Estudos feitos por IA GEMINI
SUMÁRIO
O documento contém três relatórios elaborados pelo GEMINI IA, traduzidos para o inglês, que abordam as seguintes temáticas:
I. Análise Comparativa dos Danos à Saúde e Impactos Familiares em Vítimas de Múltiplas Formas de Violência:
Este relatório detalha como diferentes tipos de violência (de gênero, etária, racial, socioeconômica e institucional) causam traumas cumulativos.
Ele enfatiza a revitimização institucional, especialmente nos sistemas de saúde e justiça, e descreve como a violação da dignidade agrava o sofrimento das vítimas, resultando em Transtorno de Estresse Pós-Traumático Complexo (TEPT-C).
II. Análise da Violência de Gênero no Judiciário à Luz da Provimento CNJ nº 201/2025:
O segundo relatório examina a violência de gênero perpetrada por operadores do direito, destacando a importância do Provimento nº 201/2025 da Corregedoria Nacional de Justiça.
Este provimento estabelece um protocolo para investigar queixas contra esses agentes, reforçando a política de tolerância zero.
O relatório também conecta a nova regulamentação ao Protocolo para Julgamento com Perspectiva de Gênero, ressaltando casos precedentes como o de Mariana Ferrer e Márcia Barbosa de Souza
III. Relatório Unificado sobre Busca de Reparação e Punição em Cenários de Múltipla Violência:
Este relatório, que inclui um aviso legal importante, consolida as análises dos impactos da violência e os caminhos para responsabilizar os agressores.
Ele discute os danos à saúde mental e física causados pela violência institucional, aprofundando-se no TEPT-C.
Apresenta o Protocolo para Julgamento com Perspectiva de Gênero e o Provimento nº 201/2025 do CNJ como ferramentas essenciais de responsabilização.
Por fim, oferece um guia prático para ações administrativas (contra juízes, advogados e defensores públicos), policiais/criminais (denúncias ao Ministério Público) e judiciais (ações de anulação e indenização por danos), com o objetivo de reverter perdas e buscar compensação.
SUMARY
The document contains three reports translated into English, which address the following themes:
- Comparative Analysis of Damages to Health and Family Impacts on Victims of Multiple Forms of Violence:This report details how different types of violence (gender, age, racial, socioeconomic, and institutional) cause cumulative traumas. It emphasizes institutional re-victimization, especially in health and justice systems, and describes how the violation of dignity exacerbates the suffering of victims, resulting in Complex Post-Traumatic Stress Disorder (CPTSD).
- Analysis of Gender Violence in the Judiciary in Light of CNJ Provision No. 201/2025: The second report examines gender violence perpetrated by legal professionals, highlighting the importance of Provision No. 201/2025 of the National Council of Justice. This provision establishes a protocol for investigating complaints against these agents, reinforcing the zero-tolerance policy. The report also connects the new regulation to the Protocol for Judgment with a Gender Perspective, emphasizing precedent cases such as those of Mariana Ferrer and Márcia Barbosa de Souza.
- Unified Report on the Search for Reparation and Punishment in Scenarios of Multiple Violence: This report, which includes an important legal notice, consolidates the analyses of the impacts of violence and the paths to hold aggressors accountable. It discusses the damages to mental and physical health caused by institutional violence, delving into CPTSD. It presents the Protocol for Judgment with a Gender Perspective and CNJ Provision No. 201/2025 as essential tools for accountability. Finally, it offers a practical guide for administrative actions (against judges, lawyers, and public defenders), police/criminal actions (denunciations to the Public Prosecutor's Office), and judicial actions (annulment and compensation for damages), with the aim of reversing losses and seeking compensation.
Here are the translations of the three reports into English.
Translation of Report 1:
Comparative Analysis of Damages to Mental and Physical Health and Family Impacts on Victims of Multiple Forms of Violence, Based on Scientific Evidence
A spiral of cumulative and overlapping traumas plagues victims of abuse and violence based on gender, age, race, social conditions, and state abandonment.
When seeking help, they are often re-victimized by a system that should protect them, including the mental health system.
Dignity, a fundamental concept in healthcare provision, is frequently violated, exacerbating the suffering.
This comparative analysis, based on scientific evidence, exposes the deep and multifaceted damage to mental and physical health, as well as the breakdown of family structures, resulting from this cruel succession of aggressions.
Individuals who suffer primary violence face a heightened risk of developing a series of health problems.
When these victims access services, especially mental health services, the experience can become a new layer of trauma.
Dignity violations are more likely to occur in contexts where there are power asymmetries and one of the actors is vulnerable, as is the case in mental healthcare.
The Cycle of Aggression and Institutional Re-victimization
Institutional violence, particularly in the context of health and justice, manifests through practices that undermine an individual's dignity.
The reference document identifies critical domains where dignity is violated, which can be extrapolated to experiences with other institutional systems:
Relationships with Professionals: The way a victim is treated by professionals (in health, law, etc.) is crucial.
Violation occurs through:
Lack of Respect: Addressing victims rudely, talking down to them instead of as an equal human being, or judging and criticizing them.
One victim recounted how a nurse shamed her for her self-harm scars, asking "how she planned to have a boyfriend".
Failures in Communication: Not listening, interrupting, or not helping victims express their experiences.
Lack of information about treatment or legal processes leaves the victim feeling helpless and disempowered.
Conversely, being listened to attentively can make the victim feel "safe and [...] liberated".
Lack of Empathy: Not showing concern for the victim's emotional needs, being negligent, or using coercive practices as a form of punishment.
For the most vulnerable victims, empathy and human connection are essential components of dignity.
Lack of Person-Centered Care: Treating the victim as a number, a diagnosis, or a case, rather than as a unique individual with a specific life context.
A Swedish victim described feeling like a number and that because they were already convinced she was "crazy," anything she said was dismissed.
Suppression of Autonomy: Not supporting the victim's ability to make informed decisions, rendering them a passive recipient of care or judgment and diminishing their personhood and self-respect.
Allowing the victim to participate in decisions can restore hope and the will to adhere to the treatment or process.
Environments and Settings: The physical environment can violate dignity.
Victims may be forced to stay in degrading conditions, exacerbating the trauma.
A man in Uganda described his experience of extreme violation: "I was isolated and locked up in a seclusion room where I was stripped naked and kept there for long hours. The room had no window [...]. There was no water or no toilet facility [...]. It was very dark in there and all I could do was to lay on very cold concrete cement floor".
This description of a dehumanizing environment is a stark example of institutional violence.
Coercive Practices:
The use of restraint, isolation, or sedation without adequate explanation makes victims and their families feel humiliated and punished, which can deter them from seeking help in the future.
Comparative Analysis of Damages
Type of Violence
Damage to Mental Health
Damage to Physical Health
Impacts on Family Structure
Gender
Depression, PTSD, anxiety, low self-esteem, suicidal ideation.
