Explanation of the Lived Experiences of Patients with Psychiatric Disorders on the Consequences of Stigma in Mental Health Centers

Document Type: Original Quantitative and Qualitative Research Paper

Authors

1 Professor, Nursing and Midwifery research center, Mashhad University of Medical Sciences, Mashhad, Iran

2 Ph.D Student in Nursing, School of Nursing and Midwifery, Mashhad University of Medical Sciences, Mashhad, Iran

3 Ph.D in Nursing Education, Department of Nursing, Mashhad Branch, Islamic Azad University, Mashhad, Iran.

Abstract

Background: According to the World Health Organization, one in four people experience a psychiatric disorder throughout his/her life. For centuries, psychiatric patients have been sent to psychiatric hospitals that often stigmatized and located out of the community. Moreover, these patients are stigmatized by the hospital staff because they are not aware of patients’ experiences in this domain. This humiliating attitude leads to low self-esteem, isolation, and frustration, and prevents patients from seeking treatment.
Aim: This study aimed to explain the lived experiences of patients with psychiatric disorders on the consequences of stigma in mental health centers.
Methods: This hermeneutic phenomenological study is a part of a larger study undertaken for partial fulfillment of the requirement for PhD dissertation in nursing. The main study was conducted on 12 psychiatric patients during 2014-2015. They were selected based on purposeful sampling method. Data were collected using unstructured interviews and analyzed by an interpretative method.
Results: Psychiatric hospital as an unsafe place is one of the main themes of the phenomenon under study in the original project. It consists of two sub-themes (i.e., an egregious hospital and cold-hearted white collars) each of which is supported by a number of common meanings.
Implications for Practice: The results of this study can shape the interventions and policies to combat and prevent the spread of stigma through health centers about people with psychiatric disorders.
 
 

Keywords

Main Subjects


Introduction

The World Health Organization estimates that one in four people experience a psychiatric disorder throughout his/her life, and its consequences affected nearly 600 million people worldwide. More than 85% of these people live in countries with low and moderate income. Therefore, it is clear that psychiatric disorders are one of the most influential issues in these countries (1). In today's world, "being a mentally ill person" is one of the most uncomfortable circumstances in the community. People with mental disorders experience all the key characteristics of the process of stigma and embarrassment. They are officially labeled and stigmatized and attached to undesirable characteristics and therefore widely criticized (2).

While people with physical illness are being treated in public hospitals, mentally ill patients have been sent for centuries to psychiatric hospitals that were located out of the community (3). Research shows that mental health providers also stigmatize patients (4). For a long time, mentally ill people have been managed based on staff's own diagnosis. According to the evidence, there is no difference between the health care providers and ordinary people in terms of describing a patient with a mental condition. They generalize all the patients as "Schizophrenic" instead of considering the specific condition in each individual. Stigmatization of a person based on his/her condition is one of the most destructive and inhumane forms of behaviors. Furthermore, mental health professionals impose restrictions and compulsory treatment on these patients. Moreover, they are not willing to treat patients with the psychiatric disorder. These misconceptions have not been changed for nearly two centuries (5).

In this regard, Nordet et al. (2006) conducted a study in Switzerland on mental health professionals (i.e., psychiatrists, nurses, and psychologists). They found that these practitioners did not make any distinction between the general public and mentally ill patients regarding the maintenance of their social distance (6). Research has shown that psychiatrists, nurses, and psychologists have more pessimistic views on the outcomes of mental illnesses than the general public (7).

Until recently, psychiatrists in some countries (e.g., European countries) demanded longer holidays and higher salaries, compared to other physicians, due to working with dangerous and violent patients. On the other hand, they believed that mental illnesses are not different from physical ones (8). With regard to this domain, Corrigan et al. (2004) conducted a review of stigmatization in mental health systems. They stated that low self-esteem, isolation, and frustration among the patients were due to the staff behavior in these environments and patients' access to resources and opportunities, such as housing and employment. This study showed that these issues will prevent patients from seeking treatment (9).

