On dignity in inpatient psychiatric care

Abstract

Dignity is an important concept in human rights legislation and medical ethics but is under-studied in psychiatric settings. It is a nuanced concept which is considered difficult to define, but nevertheless has a prominent place in legislation and regulations around the world. Psychiatric care is unusual within medical specialties, in that there typically exists provision for involuntary and coercive treatment. When a patient is involuntarily detained under psychiatric care, their rights to liberty and autonomy are legally restricted and they may be subject to physical restraint, seclusion and/or treatment against their wishes. Patient autonomy is balanced against each individual s right to treatment, as well as risks to themselves and/or others. Many patients who experienced involuntary treatment agree after the fact that it was necessary and helpful. Nevertheless, maintenance of their human dignity while their freedom and autonomy is restricted is an important human rights issue. In this research, we aim to investigate the experience of voluntary and involuntary psychiatry patients, comparing their experience of dignity in inpatient care. We conducted a systematic review of the existing literature, and a cross sectional study of inpatients in two psychiatric units in Dublin. We examined their experience of dignity and coercion using validated tools. There was a dearth of literature looking at differences between voluntary and involuntary patients in terms of dignity. From the literature that did exist, a number of themes emerged as important, namely: Coercion, Powerlessness, Care Environment, Relationship to Staff, Lasting Impact of Involuntary Care and Paradoxes. Among the 107 patients included in our study, there was no statistically significant difference between voluntary and involuntary patient groups in terms of their subjective dignity scores, after multivariate analysis. Patients with higher levels of perceived coercion on admission, patients with better insight and patients with more severe negative symptoms reported lower levels of subjective dignity. There was no association between dignity and gender, employment status, marital status, diagnosis, working alliance, positive symptoms or cognition. It is interesting to note that perceived coercion on admission and legal admission status, although theoretically linked, performed as distinct entities and demonstrated different associations with patient dignity in our analysis. Participants who experienced their care as coercive reported lower dignity, but those with involuntary legal status did not. Patients with better insight and those with fewer negative symptoms also reported poorer dignity experience. We consider a number of possible conclusions arising from this evidence on clinical correlates of dignity among psychiatry inpatients. Dignity is a concept with particular relevance for inpatients in psychiatric care, given the provisions for involuntary and coercive treatment. Respect for and maintenance of patient dignity is especially important in this setting, and requires further investigation if we are to understand and utilise this nuanced concept to improve psychiatric care. Our systematic review provides a potential framework for looking at psychiatry inpatients experience of dignity, and our cross-sectional study gives preliminary insights into factors associated with poorer dignity in inpatient care. To our knowledge, ours is the first study directly investigating the association between legal admission status and subjective experience of dignity. We encourage further investigation into this important area.