Luigi Grassi

Dignity and preservation of dignity have emerged as a central and mandatory aim to pursue in all the areas of medicine, including palliative care. People with severe mental disorders (SMI) who are at the end of life pose further challenges because of the problem of stigma, which is intrinsically imbued in palliative care, as well as of other the variables including marginalization, alienation, and epistemic injustice typically associated with mental illness and psychiatry. A person-centred approach, which promotes a medicine of the person, for the person, by the person, and with the person, can increase the sense of personal dignity, as the other side of stigma, and epistemic justice for patients with SMI who are at the end of life. Dignity-oriented intervention, such as Dignity Therapy, can also be applied in palliative care settings for people with SMI with the aim to offer them an opportunity to reflect upon crucial existential and relational issues, to review aspects of their lives and of self, and to help in preparing a legacy of memories, words of love and wisdom with significant others.

Psychotic disorders are extremely challenging for individuals and their loved ones. The experience of psychosis, as is found in schizophrenia, may subvert the foundations of the individual’s relationship with the world. Irrespective of the theoretical frame of reference, psychotic episodes are characterized by intrinsic impairment of the individual ability to know, make sense of, and experience the world, thus limiting agency and threatening dignity. In addition, individuals with acute psychosis are generally cared for within institutions that entail some degree of separation from society (e.g. the psychiatric ward) and—in extreme cases—with coercive practices. Coercion is established by the law as a “necessary evil” to avoid risky outcomes and to achieve clinical improvements, i.e. recover a better contact with reality. However, this approach may engender situations that are detrimental for individual dignity, morale, and epistemic justice. During the emergence of acute severe mental illness and its treatment, individuals may in fact encounter stigmatization and marginalization, and experience stress, loss of agency and loss of dignity. After one or more hospital admissions, the experience of severe mental illness and the conditions related to treatment may engender demoralization, which is particularly detrimental in the long term and may increase the risk of suicide. This chapter aims to provide an overview of the available evidence on these topics and broad indications on strategies and therapeutic approaches that might improve the experience of psychiatric inpatient care.

Amongst the many consequences of psychiatric disorders, such as poor quality of life and poor health, increased physical morbidity, and lower lifeexpectancy, some are of particularly relevance, such as stigma, discrimination and similar assaults to human dignity. In order to reduce the alienation of those affected by mental illness, person-centered psychiatry is an approach to promote a medicine of the person, for the person, by the person and with the person. Dignity- conserving care is part of this approach and it should be practiced in mental health care settings, enabling partnerships with people encountering psychiatric disorders that include mitigating loss of identity, shattering of their self-image, and various challenges within the psychological, interpersonal, spiritual and existential domains. Dignity Therapy, as a personalized and empirically-based intervention developed for patients with life-threatening or limiting illnesses, has been applied in psychiatric settings showing a reduction of stigma and suffering.

Psychiatric and psychosocial disorders among cancer patients have been reported as a major consequence of the disease and treatment. The problems in applying a pure psychiatric approach have determined the need for structuring more defined methods, including screening for distress and emotional symptoms and a more specific psychosocial assessment, to warrant proper care to cancer patients with psychosocial problems. This review examines some of the most significant issues related to these two steps, screening and assessment of psychosocial morbidity in cancer and palliative care. With regard to this, the many different variables, such as the factors affecting individual vulnerability (e.g. life events, chronic stress and allostatic load, well-being, and health attitudes) and the psychosocial correlates of medical disease (e.g. psychiatric disturbances, psychological symptoms, illness behavior, and quality of life) which are possibly implicated not only in “classical” psychiatric disorders but more broadly in psychosocial suffering. Multidimensional tools (e.g. and specific psychosocially oriented interview (e.g. the Diagnostic Criteria for Psychosomatic Research - DCPR) represent a way to screen for and assess emotional distress, anxiety and depression, maladaptive coping, dysfunctional attachment, as well as other significant psychosocial dimensions secondary to cancer, such as demoralization and health anxiety. Cross-cultural issues, such as language, ethnicity, race, and religion, are also discussed as possible factors influencing the patients and families perception of illness, coping mechanisms, psychological response to a cancer diagnosis.