Moreover, Hinshaw (2005) stated that stigma and degrading attitudes of therapists or hospital inhumane experiences could have lifelong consequences on patients with psychiatric disorders (10). Wisdom et al. (2006) argue that if the service providers call the patients "abnormal" or "crazy", it is more probable that patients will not follow the recommended treatment (11). It was found during the study that one of the most important issues for the patients admitted to the psychiatric hospitals was lack of request. If they needed the help of hospital personnel, they would not ask for it because they thought the staff would not listen to them.

In general, the practitioners in the health system may not provide mentally ill people with sufficient intervention, initial guidance, or community referral options due to their stigmatized beliefs (12). Health care providers, either in the community or in the hospital, have an opportunity to influence the patients regarding the perception they hold about their illness. As a result, hospital staff obvious negative attitudes towards these patients cause distress while interacting with the patient, which ultimately results in ineffective counseling or medical care.

Many patients reported that they had a deep sense of frustration because the staff did not listen to them. This feeling led to incompatibility with their daily lives (13). In addition, the patients are believed to be responsible for their unpleasant behaviors and blamed by the practitioners for not being able to overcome their illness (14). Social stigma and negative attitudes from the healthcare providers or inhuman experiences in the hospital can have lifelong consequences on individuals (15).

One of the important implications of mental health professionals’ stigmatization is that therapists are not able to provide effective treatment. Due to unusual manifestations of mental illnesses, the practitioners avoid clients and do not have emphatic and positive communication with them. Moreover, they do not hope to treat the patients, which leads to failure and further avoidance (16). A number of studies, often conducted in Western countries, have suggested that people with psychiatric disorders can enter the community if a well-organized care system meets their psychiatric needs (17). It has been found that mental health workers also maintain their social distance due to lack of familiarity with the experiences of these patients (18). Mental health workers, especially nurses, provide the care for a large number of people with mental health problems; therefore, it is crucial for them to understand the experience of stigma from the perspective of patients. Furthermore, stigmatizing views about mental illness prevent the provision of appropriate services for the needs of these clients (19).

To the best of our knowledge, there is a dearth of research on the effects of health systems stigmatization on the lives and compliance of patients. Therefore, this study was conducted with the hermeneutic phenomenology method to evaluate the meaning of the mental health system stigmatization from the perspective of the clients. It is hoped that the evaluation of the patients’ experiences of stigmatization leads the officials, health care providers, the general public, and their families to take better care of them and relieve their pains.

 

Methods

This phenomenological hermeneutic study was part of a larger study for a PhD dissertation in nursing to understand the lived experiences of patients with psychiatric disorders regarding stigmatization. Heidegger’s thought underlies this approach; therefore, it is crucial in this method to explore the lived experiences and evaluate the patients' points of views regarding the meaning of stigma. The phenomenological approach was appropriate for this study because it pursues the human experiences within the context of people’s daily lives. Human responses to health and illnesses are different due to the uniqueness of each individual. 

Based on the humanistic nursing theories, appropriate nursing intervention could be achieved through the interpretation of study results. In fact, most situations need nurses' empathic attitudes and behaviors rather than nursing intervention (20). Nurses need knowledge of human beings to provide patients with better care (21). The stories of the patients should be explored to realize the inherent experiences that they face in their struggles with their disorder.

Participants were selected using selective sampling with maximum variation. The sampling went on until all 12 patients shared their experiences of stigma, data saturation was achieved, and no more information was obtained from participants. The participants were selected among the patients with psychiatric disorders who referred to clinics of Ibn-e-Sina and 22 Bahman hospitals from 2014 to 2015. The participation was voluntary. Psychiatrists diagnosed the patients to be in the remission phase of their illness. Table 1 presents the participants’ profiles. Data were collected using unstructured interviews, conducted in a quiet room at Ibn-e-Sina and 22 Bahman hospitals. In unstructured interviews, the interviewees were encouraged to express their experiences and describe the events that were important to them.

 

Table 1. Demographic variables of participants

Participant

Gender

Disorder

Marital status

Age

Education

participant 1

Female

Schizoaffective

divorced

38yearsold

Diploma

Participant2

Female

Obsession

Single

22yearsold

Elementary

participant 3

Female

Depression

divorced

45yearsold

Elementary

participant 4

Female

Bipolar

Single

21yearsold

University student

participant 5

Female

Bipolar

Married

31yearsold

Diploma

Table 1 Continued.