Chronic pain, gynecological problems, physical injuries, sexually transmitted diseases.
Severing of ties, isolation, emotional burden on children, perpetuation of the cycle of violence.
Age (Elder Abuse)
Cognitive decline, depression, anxiety, fear, loss of trust.
Malnutrition, dehydration, worsening of chronic diseases, injuries from neglect.
Family conflicts over care, isolation of the elderly, loss of family assets.
Race
Chronic stress, depression, anxiety, PTSD, internalized oppression.
Hypertension, cardiovascular disease, type 2 diabetes.
Intergenerational transmission of trauma, stress in family relationships, socioeconomic barriers.
Socioeconomic & State Neglect
Low self-esteem, hopelessness, mood disorders, substance abuse.
Malnutrition, higher incidence of infectious and chronic diseases.
Family breakdown due to poverty, intergenerational cycle of misery, loss of child custody.
Institutional (Judiciary, Health, etc.)
Feelings of humiliation, helplessness, and powerlessness.
Loss of self-esteem and identity.
Re-victimization, complex PTSD, hopelessness, and distrust.
Worsening of pre-existing conditions due to chronic stress; psychosomatic disorders; direct harm from neglect or abuse in institutional settings.
Family's disbelief in justice or the health system; conflicts over continuing the process; breach of confidentiality by sharing information with family without permission.
Community & Family (after initial violence)
Isolation, shame, guilt, intensification of depression and anxiety.
Neglect of one's own health due to lack of support.
Severing of ties, loss of support network, family conflicts.
Criminal Organizations & "False Condominiums" or any other forms of violence
Constant fear, chronic anxiety, PTSD, feeling of powerlessness and imprisonment.
Hypertension, stress-related heart problems, sleep deprivation.
Social isolation of the family due to fear, restriction of family members' freedom, indebtedness.
The Cumulative Effect: Complex Trauma and the Loss of Dignity
The overlap of these forms of violence results in what medical literature calls Complex Post-Traumatic Stress Disorder (C-PTSD).
The trauma stems not just from the initial act, but from the systemic failure that follows.
llness is an assault on personhood and dignity, and maintaining dignity in the context of care is an ongoing process of confirming self-identity in relation to others.
When institutions fail to "see" the victim as an individual, they cause profound damage to their self-identity and self-respect.
The repeated experience of dignity violations, disrespect, and powerlessness is the core of complex trauma.
Translation of Report 2:
Analysis of Gender-Based Violence in the Judiciary in Light of CNJ Provision No. 201/2025
Gender-based violence perpetrated by judges and other legal operators represents one of the most severe failings of the justice system, as it erodes public trust and re-victimizes those seeking protection.
Provision No. 201, of July 28, 2025, from the National Justice Inspectorate (Corregedoria Nacional de Justiça), emerges as a crucial mechanism to combat this, establishing a specific protocol to investigate complaints against these agents and consolidating a zero-tolerance policy for such practices.
This analysis addresses the dimension of this institutional violence and the impact of the new regulation, connecting it to precedents and the fundamental Protocol for Judging with a Gender Perspective.
The Nature of Judicial Gender-Based Violence
Gender-based violence within the Judiciary is not limited to acts of physical aggression or sexual harassment.
It manifests in subtle and structural ways, deeply rooted in a culture that often discredits a woman's word.
Legal operators can perpetuate violence through:
Re-victimization in Hearings:
Conducting interrogations that expose the victim's private life, question her morals and behavior, and force her to relive the trauma repeatedly in a humiliating manner.
Stereotyped Decisions:
Rulings and orders based on gender stereotypes, such as the idea of the "provocative woman" or minimizing violence in the context of a "couple's quarrel."
Discrediting the Victim's Testimony:
A posture of skepticism and distrust towards the woman's account, demanding a standard of proof that is often impossible to produce, ignoring that domestic violence frequently occurs in private.
Moral and Sexual Harassment:
Using a hierarchical position to embarrass, humiliate, or obtain favors from female staff, lawyers, or even parties in a case.
These practices violate not only national legislation, such as the Maria da Penha Law, but also international treaties signed by Brazil, such as the Convention of Belém do Pará and CEDAW.
Provision No. 201/2025: A Turning Point
Provision No. 201/2025 from the National Justice Inspectorate directly attacks the impunity and lack of a proper channel for these complaints.
Its central points are:
Integrated Complaint Flow:
It creates a clear procedure for receiving complaints of violence against women involving judges, court staff, notaries, and registrars, in an integrated flow with the National Women's Ombudsman.
Humanized Care Protocol:
It requires that the victim's testimony be heard in a qualified manner, ensuring confidentiality, respect for autonomy, and free and informed consent, eliminating preconceived notions.
Accountability and Transparency:
It mandates that the courts of origin inform the National Inspectorate about cases within 15 days, allowing for centralized control and a more agile response.
Simplified Access:
It simplifies victims' access to the complaint system through a specific portal and direct forms.
This provision materializes the policy of confronting gender-based violence within the Judiciary itself, recognizing that the institution must first correct its own flaws to effectively judge the cases presented to it.
Connection to the Protocol for Judging with a Gender Perspective
Provision No. 201/2025 cannot be understood in isolation.
It is the administrative and disciplinary consequence of a paradigm shift driven by the Protocol for Judging with a Gender Perspective, which became mandatory throughout the Judiciary via CNJ Resolution No. 492/2023.
The Protocol is a guide for judges to:
Identify and neutralize structural inequalities in their decisions.
Avoid using stereotypes and prejudices that distort the analysis of facts.
Understand the power dynamics in gender relations and how they impact the cycle of violence.
By making the Protocol mandatory, the CNJ set the expected standard of conduct.
Provision No. 201, in turn, creates the tool to punish those who deviate from this standard.
The combination of the two instruments forms a siege against institutional gender-based violence.
Relevant Cases and Precedents
The Mariana Ferrer Case:
The public exposure of the hearing in which the victim was humiliated by the defendant's lawyer, with the apparent passivity of the judge, shocked the country and spurred the creation of Law No. 14.245/2021 (Mariana Ferrer Law), which protects victims and witnesses from acts against their dignity during hearings.
Link (in Portuguese) to news about the case and the law:
Brazil's Condemnation by the IACHR (Case of Márcia Barbosa de Souza): Brazil was condemned by the Inter-American Court of Human Rights for its negligence in investigating the femicide of Márcia Barbosa.
One of the Court's determinations was the creation of protocols to investigate and judge violent deaths of women with a gender perspective, which directly influenced the creation of the CNJ's Protocol.
Link (in Portuguese) to information on the case on the CNJ portal:
Removal of Judges by the CNJ:
The National Justice Council has acted in cases of harassment involving judges.
A notable example was the removal of an appellate judge from the São Paulo Court of Justice, who was the target of harassment allegations by dozens of women.
