اثربخشی آموزش روانی در کاهش برامدگی‌ درونی در بیماران مبتلا به اختلال دوقطبی

Abstract This research was conducted as an experiment–control experimental study which aimed to determine the effectiveness of a psychoeducation program prepared to reduce internalized stigmatization. The study included 47 patients (24 experimental, 23 control) who had been diagnosed with bipolar disorder. At the end of the psychoeducation program, a significant decrease was observed in the total ISSMI mean scores, as well as in the ISSMI subscale mean scores for subscales such as alienation, approval of stereotypes, perceived discrimination and social withdrawal (p < 0.05). The results demonstrated that a psychoeducation program designed for internalized stigmatization may have positive effects on the internalized stigmatization levels of patients with bipolar disorder. Individuals with marked mental disorder usually display their difference from the rest of the society through words and gestures; and this difference causes discrimination in society towards these individuals. In every epoch of history, other people have failed to make sense of these individuals' words, thoughts and gestures, and therefore considered them to be dangerous and harmful for their environment (Bahar, 2007). It is observed that once individuals are referred to a psychiatrist and are diagnosed with a mental disorder, they feel stigmatized although they are not exposed to explicit discrimination. These patients experience embarrassment, a sense of insufficiency, an increase in negative automatic thoughts, withdrawal from social relationships, and a decrease in their self-esteem (Taşkın, 2007a). It has been reported that a negative outcome depends on the internalization of stigmatic beliefs and the meaning that patients attach to their illness. While some patients believe that they no longer have the ability to achieve valued social roles, others disagree, remain hopeful and engage in active coping. The post-diagnostic identity of patients with mental illness has two dimensions; one of them is the amount of identification with a community of people with severe mental illness, and the other is the amount of stigma that is internalized in the self narrative. Patients with high identification but low internalized stigma are assumed to be socially active and to not experience diminished self-esteem (Staring, Van de Gaag, Van den Berge, Duivenvoorden, & Mulder, 2009). Internalized stigmatization is a condition experienced extensively by one in three people with severe mental illness. Internalized stigmatization or self-stigmatization refers to a process in which the individual with a mental illness adopts and internalizes the stigmatizing opinions of the society, such as dangerousness and insufficiency; and it includes low self-esteem and poor social relationships (Werner, Aviv, & Barak, 2007). The objective behaviors of stigmatization are discrimination and exclusion. With stigmatization it is emphasized that individuals or groups who are stigmatized are different from us, and due to this difference, a lot of negative features are attributed to these people. Perceived stigmatization is the feeling of stigmatization and social exclusion which emerges as a result of individuals' diagnosis of mental illness and is independent from objective experiences such as stigmatizing and excluding. As a result of internalized stigmatization, the sick person begins to think that it is the society that stigmatizes and excludes him/her. This in turn causes the patient to experience a feeling of stigmatization. The individual begins to make some negative judgments about his/her own condition without any concrete evidence, and thinks that the society devalues him/her and stigmatizes and excludes him/her because of his/her illness. The behavior of others is perceived as discrimination and exclusion, either when intended or unintended. Nevertheless, the main determinant of the feeling of stigmatization is one's internalized tendency of stigmatization (Taşkın, 2007b). Bipolar disorder is known and stigmatized by society relatively less than other disorders, yet patients report experiencing an intense feeling of