 

 

 

 

 

participant 6

Female

Borderline personality disorder

divorced

33yearsold

Elementary

participant 7

Man

Schizophrenia

Single

43yearsold

University student

participant 8

Man

Bipolar

divorced

48yearsold

teacher

participant 9

Female

Bipolar

Single

36yearsold

Graphic engineer

participant 10

Man

Bipolar

divorced

54yearsold

Elementary

participant 11

Man

Bipolar

Single

45yearsold

Bachelor of Education

participant 12

Man

Bipolar

Single

26yearsold

University student

 

They were also persuaded to describe the conditions and give their opinions and attitudes to the interviewers. According to Bryman (1988), this method includes the least participants’ guidance, and freedom in expression, compared to other methods, such as focus groups. According to May (2001), unstructured interviews are flexible and do not limit interviews (8). One of the authors, who was a PhD candidate of psychiatric nursing and trained based on qualitative-based research conducted all the interviews. In such interviews, the interviewer may start the interview with an open-ended question: “Would you please tell me what psychiatric disorder means to you?” The interviewer used probing techniques to clarify some parts of the dialogue and elicit more data during the interviews. Interviews were carried out on topics preferred by the participants. These interviews lasted between 30 to 110 minutes. Recorded interviews were transcribed into written form as soon as possible.

Data were analyzed based on the interpretative method of Diekelmann, Allen, and Tanner (1989) (22). Initially, all manuscripts from the interviews were read to reach a general understanding of each text and interpretational abstracts were written for each text. The first meeting of the research group (a professor, an assistant professor, and a PhD candidate) was devoted to discussing the experiences of the participants. The implications obtained from the interpretive guide of the first study paved the way for a thorough understanding of interviews and subsequent samples. Missing parts or implicitly identified ones were discussed to reach a deeper and richer understanding of the follow-up interviews. Subsequently, the implicit meanings or themes, which were extracted from the texts, were confirmed by the researcher to support the formation of categories.

The study themes and significant concepts were identified at this stage. During the interviews, there was continuous movement between the whole and the parts of the text. At first, lines of itemized text were read, all codes were recorded, the whole paragraph was read, and then a general theme was obtained in this study. In the next step, the researchers returned to the original texts and group analysis to compare the similarities and differences between the categories. After detecting the main cases, the researcher and the group obtained a shared meaning. According to the basic communication obtained in this step, subsequent interviews and observations were organized leading to the identification of common themes. The obtained text by the research team was reviewed, written, discussed, and interpreted in the last step.

The study protocol was approved by the Ethics Committee of Mashhad University of Medical Sciences, Mashhad, Iran (IRCT Code: 921487). Before the interview, informed consent was taken from the participants and they were all informed about the voice recording. Moreover, the participants were reminded of the right to withdraw from the study at any time. Furthermore, they were assured of the anonymity of their information.

 

Results

The findings suggest that the negative effects of stigma are widespread and are even more than the disease symptoms. The main theme that was elicited from the experiences of these patients was about the psychiatric hospital which they called it an unsafe place. Two sub-themes (i.e., an egregious hospital and cold-hearted white collars) were also obtained from the patients' experiences. Each subtheme was then supported by a number of common meanings. Table 2 summarizes these subthemes.

The main theme of "Psychiatric hospital: an unsafe place" is elicited from the experience of the patients in this study. On the one hand, it connotes a bad reputation and remoteness of psychiatric hospitals and on the other hand the ill-treatment of hospital staff. The sub-theme of "an egregious

 

 

Table 2. Summary of the subthemes and common meanings

Meaning units

Common meanings

Subtheme

Theme

 

Referral to a psychiatric hospital  is obscene 


Hospitalization in a psychiatric hospital is a criterion for being insane

 

An appointment with a  psychiatrist leads to stigmatization

 

Hospitalization in a psychiatric hospital leads to stigmatization

 

After being admitted to a psychiatric hospital, the patient is treated  differently by ordinary people 

 

Hospital called “Asylum”

An egregious hospital

Psychiatric hospital: An unsafe place

Psychiatric hospitals: Undesirable places

 