Link (in Portuguese) to news about the case:
Translation of Report 3:
Unified Report on Seeking Reparation and Punishment...
IMPORTANT LEGAL DISCLAIMER
This report is for informational and educational purposes only.
The information contained herein does not constitute legal advice, a legal opinion, or any form of legal consultation.
The analysis of the concrete case is based solely on your account and serves as an illustration for the application of the concepts discussed.
Every case has specific details that must be evaluated by a lawyer duly registered with the Brazilian Bar Association (OAB), who is the only professional qualified to provide legal guidance, represent you, and defend your interests.
It is imperative that you immediately seek a trusted lawyer.
UNIFIED REPORT ON REPARATION OF DAMAGES AND PUNISHMENT OF PERPETRATORS IN SCENARIOS OF MULTIPLE VIOLENCE
Preamble:
This document consolidates analyses of the impacts of multiple forms of violence, the normative framework for protection, and the pathways to hold perpetrators accountable, with the goal of providing a clear guide for victims and their families.
Chapter 1: The Landscape of Trauma:
Impacts of Multiple Violence and Dignity Violation
The experience of violence—whether based on gender, age, race, or socioeconomic status—leaves profound damage to a victim's physical and mental health and family structure.
As demonstrated by scientific studies, this damage is exponentially worsened when the victim, upon seeking help, is subjected to a new layer of violence: institutional violence.
This violence manifests when state agents (judges, public servants, police, public defenders) and other operators (lawyers) fail to protect, welcome, and guarantee the victim's rights, perpetuating the cycle of aggression through:
Dignity Violation:
Dignity, a central concept for mental health, is attacked when the victim is treated with disrespect, disdain, has their word discredited, or is subjected to humiliating environments and procedures.
Studies show that a lack of empathy and the suppression of autonomy cause profound psychological suffering.
Damage to Mental Health:
The overlap of traumas leads to what medical literature classifies as Complex Post-Traumatic Stress Disorder (C-PTSD). It is characterized by hopelessness, loss of trust in institutions, difficulties with emotional regulation, and a persistent feeling of powerlessness and helplessness.
Damage to Physical Health:
The chronic stress resulting from judicial persecution and institutional violence aggravates pre-existing health conditions and causes new illnesses, such as hypertension, heart problems, and psychosomatic disorders.
Family Impacts:
Disbelief in the justice system, the emotional and financial strain of legal processes, and the breakdown of bonds of trust disrupt the entire family unit, which becomes ill along with the victim.
This dynamic creates a spiral of suffering where the search for justice paradoxically becomes an additional source of trauma and illness.
Chapter 2: The Accountability Framework: Norms and Protocols Against Institutional Violence
The recognition of this severe systemic failure led the National Council of Justice (CNJ) to develop mechanisms to hold legal operators who commit gender-based violence accountable.
Two instruments are fundamental:
Protocol for Judging with a Gender Perspective (CNJ Resolution No. 492/2023):
This protocol, mandatory throughout the Judiciary, is a guide for judges and staff to act in a way that neutralizes stereotypes, prejudices, and structural inequalities. Judging without following this protocol constitutes a functional failure and violates the duties of the office.
Provision No. 201, of July 28, 2025, from the National Justice Inspectorate:
This regulation establishes a clear and direct flow for receiving and processing complaints of gender-based violence involving judges, court staff, notaries, and registrars.
It creates a direct channel for accountability for those who violate the Protocol and commit other forms of institutional violence.
URL for news about the Provision:
These instruments are the legal basis for a victim to administratively report public agents who have failed in their duty, seeking their disciplinary punishment, which can range from a warning to compulsory retirement or removal from office.
Chapter 3: Concrete Case: Analysis of an Account of Complex Institutional Violence
The following is a theoretical analysis, based exclusively on the information provided, of an account of a concrete case that illustrates the confluence of multiple forms of violence and crimes within the Rio de Janeiro Court of Justice.
Summary of the Account:
A female legal heir, a defendant in a lawsuit, was the victim of a scheme orchestrated by the heir-executor.
The scheme aimed to unlawfully seize the most valuable asset of the estate before the distribution of assets.
To achieve this, it allegedly involved the participation or omission of judges, public servants, lawyers, and the Public Defender's Office.
Analysis of the Violations and Crimes Pointed out in the Account:
Obstruction of Access to Justice and Corruption (Active and Passive):
The narrative points to a deliberate manipulation of the judicial process to prevent the female heir from defending herself.
Concealing the death of the estate's grantor from the civil judge and changing the jurisdiction from the specialized Probate Court to a general civil court, if proven, are extremely serious acts that suggest procedural fraud and could constitute acts of corruption to benefit the executor.
Use of Illicit Evidence and Document Forgery:
The use of false public documents to simulate the defendant-heir's default in court and to conceal the existence of other legal heirs constitutes the crimes of Ideological Falsity (Art. 299 of the Brazilian Penal Code) and Use of a False Document (Art. 304).
Aggravated Fraud (Estelionato) and Unlawful Seizure (Esbulho): The ultimate goal of auctioning the asset at a pittance, deceiving the court and harming the heirs, characterizes the crime of Fraud (Art. 171), aggravated by the nature of the scheme.
The act of taking possession of the asset constitutes unlawful seizure.
Institutional Gender-Based Violence:
The handling of the case, disregarding the vulnerability of the female defendant, and the apparent facilitation of the illegalities committed by the male executor constitute a direct violation of the Protocol for Judging with a Gender Perspective.
Abandonment by the Public Defender's Office:
The failure of the Public Defender's Office to provide a defense, especially without personal notice during the COVID-19 pandemic, represents a denial of access to justice and a serious institutional failure.
The absence of an effective technical defense vitiates the entire process and causes irreparable harm to the party.
This case, as reported, is an emblematic example of how corruption and procedural fraud intertwine with institutional gender-based violence, using the judicial machine not to apply the law but to strip away rights, with devastating consequences for the victim.
Chapter 4: Practical Guide to Taking Action: Pathways to Reparation and Punishment
Faced with such a complex scenario, the victim and their family can and should take action on multiple fronts.
A. Administrative Measures (Disciplinary Punishment)
The goal is to punish public agents for their functional misconduct.
Against Judges and Court Staff:
Action: File a disciplinary complaint with the Internal Affairs Office (Corregedoria) of the Rio de Janeiro Court of Justice and, simultaneously, with the National Women's Ombudsman of the National Council of Justice (CNJ), using the channel created by Provision No. 201/2025.
What to allege:
Violation of the Protocol for Judging with a Gender Perspective, judicial bias, suspicion of corruption, serious procedural flaws, and collusion with illegal acts.
URL (National Women's Ombudsman):
Against the Executor's Lawyer:
Action:
File a complaint with the Ethics and Discipline Tribunal (TED) of the Brazilian Bar Association - Rio de Janeiro Section (OAB/RJ).