stigmatization (Aydemir, 2004). It has been reported given in the literature that bipolar patients present lower rates of autonomy and fewer interpersonal relationships than individuals without bipolar disorder, and such difficulties may lead to embarrassment and discrimination among bipolar patients which in turn contributes to high levels of perceived stigma. Stigma-related impairment in functioning could result from the avoidant coping strategies such as withdrawal and behavioral avoidance that bipolar disorder patients may use as a strategy to avoid people from outside their family. Bipolar patients with concerns about stigmatization may adapt their social behavior to avoid exposure to rejection or discrimination (Cerit et al., 2012 and Vazquez et al., 2011). Developing awareness is the essential focus of a successful psychoeducation program for this illness and reducing stigmatization. Many patients have negative myths in their minds about this illness. This causes them to experience additional difficulties in coping with their diagnosis and complying with the treatment (Colom & Vieta, 2004). Internalized stigmatization may decrease once individuals acquire research-based information on how to resist this feeling. Educating individuals with internalized stigmatization on mental illnesses has been shown to help them cope with negative beliefs (Watson & Corrigan, 2010). Psychoeducational interventions generally emphasize the presentation of factual information about mental illness and treatment in order to address misperceptions, and these interventions generally provide optimistic messages about the treatability of mental health problems. For individuals already in treatment, stigma-focused psychoeducation can decrease perceived stigmatization (Alvidrez, Snowden, Rao, & Boccelari, 2009). According to the results of a systematic literature review of the psychotherapeutic and psychosocial approaches to bipolar disorder (Cakır & Özerdem, 2010), psychoeducation, family -focused therapies and CBT have benefits in terms of the prevention of manic or depressive episodes, medication compliance, the number and duration of hospitalizations and the time to recurrence. Eker and Harkın (2012) used psychoeducation for 6 weeks, 2 hours/week to evaluate the adherence to treatment in bipolar disorder patients, and they found that adherence in the intervention group increased significantly. Several studies discuss reducing internalized stigmatization in patients with mental illness. Macinnes and Lewis (2008) used a structured program using cognitive therapy with psychoeducational input of 6 sessions with schizophrenia patients and found a significant reduction in stigma. Alvidrez et al. (2009) used psychoeducation for 3 months (plus or minus 14 days) and determined that stigma reduced. Yanos, Roe, and Lysaker (2011) used a combination of psychoeducation (3 weeks), cognitive restructuring (8 weeks) and narrative enhancement (8 weeks) with mental illness patients and reported that internalized stigma reduced. Parikh et al. (2012) used cognitive behavioral therapy and psychoeducation (20 sessions of CBT, 6 sessions of psychoeducation) and found that psychoeducation showed greater clinical benefit compared to cognitive behavioral therapy. The aim of this study was to determine the effectiveness of a psychoeducation program designed to reduce internalized stigmatization in patients diagnosed with bipolar disorder.

Results When the sociodemographic characteristics of the patients were analyzed, 83.0% of patients were female, 53.2% were married, 40.4% had completed elementary school, 63.8% were living in cities, 80.9% were unemployed, 48.9% of them had a family member with bipolar disorder, 72.3% of them had been hospitalized for bipolar disorder, 89.4% of patients used medications regularly, 93.6% of patients had regular follow up visits, and 95.7% of patients didn’t use alcohol. The mean scores of the BDFQ subscales and ISSMI subscales of all patients before intervention are shown in Table 1. Table 1. ISSMI and BDFQ Mean Scores of Patients Before Psychoeducation (N = 47). ISSMI Subscales Mean SD Alienation 13.72 4.06 Approval of stereotypes 14.80 3.40 