Poor conditions of psychiatric hospitals

 

Psychiatric hospitals: The end of the world

 

The scary environment of the psychiatric hospitals at the first visit

 

Psychiatric hospitals: Somewhere outside the city

 

Psychiatric hospitals, dark abandoned

 

The patients are not treated as human beings in  psychiatric hospitals

 

The human rights of the patients are violated in

 psychiatric hospitals

 

The patients are treated as criminals in psychiatric hospitals

 

The  hospital staff stigmatize the patients the same as ordinary people do

 

 

Personality Crush

Cold hearted white collars

Imprisonment in terrible environment of psychiatric hospitals

 

Immersion in the swamp of the psychiatric hospitals

 

Psychiatric hospitals: Similar to the hell

 

Psychiatric hospitals: Similar to prison

Getting locked up

hospital" indicates that the psychiatric hospitals are in poor conditions (e.g., old buildings) and are often located at remote and out-of-town areas. The patients in these hospitals are frequently faced with issues, such as large numbers of patients, insecurity as well as physical and verbal conflicts among patients, allocation of limited resources to these hospitals, and employment of low-motivated staffs. In addition, the condition of clothing, nutrition, and health is considered as regrettable. Therefore, the general public feels embarrassed and insane to visit these centers and anyone who visits these places will be stigmatized.

A 22-year-old woman said: “When I went to Ibn-e-Sina hospital, I noticed the name of the hospital as "Psychiatric hospital". I was really upset. I said to myself, I'm here because I am insane. Now our families say she is in a psychiatric hospital ".

A 36-year-old woman, who had a bachelor's degree, also expressed her experience:

"I don’t want to go to the psychiatric clinic. I don’t want anyone to visit me there, because insane people go there, everyone says insane people visit the psychiatrist ".

Sub-themes of "cold-hearted white collars" reflect the mistreatment of hospital staffs who ignore the human rights of the clients.

Mental health centers employ a pejorative approach to the identification of patients which distorts their identity. This inhumane behavior of staff toward the patients was the most emphasized issue in the experiences of participants. Many of them were clearly insulted by health care providers. For instance, they were seen as worthless people that no one paid attention to their demands, they were tied down to the bed without their consent, and they were always kept in a closed and restricted place with no privacy. Lack of privacy has been a pejorative event for many participants.

A 33-year-old woman said: "When you go to a psychiatric hospital, the staff hold your hands and feet to make you believe that you have a psychiatric disorder, and if you say no, they say that is the symptoms of the disorder and if you resist, they give you medicine and shock! "

Except for one patient who had no history of admission, the rest of the participants of this study believed that discrimination against them had begun after referral to psychiatric hospitals. The negative experiences of most participants in this study included lack of power to decide, staffs' abusive manner, lack of privacy, the presence of ambulance to take the patient to the hospital contrary to his/her will, treating the patient as a non-existing being, lack of access to private and personal possessions, and enforcement of the law and regulations.

A 53-year-old man said": one of the staff begins to inject medicine; it's like taking a dangerous criminal. Once they took my clothes and I was wearing a panty. I told the nurse to give me a piece of clothes, he said: "shut up mad man, I'll tie your hands and feet to bed with chains".

 

Discussion

The results of this study revealed that the stigmatization in psychiatric systems has adverse effects on patients. Sub-themes, such as "an egregious hospital", indicate that referral to psychiatric hospitals leads to be stigmatized by others because these hospitals connote bad reputation among the public. While people with physical illnesses, with the exception of leprosy and tuberculosis, are always being treated in public hospitals in their communities, patients with psychiatric disorders have been sent for centuries to "Asylums" usually located out of the community.

Although the intention behind sending people with psychiatric disorders to distant hospitals is just for help, it caused patients to be isolated and stigmatized. At the academic level, the distinction between these two health systems means the exodus of psychiatric disorders from the general medical context (23). For instance, in a study conducted by Müller et al. (2016), people's perceptions of psychiatric hospitals included locked doors, restrictive clothing, psychotropic drugs that are addictive, and invasive and non-effective treatment, while their positive effects are underestimated (24).