What to allege:
Violation of the Code of Ethics and Discipline, bad-faith litigation, use of illicit means to win the case, and possible participation in fraud.
URL (OAB/RJ): https://www.oabrj.org.br/tribunal-de-etica-e-disciplina
Against the Public Defender's Office:
Action:
File a formal complaint with the Internal Affairs Office (Corregedoria-Geral) of the Public Defender's Office of the State of Rio de Janeiro.
What to allege:
Abandonment of the case, negligence, lack of personal communication, and violation of the constitutional right to a full defense and access to justice.
B. Police and Criminal Measures (Penal Punishment)
The goal is the investigation and punishment of the crimes committed.
Crime Report (Notícia-Crime):
Action:
File a Police Report at the competent police station or, more effectively, submit a Notícia-Crime (a formal petition detailing the facts and alleged crimes) directly to the Public Prosecutor's Office of the State of Rio de Janeiro (MPRJ).
What to allege:
Detail the crimes of Fraud (Estelionato), Ideological Falsity, Use of a False Document, Procedural Fraud, and, if there is evidence, Active Corruption (by the executor) and Passive Corruption (by public agents).
The MPRJ has the duty to investigate crimes committed by citizens and also by public officials.
URL (MPRJ):
C. Judicial Measures (Reparation of Damages and Annulment of Acts)
The goal is to reverse material losses and obtain financial compensation for the damages suffered.
Action:
This is a specific lawsuit to declare an entire judicial process null and void when incurable defects occur, such as the lack or fraudulent nature of the summons (which led to the false default).
It is a powerful measure to overturn a final judgment in cases of fraud.
Relevant Precedent (in ABNT format): BRASIL. Superior Tribunal de Justiça. Recurso Especial nº 1.631.783 – SP. Relatora: Ministra Nancy Andrighi. Brasília, DF, 20 de agosto de 2019. Diário de Justiça Eletrônico. Brasília, 22 ago. 2019. (This precedent discusses the nature and applicability of querela nullitatis in cases of defective summons).
Action:
File a civil lawsuit against all those directly responsible for the damages (the executor, their lawyer, and even the State, for the failure of its agents).
What to request:
The return of all material losses (the value of the seized asset) and robust compensation for moral damages resulting from all the suffering, humiliation, and violation of rights.
Relevant Precedent (in ABNT format): BRASIL. Superior Tribunal de Justiça. Recurso Especial nº 1.881.453 – RS. Relator: Ministro Marco Aurélio Bellizze. Brasília, DF, 26 de outubro de 2021. Diário de Justiça Eletrônico. Brasília, 03 nov. 2021. (This case deals with the liability of the State for judicial acts that cause damage, in exceptional situations of gross error or willful misconduct).
Final Conclusion
The path to reparation is arduous and requires a strategic approach on multiple fronts.
It is crucial to gather all documentary evidence (copies of the lawsuit, false documents, emails, etc.) and, if possible, witness testimonies.
Hiring a combative, experienced, and trustworthy lawyer is the most important and urgent step.
The combination of administrative complaints (to punish the agents), criminal actions (to punish the crimes), and civil lawsuits (to nullify fraud and repair damages) is the most complete strategy for seeking justice in this complex scenario.
SOURCES
Review Article Published: 2025-02-18
Just published in Academia Mental Health and Well-Being: "Dignity in mental health—examining the dynamics of mental health stigma: a narrative review" (Recém-publicado na Academia Saúde Mental e Bem-Estar: "Dignidade na saúde mental — examinando a dinâmica do estigma da saúde mental: uma revisão narrativa")
Dignity in mental healthcare: service user perspectives
Claire Brooks1,2,*, Charlene Sunkel3, Hannah L.N. Stewart4,5
Academic Editor: Takeshi Terao
Abstract
Dignity is widely recognized as a foundational concept in the provision of healthcare. Despite this, concepts of dignity are only vaguely described in the literature relating to mental health services, contributing to frequent violations of service users’ dignity.
Notably, discussions of dignity in mental health services often do not include the service user perspective.
We offer a narrative review of the literature to examine how service users and peer workers articulate the co-production of dignity within mental health services.
Seven overarching dimensions of dignity emerge from the available evidence, spanning the social dignity that service users experience in relation with healthcare professionals, the mental health system itself, the physical settings in which mental health services are delivered, and the use of peers as valued members of the mental health workforce and co-creators of knowledge.
To ensure that mental health service users are empowered by the mental healthcare they receive, it is imperative that concepts of dignity move beyond ‘vague’ moral and ethical concepts to operational guidelines for best practice in mental health service design and delivery which are grounded in service user perspectives.
To this end, we make meaningful recommendations to improve how healthcare professionals are trained, to implement alternatives to coercion in mental healthcare and to explore how lived experience can be centered in mental health services, and we call for the recognition of service users as experts by experience in peer work and the co-creation of new knowledge and evidence.
Keywords: dignity, mental healthcare, service users, peer work, knowledge co-creation
Citation: Brooks C, Sunkel C, Stewart HLN. Dignity in mental healthcare: service user perspectives. Academia Mental Health and Well-Being 2025;2. https://doi.org/10.20935/MHealthWellB7523
Introduction
Dignity is an important moral and ethical concept in mental health- care, yet worldwide, the dignity and human rights of service users are violated during care.
While there are complex factors involved in dignity violation, operational definitions of dignity are vague and lack the service user perspective.
Dignity must be co-produced between mental healthcare service users and providers, includ- ing the full involvement of peer workers with lived experience of mental health conditions in designing and delivering services and co-creating research.
This narrative review examines the evidence for service user and peer worker perspectives on co-producing dig- nity in mental healthcare and offers recommendations for service design and delivery.
Materials and methods
This paper addresses the following question:
what is dignity in mental healthcare service delivery from a service user perspective?
Its aim is to conduct a narrative review of the currently available peer-reviewed literature on this topic.
In particular, we draw on 2 qualitative research studies with service users around the world which the authors, who are lived experience researchers, were in- volved in co-producing with individuals who have lived experience of using mental health services [1, 2].
These 2 studies were pre- sented at peer-reviewed conferences [1, 2], and quotes from participants in these studies are presented throughout this paper.
A narrative review is one in which the reviewers select evidence purposively to address the research question and offer an inter- pretive summary which deepens understanding of the topic [3].
Searches were conducted on the databases Medline, APA Psych Info, CINAHL, Embase and Web of Science using the search terms dignity AND mental health; mental health dignity; dignity AND mental healthcare; mental health services AND dignity.
No date limit was applied.
Only original research studies published in English which primarily gave a service user perspective (i.e., the study sample was solely or primarily drawn from mental health service users) were considered, resulting in 17 studies which were reviewed.
There is a lack of studies in the recent literature which give clear evidence of the service user perspective, as opposed to a healthcare or legal professional perspective, which is confirmed by 2 recent systematic reviews [4, 5].
