is therapeutic. When you focus on the other side, the healing happens.
Most profoundly, these individuals learn to accept themselves beyond their diagnosis and so-called “labels”, and feel that they are worthy and dignified individuals by their own right, they go on to do amazing things in life. As Freud once said of his purpose in life, is simply, “to work, and to love.”
Finally, dignity in mental health among community members hovers around the capacity of the community to accept the importance of mental health. It is just not enough to say that there will be no health without mental health. Mental health issues should be freely discussed among community members and confessions of ongoing mental health issues or diagnoses of mental disorders should not lead to rejection and despair. The confession should instead mobilise family and community support, and provide hope and practical help. Members of the community must be empowered to detect and approach individuals suffering from mental health issues. These mental health first-aiders can offer information, practical help such as problem-solving skills or encourage the sufferers to get professional help. Community empowerment can occur in a community that places high regards on mental health literacy. High level of mental health literacy will greatly assist primary prevention of mental illness. In a technological advanced era where information spreads like wildfire electronically, community empowerment can easily occur through the use of internet and social media.
Dignity in mental health is about entities that foster the de-stigmatisation, de-labeling and de-marginalisation of people with mental illnesses; they have the right and equality to live a meaningful and contributing life. The stigma stops here. It is time to act.