Sub-themes of "cold-hearted white collars" showed inhuman treatment of staff with clients. Health care providers, whether in the community or in the hospitals, have an opportunity to influence patients. As a result, obvious negative attitudes cause anxiety or discomfort while interacting with the patient and leading to ineffective counseling or lack of medical care.

In a study performed by Padgett et al. (2011), many patients reported that they had a deep sense of frustration because the health care providers did not listen to them and the feelings of being ignored led to a failure to comply with their everyday life (25). In addition, the patients were believed to be responsible for their unpleasant behaviors and blamed by the practitioners for not being able to overcome their illness (26). Social stigma and negative attitudes of the health care providers or inhuman experiences in the hospital can have lifelong consequences on individuals with psychiatric disorders (27). One of the important implications of mental health professionals’ stigmatization is that therapists are not able to provide effective treatment. Due to unusual manifestations of mental illnesses, the practitioners ignore clients and do not have emphatic and positive communication with these patients.

Moreover, they do not hope to treat the patients, which leads to failure and further avoidance (28). There is documentary evidence from many parts of the world that people with psychiatric disorders experience the most severe cases of human rights violations, including tied down to the bed, kept isolated in psychiatric hospitals, chained and imprisoned in small cells, and mistreatment (29). Nordt et al. (2006), in a telephone survey, showed that mental health professionals and the general public do not make a distinction in their attitudes toward clients with psychiatric disorders, and they describe them as dangerous and strange. Furthermore, mental health practitioners reported similar levels of social distance (unwillingness to communicate) with mentally ill patients (30).

Patients with psychiatric dysfunction feel that they are being treated and mocked with disrespect in mental health systems. In addition, their physical symptoms are often overlooked and they should be hospitalized longer than other patients. They are often deprived of basic health care in psychiatric institutions and are also subjected to torture or other cruelties, inhuman or degrading treatments. Moreover, in spite of the shortage of hospital beds and the need for many patients to be admitted, they are sometimes admitted with violation of their rights. In addition, they are often overlooked regarding their satisfaction with the treatment process and services provided at these centers (31).

During the hospitalization period, the autonomy and freedom of patients to have free relationships or appointments (due to inappropriate restrictions) are ignored in many hospitals. Furthermore, physical, sexual, and psychological abuses are among the everyday experiences of many patients with psychiatric disorders (32).

The shocking statistics of sexual assault on female patients in psychiatric hospitals in the United States have challenged American medical ethics and the health system. According to the Victoria Council for Psychiatric Disorders, nearly half of the women in the US psychiatric hospitals experienced rape. A total of 67% of women had sexual abuse and 85% of them expressed dissatisfaction with being hospitalized in such unsafe places. According to the reports, strangers can easily enter the women's room, while the nurses do not pay attention to it at all (33). Many patients with psychiatric disorders are assumed to be unable to decide for themselves; therefore, they are admitted to psychiatric hospitals against their will, where they are terribly being treated (33).

In the United Arab Emirates, Eapen and Ghubash (2004) selected the factors that influenced parents to help overcome mental and psychological problems through interviews. Initially, the parents acknowledged reluctantly that one of their family members suffered from a psychiatric disorder. In total, 38 % of the participants under study revealed that they were not seeking help from mental health professionals even if it seemed that their children had mental and psychological disorders. A key factor preventing the parents from seeking help is stigmatization which is associated with the use of mental health services (34). A study conducted in the United States on health care systems showed that mentally ill patients were less likely to receive medical services as well as wider range of insurance benefits than those with physical illness (35).

 

Implications for Practice

This study dealt with the issues of stigmatization experienced by patients who admitted to psychiatric hospitals only once. In addition, it was revealed that psychiatric hospitals are undesirable places with repressive and regressive environment worldwide. Since the lay people call all patients who admitted to psychiatric hospitals as ''insane'', there is a fear of referral to mental health centers. That is the reason why many patients are not willing to stay in psychiatric hospitals at all. Furthermore, the mistreatment of hospital staffs was also found in all studies in a variety of ways, which also reflected the health care provider negative attitudes to these patients. This is may be due to the fact that the staffs always meet the patients when they are suffering from the peak symptoms of their illness that require hospitalization. Accordingly, they find that a psychiatric patient is always in the same state. Therefore, mental health centers must be located within public hospitals and health care providers should also understand how to deal with mental illness stigma and help mentally ill people cope with stigmatization. As a result, support, acceptance, and assurance should be the main focus of all caring activities.