The 2 qualitative studies with which the authors were involved [1, 2] were conducted online in partnership with the World Dignity Project, a UK charity.
Members of the charity, who are senior mental healthcare professionals and academics who publish in the field, advised on study design and et-
hical considerations. All participants were over the age of 18, and informed consent was obtained prior to each study.
Both these studies asked for narratives about service user experiences of mental healthcare. The first study had a purposeful sample of 17 individuals, 8 men and 9 women from 11 countries, referred with their consent by their mental healthcare professional (HCP). They were asked for a narrative about an experience when they felt their dignity, or that of someone whom they cared for, was respected. The second study had a purposeful sample of 78 individuals, 27 men and 51 women from 21 countries, recruited from service user organizations and forums with permission from their admins. They were asked for 2 service experience narratives, one negative and one positive.
Results
Moral and ethical concepts of dignity in mental healthcare
In a moral context, dignity is inherent in all humans and inalien- able: the human worth which a person enjoys simply by virtue of being human and which cannot be lost except in death [6, 7]. As an intrinsic human quality, dignity is shared and acknowledged between human beings; dignity is both being (‘What I am’) and the recognition of being in others [8]. Human dignity is univer- sally understood as part of the collective unconscious, creating an archetypal understanding across cultures of how individuals want to be perceived [9].
Human rights are “specifications of human dignity” [10] and are the conduit through which abstract concepts of morality become legislation. According to the human rights statute, all humans are equal in dignity and rights, and discriminating against a person on the basis of disability, including mental or cognitive disability, is a violation of their inherent dignity and human rights [11, 12].
The importance of dignity as a moral concept has been widely recognized in mental healthcare professional (HCP) ethics, health- care policy and patient experience measurement protocols, yet mental healthcare services worldwide, according to the most re- cent guidance from the World Health Organization (WHO) and the United Nations (UN), do not respect the dignity of service users; further, stigma and the continued use of coercive practices leads to human rights violations in mental healthcare [13]. The contributory factors to dignity violation in mental health services are complex and include policy planning and monitoring, lim- ited resources being allocated to mental healthcare and under- investment in mental health services in primary healthcare. Only 2% of global expenditure on health is spent on mental health, with just under 4% in high-income countries (HICs) [14]. Shortages of mental healthcare professionals (HCPs) are increasing in mental healthcare, and there is an increased use of temporary staff, making it challenging to build effective therapeutic relationships between service users and providers and deliver person-centered planning and care, including minimizing seclusion and restraint by the use of specialist skills in de-escalation [15]. Only 38% of WHO member states have a mental health policy or plan that is fully compliant with human rights instruments, including only 43% of HICs, and 40% do not have an effective independent authority to ensure mental health facilities are compliant with international human rights instruments [14]. Only 25% of WHO member states have int-
egrated mental health into primary care, resulting in 70% of men- tal health expenditure being allocated to psychiatric hospitals in lower–middle-income countries [14]. However, despite this com- plexity, the following question should be asked: is there a proper understanding of dignity beyond its moral and ethical importance, in order to enable the design and delivery of mental health services and ensure a dignity experience for service users?
Subjective moral concepts of dignity in mental healthcare
The first question which might be asked is as follows: if dignity (as a moral concept) is inherent and inalienable, how can it be violated in mental health service design and delivery? It has been pro- posed that in practice, dignity is a subjective psychological concept; lack of respect from others, which excludes, rejects, demeans and stigmatizes individuals, thus injuring their subjective self-respect, makes dignity a moral issue [16]. Taking this subjective moral perspective, dignity can be described as an inherent and inalienable human quality (human dignity) which is dynamically manifested as self-respect and also as respect from others [17].
In practice, it is proposed that dignity flows from two separate sources: one internal (self-respect, ‘how I see myself’) and one external (respect, ‘how others see me’) in a constantly dynamic process involving both internal and external components [18]. This is illustrated in Figure 1. The ‘dignified self’ has self-respect and respect from others; because self-respect is dynamic, so must dignity be dynamic [19]. This definition of dignity as ‘dignity of identity’ can be enhanced or undermined by other people or situ- ations including illness and aging [20]. Dignity is characterized by ‘being seen’ by others; ‘not being seen’ involves not being heard and acknowledged, as well as being seen only as a member of a group and not as an individual or being separated from a group or social norm, i.e., being stigmatized [18].
Illness is an assault on personhood and dignity [21], causing a fundamental shift in self-perception from both intrinsic (auton- omy and identity) and extrinsic (relational/social and societal) perspectives. However, it is the extrinsic perspective that is at greater threat from stigma, i.e., loss of respect and recognition as an individual from others affects self-identity and self-respect [22]. Dignity is vested in identity, which is constantly under threat from illness; maintaining dignity in the healthcare context is an ongoing process of maintaining and confirming self-identity in relation to others [19, 20]. In mental healthcare, human dignity is recognized by symbolic acts of respect (‘deference’) from others which allow individuals to feel and behave with self-respect (‘demeanor’), even when they are at their most vulnerable, which is particularly the case for psychiatric inpatients [23].
The characteristics of mental health conditions and mental health- care relationships and settings can pose a particular threat to the self-dignity of a service user and their ability to maintain a sense of self-identity. This is because dignity has been characterized as primarily social and influenced by the relationship between the actors in the context of the setting and relationship [24]. Dignity violations are more likely to occur when there are asymmetries of power and one actor is vulnerable, in harsh or hierarchical settings which lack resources or in circumstances where inequality flourishes, which is the case for mental healthcare [24].
Figure 1 • Concepts of dignity in mental health service delivery.
“What is dignity? I can divide dignity into two parts. The first part is dignity within, how much dignity I feel for myself…The second part is dignity from outside, from people, government, laws and from the commu- nity…that together with inner dignity, I could live my life with pride and hope.”
Service User narrative, Male, age 25–34, Israel [1]
Defining criteria for dignity in mental healthcare
It has been claimed that dignity has a widely accepted, archetypal meaning for most individuals which is passed on professionally across generations of HCPs and reflected in medical ethics [9, 19]. However, dignity as a purely moral or ethical concept is prob- lematic in mental healthcare service delivery, because it lacks operational specificity, implying rather than stating obligations to service users [25, 26]. This top–down definition of how service user dignity is ensured also minimizes the service user’s own agency in maintaining and promoting their self-dignity in practice. Studies have aimed to evidence the behaviors and settings which promote or violate mental healthcare service user dignity. However, there is little in the literature which explicitly mentions dignity in mental healthcare, and much of what exists is either unclear on the extent to which the mental healthcare service user voice has been repre- sented or does not include any original research with service users at all [4, 5]. In 2003, Ruth Macklin threw down the dignity gauntlet in a widely cited and debated article which proposed that, in the absence of operational measures for the violation of a person’s dignity, it remains a “hopelessly vague” and “useless” concept amounting to a broad statement of ideals rather than guidelines or enforceable codes for best practice in healthcare service design and delivery [27]. Rebuttals to the argument state that the ‘vagueness’ of the topic is not a reason to abandon it but a challenge to double down on developing theoretical and empirical work to address the disconnect between philosophical and empirical research on dignity that includes the service user perspective. The next sec- tion examines the evidence for dignity produced by studies which included the service user perspective.