It is hoped that the findings of this study pave the ways for destigmatization of patients in psychiatric hospitals using training sessions for the staff. There are also policies at the ministry level, such as the closure of old psychiatric institutions, and placement of psychiatric departments in public hospitals in order to stop stigmatization. In nursing education at the undergraduate and postgraduate level, a part of nursing courses can be devoted to psychiatric disorders. Moreover, students' familiarity with psychiatric disorders and destigmatization methods can be taught in the course of psychiatric ward rotations.

 

Acknowledgments

This study was extracted from a PhD dissertation approved and funded by the Research Deputy of Mashhad University of Medical Sciences, Mashhad, Iran (code: 921487). The authors would like to thank all psychiatric centers’ staff and psychiatric patients in Mashhad for their kind cooperation in this study.

 

Conflict of Interest

The authors declare no conflicts of interest regarding the publication of this article.

References

1. World Health Organization. Mental disorders affect one in four people. World Health Report. 2001. Available from: http://www.who.int/whr/2001/media_centre/ press_release/en/.

2.Stout PA, Villegas J, Jennings NA. Images of mental illness in the media: identifying gaps in the research. Schizophrenia Bulletin. 2004;30(3):543-61.

3.Arboleda-Flórez J, Sartorius N, editors. Understanding the stigma of mental illness: theory and interventions. John Wiley & Sons. 2008 Sep 15;226.

4.Lyons C, Hopley P, Horrocks J. A decade of stigma and discrimination in mental health: plus ça change, plus c'est la même chose (the more things change, the more they stay the same). J Psychiatr Ment Health Nurs. 2009 Aug;16(6):501-7.

5.Flanagan EH, Miller R, Davidson L. “Unfortunately, we treat the chart:” Sources of stigma in mental health settings. Psychiatr Q. 2009 Mar;80 (1):55-64.

6.Nordet C, Rössler W, Lauber C. Attitudes of mental health professionals toward people with schizophrenia and major depression. Schizophr bull. 2006;32 (4):709-14.

7.Al-Adawi S, Dorvlo AS, Al-Ismaily SS, Al-Ghafry DA, Al-Noobi BZ, Al-Salmi A, et al. Perception of and attitude towards mental illness in Oman. Int J Soc Psychiatry. 2002 Dec;48(4):305-17.

8.Sartorius N, Iatrogenic stigma of mental illness Begins with behaviour and attitudes of medical professionals,especially psychiatrists. BMJ. 2002;324:1471–2

9.Corrigan P, Markowitz F, Watson A. Structural levels of mental illness stigma and discrimination. Schizophr Bull. 2004; 30 (3):481-49.

10.Hinshaw SP. The stigmatization of mental illness in children and parents: Developmental issues, family concerns, and research needs. J Child Psychol Psychiatry. 2005 JUL; 46 (7): 714–34.

11.Wisdom JP, Clarke GN, Green CA. What teens need: barriers to seeking care for depression. Adm Policy Ment Health. 2006;33 (2): 133–145.

12.Heydari A, Meshkin yazd A, Sodmand P. Stigma in Health Systems: A Review Article. Journal of Ilam University of Medical Sciences. 2015; 23 (4): 217-228.

13.Padgett DK, Stanhope V, Henwood BF, Stefanic A. Substance use outcomes among homeless clients with serious mental illness: comparing housing first with treatment first programs. Community Ment Health J. 2011 Apr;47(2):227-32.

14.Solomon P, Alexander L, Uhl S. The relationship of case managers expressed emotion to clients outcomes. Soc Psychiatry Psychiatr Epidemiol. 2010 Feb;45(2):165-74.

15.Craig S, Allison L. Stigma and mental illness: Investigating Attitudes of Mental Health and Non-Mental-Health Professionals and Trainees. Journal of Humanistic Counseling, Education, and Development, 49, 189-202.

16.Karshaki H, MeshkinYazd A, Soudmand P. Validation of the mental illness stigma scale, Ibn Sina Hospital, Mashhad. Journal of Mazandaran University of Medical Sciences 24(113):72-79 ·

17.Haberfellner EM, Grausgruber A, Grausgruber-Berner R, Ortmair M , Schony W. Deinstitutionalization of long-stay psychiatric patients in upper austria-living situation, social and clinical characteristics more than one year after discharge.Psychiatr Prax2004;31(4):192–7.

18.Crisp A H. The stigmatization of sufferers with mental disorder. Br J Gen Pract. 1999 Jan; 49(438): 3–4.

19.Corrigan PW, Markowitz FE, Watson AC. Structural levels of mental illness stigma and discrimination. Schizophr Bull. 2004; 30(3):481-91.

20.Orme D. M. A Qualitative Examination of Mothers' Resolution or Non-Resolution of Their Children's' Disability of Down Syndrome or Autism Using a Cognitive Intervention. The Qualitative Report, 2005; 10(3), 561-592.

21.Dowling, M. From Husserl to Van Manen: A review of different phenomenological approaches.Int J Nurs Stud,2007; 44(1) 131-42. .

22.Diekelmann NL. Behavioral pedagogy: A Heideggerian hermeneutical analysis of the lived experiences of students and teachers in baccalaureate nursing education. J Nurs Educ. 1993 Jun; 32(6):245-50.

23.Arboleda-Flórez J, Sartorius N, editors. Understanding the stigma of mental illness: theory and interventions. John Wiley & Sons; 2008 Apr. Avalable from: https://www.wiley.com/en-ad/Understanding+the+Stigma+of+Mental+Illness%3A+Theory+and+Interventions-p-9780470723289

24.Möller-Leimkuhler AM, Moller HJ, Maier W, Gaebel W, Falkai P. Erratum to:EPA guidance on improving the image of psychiatry. Eur Arch Psychiatry Clin Neurosci. 2016 Mar;266 (4):383.

25.Padgett DK, Stanhope V, Henwood BF,Stefanic A. Substance use outcomes among homeless clients with serious mental illness: comparing housing first with treatment first programs. Community Ment Health J. 2011 Apr;47(2):227-32.

26.Solomon P,Alexander L, Uhl S. The relationship of case managers expressed emotion to clients outcomes. Social Psychiatry and Psychiatric Epidemiology .2010;45(2):165-74.

27.Alvidrez J, Snowden LR, Kaiser DM. The experience of stigma among Black mental health consumers. J Health Care Poor Underserved. 2008 Aug;19 (3):874-93.

28. Ahmedani BK. Mental health stigma: society, individuals, and the profession. J Soc Work Values Ethics. 2011;8(2):4-1.

29. Corrigan P, Rao D, Tsang H W. Challenging the Stigma of Mental Illness. 1nd ed.Uk (chichester): John Wiley & Sons Ltd; 2011

30.Nordt C, Rössler W, Lauber C. Attitudes of mental health professionals toward people with schizophrenia and major depression. Schizophr bull. 2006;32 (4):709-14.

31.Abbasi M, Rashidian A, Arab M, Amini H, Hoseini M. Medical Staff and Hospitalized Patients' Attitude in Selected Psychiatric Hospitals in Tehran about Adaptation of Patients Rights Charter of Patients with Mental Disorder. Iran J Psychiatry Behav Sci. 2010 Nov;16(3):172-80.

32.Arboledaflorez J, Stuart H. From sin to science: fighting the stigmatization of mental illness. Can J Psychiatr. 2012;57(8):457–63.

33.Heydari A, MeshkinYazd A, Sodmand P. Stigma in Health Systems: A Review Article.sjimu 2015;23(4):217-28.

34.Sewilam AM, Watson AM, Kassem AM, Clifton S, McDonald MC, Lipski R,et al. Suggested avenues to reduce the stigma of mental illness in the Middle East. Int J Soc Psychiatry. 2015; 61 (2): 111–120.

35.Nojomi M, Malakouti S.K, Ghanean H, Joghataei M.T, Jacobson L. Mental illness stigma in city of Tehran. Razi Journal of Medical Sciences. 2011; 17 (78 – 79) :45-52.