Criteria for dignity in mental healthcare from a service user perspective
A recent systematic review of the literature on dignity in invol- untary psychiatric care [5] identified mental health service user dignity domains as relationships with staff, the care environment, management of coercion, and addressing feelings of powerlessness in therapeutic relationships and environments. Broadly in line with this taxonomy, a recent systematic review of the literature on mental health patient experience identifies dimensions which pos- itively influence mental health in-patients’ experience of recovery- focused care, specifically high-quality relationships with HCPs, a healthy, safe, and enabling physical environment, authentic expe- riences of patient-centered care, and averting negative experiences of coercion [4]. This review explores studies which include service user perspectives of dignity criteria in mental healthcare service delivery and identifies seven dimensions of service user dignity relating to mental healthcare relationships and settings.
Relationships
Dignity is primarily experienced in interactions or ‘relationships’ between individuals or institutions, which Jacobson calls ‘social dignity’ [28]. Collaborative therapeutic relationships are at the heart of dignity co-production, consistent with the WPA’s code of ethics [29], which calls for HCPs to build relationships with service users that acknowledge the service user’s role as a partner in diagnosis, treatment, and recovery.
The literature on mental health dignity points to five themes within the relationships domain: respect, communication, empa- thy, patient-centered care and autonomy.
Respect
Recognizing the equality of shared humanity by the provision and reception of respect is critical within the relationship domain; mental healthcare service users who experience dignity describe a perfect circle of respect: they have self-respect, feel respected
and treat others with respect [30, 31]. Service users must be ad- dressed courteously as equal human beings [32, 33], and their opinions and feelings about their mental health must be taken se- riously [2, 31, 33–35]. HCPs must acknowledge common humanity and respect, for example by not talking down to service users but speaking to them as if to an equal human being [36, 37]. Staff must not stigmatize service users, undermining their status as included, valued equal human beings and their self-respect, for example by demeaning them or trying to make them feel inferior, judging them, looking on them with distaste or criticizing them [32, 35, 37, 38]. One service user described her experience interacting with HCPs, outlining how one nurse went so far as to shame the individual for the impact that self-harm scars could have on her future romantic life:
“The nurse seemed very hostile and aggressive. Asked me if I self-harm (which I did) and asked me how I plan to have a boyfriend if I have all these scars.”
Service User Narrative, Female, 18–34, Canada [2]
Communication
Effective and respectful communication from healthcare profes- sionals is closely linked with dignity for both psychiatric inpatient and primary care service users with a mental health condition [39]. Listening without interrupting and helping service users express their experiences and be understood privileges the service user’s voice in the therapeutic relationship, helps them make sense of their lived experiences and gives them a sense of control and affir- mation of self-identity as part of the process of recovery [1, 2, 21]. A service user describes this type of communication and the impact it had, saying the following:
“He was quiet when he needed to be. He waited a few seconds after each of my statements, so I didn’t feel too overwhelmed, and he didn’t interrupt me at any point.”
Service User Narrative, Male, 35–49, UK [2]
Self-dignity is reinforced when the identity of a service user is con- firmed through narrative: by being listened to, their concerns are acknowledged and they can feel less shame and stigma about their condition [5, 40]. This connection between HCP communication and self-dignity is illustrated in the recollection of a service user from the UK:
“I talked. She listened. I talked. She listened. I talked. She listened. Not only was I treated with dignity, but I was treated with warmth. I felt safe and I felt liberated of my own feelings which, until then, had been buried somewhere inside my skinny body…In this experience, I felt that I wasn’t shamed for the difficulties I was facing or questioned for the things I did. This is what it feels like to be treated with dignity.”
Service User narrative, Female, age 18–24, UK [1]
HCPs must not only be willing to listen, but also, especially for more vulnerable service users, to see non-verbal cues and the unspoken wish to be heard [31, 39]. Being encouraged to have hope, to see the positives in life and carry on, is also a critical outcome of
communication and is key to recovery because it helps service users with the belief that they can move forward [2, 30, 33, 41].
Communication is essential in person-centered care, which sup- ports the co-production of dignity between the service user and provider. Open, collaborative communication a ensures shared understanding of recovery goals and lifeworld context and fa- cilitates shared decision-making, an equal partnership in which clinicians and service users can work together to achieve recovery goals. Providing information confers a sense of control, while not knowing leaves the service user feeling helpless and disempowered. Mental healthcare service users must be kept informed about their treatment plan, who they would see and when, and medication and its side-effects; their questions must be answered, and they must not be labeled difficult for asking questions or expressing opinions and wishes [42–44].
In order to reinforce self-dignity in communication, staff must be approachable, take cultural backgrounds and preferences into ac- count in communications, maintain eye contact, speak courteously and not use technical language which reinforces unequal power dynamics [4, 28, 45].
Empathy
Empathy is an important domain of dignity [40, 46, 47]. Em- pathy involves recognizing the shared humanity between service providers and service users while maintaining the sense of sep- aration necessary for objective perspective-taking, and promotes dignity through the mechanism of understanding a service user as an individual in need of care and meeting them as an equal human being with humane warmth and understanding [33, 48].
For the most vulnerable service users, empathy is about human connectedness and kindness as a professional response to a cry for help and protection [1, 49]. For psychiatric in-patients, human contact and conversation is an essential component of dignity [5]. Regaining dignity through human connection by being reaffirmed as a unique individual with human worth is an essential aspect of recovery for the most vulnerable mental healthcare service users, such as those at risk of suicide [50]. For some service users, empa- thy from HCPs can be a “game changer” in the recovery process:
“During one of my hospitalizations I was on suicide watch…nurses were not just sitting with me or impos- ing their views on me- they were allowing me to feel, supporting me as a human being with challenges, but who is loved and valued. That was a game changer in my healing.”
Female, 18–34, USA [2]
Empathy is closely linked with communication within therapeutic engagement: listening, understanding, and helping service users to express experiences, thoughts and feelings [1, 24, 38, 40, 51]. As illustrated in the service user narrative above, empathy in- volves speaking kindly; offering comfort, support and love; and showing concern for emotional needs and responses rather than showing rejection or neglect of service users and their families, or humiliating them by using medication or coercive practices such as sedation and restraint [32, 39, 52]. If such coercive practices are used, management with empathy is essential, giving information and reassurance during and after sedation or restraint [4, 5, 53].
Person-centered care
Seeing and treating a service user as an individual with a unique lifeworld context and providing an individual approach to treat- ment is core to the concept of person-centered care, which takes a holistic approach to the treatment of the individual and focuses on the co-production of recovery goals. Being recognized and treated as a competent individual is crucial for service users’ self-dignity because dignity is vested in identity (‘how others see me’ and ‘how I see myself’) and a diagnosis can objectify an individual, threatening identity, as maintaining dignity is about having unique personhood seen and confirmed [18]. Service users wish to be treated as unique persons and not ‘things’, not labeled as a diagnosis or care task, or stigmatized and socially excluded as ‘mentally ill’ [5, 24]. A lack of person-centered care, often in the form of objectification and stigmatization of service users, can make the service user feel unseen and unsafe. One service user from Sweden has the following perspective:
“I was often treated like a number…met with stone faces and cold attitudes. When I tried to communicate…they were already convinced that I was “crazy” and brushed off anything I had to say as just ‘insane rambling’… I didn’t feel safe in a place that was supposed to help me get out from my dark place.”
Female, 18–34, Sweden [2]
Being treated as an individual is also closely linked with empathy: service users must be non-judgmentally accepted, valued and loved for who they are as unique individuals and be comforted to truly feel confirmed in identity, which builds trust in HCP relation- ships [30, 33, 40, 42]. In recounting her experience with mental health treatment, one Portuguese service user says the following:
“I remember perfectly the first and best session…I felt that all my issues were actually valid, and someone understood the pain I was dealing with.”
Female, 18–34, Portugal [2]
Here, she illustrates how the experience of connecting with and be- ing understood by her HCP was a memorable experience, allowing her to feel validated in the suffering she experienced.
Autonomy
In a healthcare context, dignity exists when an individual has self-determination and can exercise choice and control over their environment, actions and the way in which others treat them [19, 34, 41]. Autonomy recognizes an individual’s compe- tence; therefore, dignity is undermined when service users are not supported in exercising their capabilities autonomously, thereby making them powerless, passive recipients of care and diminishing their personhood and self-respect [26, 30]. By contrast, dignity is promoted when a healthcare service user’s competence is enabled and they are empowered to make informed decisions and give informed consent for treatment.
Leveling asymmetries of power within the therapeutic relation- ship is essential to empower service user autonomy and dignity by giving them information and tools to make choices about
their care and promote their own recovery according to personal goals [24, 32, 33, 53]. Shared or supported decision-making, in- cluding for service users with a serious mental illness, empowers the autonomy of the person as an ‘equal expert’ in their care and the final decision-maker on treatment, protecting their human rights [13]. Individuals who feel they do not have at least some self-determination can become disengaged with what they perceive as institutional disrespect, resulting in non-adherence and nega- tive health outcomes. Conversely, as explained by one service user below, having their self-determination and autonomy respected can help build or restore faith in the treatment plan.
“I still had the power to make decisions…I could still live and all was not lost. I felt understood and valued like all normal people… there was still hope. This gave me the will to adhere to the treatment because I had been involved in the decision-making.”
Female, 18–34, Uganda [2]
For hospitalized service users, autonomy is promoted by enabling everyday freedom of choice, not imposing petty ‘house rules’, for example on how individuals choose to dress or their possessions, and requiring permission to perform routine daily tasks [5, 33]. Hospitals can be boring as well as restrictive, and autonomy is supported by offering a choice of meaningful activities suited to in-patients’ interests, and offering choice in everyday decisions such as when to have a snack or drink [30, 44, 45].
The Convention on the Rights of Persons with Disabilities [11] recognizes the importance of an individual’s autonomy and inde- pendence, and calls for an end to coercive practices which restrict autonomy are widespread from both human rights institutions and mental healthcare professional bodies, but these practices continue to be used and can sometimes be seen as necessary in exceptional circumstances by both service users and staff [5]. Advanced plan- ning directives which explain the service user’s wishes should be mandatory [54]. However, if coercive measures such as restraint, isolation or sedation are used, they should not be imposed with- out discussing options and explaining procedures, and sedation must be used for therapeutic purposes and not merely to keep persons quiet [32, 49, 53]. The management of coercion affects dignity—notably its duration, proportionality and the efforts made to explain coercive measures—and also makes service users are more likely to see a hospital as an ally in their care [5]. Inad- equate communication about the need for restraint or seclusion and possible alternative options makes service users and families feel they are being humiliated and punished and can put them off seeking help, whereas explaining the reasons for coercive measures increases service user trust in staff and helps them feel like the hospital can be the safe space they need [4, 53].
Settings
The care environment
The care environment is an important domain for dignity experi- ences, and often, insufficient attention is given to creating archi- tectural spaces and respectful environments which foster dignity, privacy and a sense of hopefulness for recovery. By contrast, home- like surroundings which offer a sense of human connection and existential control can enhance self-dignity and improve the service user’s perceptions of the quality of care [40].
Attractive, comfortable spaces which feel calm and homely support dignity and personhood in very simple, basic ways, by humaniz- ing the care environment. These spaces include clean bathrooms, access to clean clothes, drinks and snacks, use of a TV, reading material or other ways to pass the time and help with personal care [33, 45, 55]. Noise control measures are important to create a calm space where service users feel safe and which promotes healing; bright and uplifting spaces with access to nature (or even representational art) can contribute to recovery [56, 57].
Dignity is violated when personal space is invaded and personal boundaries are not respected in unpleasant or threatening physical settings [37, 44]. High-density architectural spaces which lack privacy, are overcrowded or mix different types of service users inappropriately do not feel like safe, calm, personal spaces which promote recovery, and can exacerbate stress and aggressive behav- ior [58]. Forcing individuals who are subject to coercive measures to be in foul conditions is a gross violation of their dignity in circumstances in which they lack any form of existential control whatsoever [1, 2, 53]. One man described the horrid, undignified conditions of his hospitalization in the following manner:
“I was isolated and locked up in a seclusion room where I was stripped naked and kept there for long hours. The room had no window and therefore no light came through. There was no water or no toilet facility to use and no mattress or any form of bedding facility provided. It was very dark in there and all I could do was to lay on very cold concrete cement floor.”
Male, 35–49, Uganda [2]
Privacy and confidentiality
Privacy is one of the aspects of the dignity domain of health sys- tem responsiveness to patient expectations of mental healthcare according to the WHO [42]. Physical privacy respects ‘embod- ied’ dignity, which is the personal identity and agency embod- ied in an independent individual, and institutionalized ‘deference’ for the individual requires distance and ritual avoidance, so as not to encroach on their personal space and violate personal or physical boundaries, which in turn would violate demeanor (self- dignity) [23]. In mental healthcare, physical privacy and respect for personal space is important to hospitalized in-patients but often not respected [32, 44]. Protecting physical privacy requires not examining, treating or restraining individuals in front of others or allowing students or others to observe said treatment [37, 52, 53].
Confidentiality is more important than physical privacy to mental healthcare service users. The crucial importance of confidentiality with regards to a mental health diagnosis to service users is in avoiding stigma, which may negatively impact many aspects of their lives and can be a barrier to seeking help [37, 54]. The right to confidentiality is enshrined in psychiatric ethics, along with human dignity and rights. Protecting confidentiality involves keeping personal information confidential to the immediate care team and not disclosing it in front of others or outside the health system or sharing information with the service user’s spouse or family without asking for permission [23, 24, 32]. Confidentiality within therapeutic relationships is important to maintain trust and openness and encourage service users to disclose symptoms and concerns; it is important not to invade personal boundaries by ask- ing unnecessary personal questions [2]. Confidentiality concerns
have increased due to the more widespread use of telehealth, and there is now a greater need to protect digital information and to ensure the privacy of online consultations [59].
Dignity in mental health knowledge co-creation
Aside from the co-production of dignity experiences between men- tal healthcare service users and providers, there is a growing need for collaboration in mental health research. Knowledge creation in mental healthcare must be dignity-based; it must respect the equal humanity of service users as ‘knowers’ in the collection and interpretation of data about them [60]. The involvement of people in co-creating knowledge in areas which might either benefit or harm them can be seen as a basic human right, an issue of social justice [61]. People with lived experiences must be empowered as ‘experts by experience’ in the co-creation of new knowledge and ev- idence in mental healthcare to increase the speed and effectiveness of implementing interventions and empower recovery through lived experience leadership and career development [62–64].
Dignity in peer work
Peer work in mental health refers to the practices observed by individuals with lived experience of mental health conditions in providing support, guidance, and mentorship to others with similar lived experiences. Peer workers draw on their personal journeys to offer empathy, understanding, and practical assistance, fostering hope and recovery. Peer work is built upon the autonomy, strengths and rights of peers, whilst creating an empowering and engaging space where individuals are able to share experiences without fear of stigma or discrimination.
Dignity is a fundamental principle in peer work, as it encapsulates respect for and the recognition and valuing of lived experience expertise. Dignity in peer work requires the provision of fair remu- neration practices, supporting professional development, and pro- moting genuine inclusion in decision-making processes. Activating the elements of dignity in peer work fosters mutual respect, builds trust, and enhances the effectiveness of peer-led initiatives, whilst contributing to more compassionate and person-centered mental healthcare practices [65].
Peer work in mental health remains significantly underutilized in low- and middle-income countries (LMICs) compared to high- income countries (HICs), where it has gained broader recogni- tion and integration into mental health systems. In high-income settings, peer workers are often formally trained and employed within mental health services, contributing to improved outcomes through shared experiences and advocacy. However, in LMICs, there are numerous barriers hindering the adoption of peer work, including limited resources, stigma, a lack of recognition of exper- tise from lived experience, and insufficient policies supporting the inclusion of peer workers. Expanding peer work in LMICs is crucial for fostering more equitable, culturally responsive, and sustainable mental health support systems that uphold the fundamental right to dignity [66, 67].
Study limitations
This paper presented a narrative review of the literature on dignity in mental healthcare from a service user perspective. A limitation
of this approach is that it is more biased than a scoping or system- atic review. Weighed against this limitation is the importance of including a lived experience perspective on key topics in mental healthcare. Indeed, it has been suggested that narrative reviews, in which the authors use their expertise to select studies from the literature that are most relevant to policy questions, should not be undervalued for their potential to contribute new insights into a topic that has lacked a service user perspective to inform policy and service design [3–5]. A further limitation is that this narrative review included primary data from two studies which the authors were involved in coproducing, and which were presented at peer-reviewed conferences but not published in peer-reviewed journals, also adding a risk of bias in interpretation.
Conclusions
In summary, it has been proposed that human dignity is an abstract but widely understood moral concept and a foundation for human rights legislation, including that relating to mental healthcare. However, around the world, the dignity, equality and rights of mental healthcare service users continue to be violated by coercive practices, discrimination and a focus on the biomedical recovery model. This review identified seven dimensions of dignity co- production in mental healthcare service design delivery from ser- vice user perspectives. All mental healthcare service users should be empowered by their healthcare service experience to strengthen self-dignity and find a new sense of self-identity in a recovery journey directed by their personal goals and choices. Peer work enables dignity co-production when integrated fully into mental healthcare but is underutilized in LMICs. Research must cease exploiting those with lived experience of mental health conditions as research subjects and fully enable lived experience leadership in knowledge co-creation.
This review makes the following recommendations:
Firstly, HCPs, students and staff must be enabled, through edu- cation, training and continuing professional development, to un- derstand service user perspectives on the aspects of mental health service delivery which encourage dignity co-productioSecondly, given the gaps in provision of specialist mental health services, mental health dignity must be a topic in the pre-service training of non-mental health specialist HCPs.
Thirdly, mental health systems and legislators must continue to work towards implementing alternatives to coercive practices which violate the dignity, autonomy and human rights of service users.
Finally, the dignity of peer workers must be paramount in mental health service design, professional development and remunera- tion. Resources must be set aside for expanding peer work, es- pecially in LMICs. Mental health research must be reframed as knowledge co-creation with lived experience leadership.
Funding
The authors declare no financial support for the research, author- ship, or publication of this article.
Author contributions
Conceptualization: C.B., C.S. and H.L.N.S.; Methodology: C.B.; Formal analysis: C.B. and H.L.N.S.; Resources: C.B.; Data curation, C.B., C.S. and H.L.N.S.; Writing—original draft preparation, C.B.,
C.S. and H.L.N.S.; Writing—review and editing, C.B., C.S. and H.L.N.S.; Visualization: C.B. All authors have read and agreed to the published version of the manuscript.
Conflict of interest
The authors declare no conflicts of interest.
Data availability statement
Data supporting these findings are available within the article, at https://doi.org/10.20935/MHealthWellB7523, or upon request.
Institutional review board statement
Not applicable.
Informed consent statement
Not applicable.
Additional information
Received: 2024-10-22
Accepted: 2025-01-17
Published: 2025-02-18
Academia Mental Health and Well-Being papers should be cited as Academia Mental Health and Well-Being 2025, ISSN 2997-9196, https://doi.org/10.20935/MHealthWellB7523. The journal’s offi- cial abbreviation is Acad. Ment. Health WellB.
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1ModelPeople Inc., San Luis Obispo, CA 93401, USA.
2Faculty of Management, Law & Social Sciences, University of Bradford, Bradford BD7 1DP, UK.
3Global Mental Health Peer Network, Paarl 7646, Western Cape, South Africa.
4Generation Mental Health Association, New York, NY 10022, USA.
5Department of Health Promotion & Behavioral Science, School of Public Health, UTHealth Houston, Houston, TX 77030, USA.
∗email: c.brooks10@bradford.ac.uk
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