Perceived discrimination 11.76 3.45 Social withdrawal 14.25 3.90 Resistance against stigmatization 11.53 2.78 Total ISSMI 43.02 12.55 BDFQ subscales Emotional functioning 7.68 1.47 Mental functioning 8.80 2.04 Sexual functioning 8.26 2.58 Feeling of stigmatization 8.29 2.69 Introversion 6.63 1.69 Domestic relationships 14.02 3.15 Relationships with friends 9.65 3.24 Participation in social activities 10.87 3.37 Participation in daily activities and hobbies 13.76 3.52 Taking initiative and using one's potential 5.61 1.70 Work 9.47 1.97 Table options The correlations of all participants' levels of internalized stigmatization and types of functionality before intervention (N = 47) are shown in Table 2. Significant correlations were found between the internalized stigmatization score and the functionality subscales scores for emotional functioning, mental functioning, feeling of stigmatization, relationship with friends, participation in social activities and taking initiative and using one's potential. Table 2. Relationship Between Patients' Mean Scores Obtained From BDFQ Subscales and the ISSMI scale Before Psychoeducation (N = 47). BDFQ subscales ISSMI Spearman rank correlation analysis R p Emotional functioning − .461 0.001 Mental functioning − .472 0.001 Sexual functioning − .238 0.175 Feeling of stigmatization .422 0.003 Introversion − .186 0.211 Domestic relationships − .102 0.494 Relationships with friends − .403 0.005 Participation in social activities − .435 0.002 Participation in daily activities and hobbies − .222 0.134 Taking initiative and using one's potential − .330 0.024 Work − .003 0.987 Table options A comparison of the changes in BDFQ subscales pre- and post-test scores between the intervention and control groups is shown in Table 3. Only the mean score of the domestic relationship subscales of the BDFQ was significantly increased at the < .05 level in the intervention group. BDFQ subscales mean scores didn’t change as significantly in the control group. Table 3. Comparison of BDFQ Subscales Scores Obtained by Intervention and Control Patients Before and After Pyschoeducation (N = 47). BDFQ subscales 1st Week 7th Week Analysis result Emotional functioning Intervention 7.25 ± 1.42 7.37 ± 1.37 Z = − .213, p = 0.831 Control 8.13 ± 1.42 8.43 ± 1.12 Z = − 1. 029, p = 0.304 Mental functioning Intervention 8.33 ± 2.35 9.45 ± 2.28 Z = − 1.930, p = 0.054 Control 9.30 ± 1.57 9.60 ± 2.06 Z = − .785, p = 0.432 Sexual functioning Intervention 7.73 ± 2.40 7.78 ± 2.50 Z = − .343, p = 0.732 Control 8.93 ± 2.73 9.0 ± 3.13 Z = − .052 p = 0.959 Feeling of stigmatization Intervention 7.66 ± 2.56 8.25 ± 2.59 Z = − .949, p = 0.343 Control 8.95 ± 2.72 9.08 ± 2.46 Z = − .119, p = 0.905 Introversion Intervention 6.20 ± 1.35 6.66 ± 1.34 Z = − 1.500, p = 0.134 Control 7.08 ± 1.92 6.65 ± 1.50 Z = − .934, p = 0.350 Domestic relationships Intervention 13.04 ± 3.29 14.30 ± 2.77 Z = − 2.176, p = 0.030 Control 15.04 ± 2.72 14.13 ± 3.79 Z = − .987, p = 0.324 Relationships with friends Intervention 9.41 ± 3.43 10.62 ± 2.37 Z = − 1. 593, p = 0.111 Control 9.91 ± 3.08 9.82 ± 3.51 Z = − .029, p = 0.977 Participation in social activities Intervention 10.37 ± 2.85 11.41 ± 2.79 Z = − 1.804, p = 0.071 Control 11.39 ± 3.84 10.34 ± 2.93 Z = − 1.042, p = 0.297 Participation in daily activities and hobbies Intervention 13.41 ± 3.41 13.33 ± 2.98 Z = − .151, p = 0.880 Control 14.13 ± 3.67 13.91 ± 2.90 Z = − 366, p = 0.715 Taking initiative and using one's potential Intervention 5.58 ± 1.55 5.58 ± 1.55 Z = − .000, p = 1.00 Control 5.65 ± 1.87 5.65 ± 1.87 Z = − .000, p = 1.00 Work Intervention 9.73 ± 2.34 10.11 ± 2.05 Z = − .536, p = 0.592 Control 9.26 ± 1.66 9.21 ± 2.04 Z = − .032, p = 975 Table options In Table 4, a comparison of the changes in internalized stigmatization pre- and post-test scores between the intervention and control groups (N = 47) is shown. Internalized stigmatization subscales scores of alienation, approval of stereotypes, social withdrawal and total internalized stigmatization were significantly reduced at the < .001 level for the intervention group. Perceived discrimination was significantly reduced at the < .05 level for the control group and < .001 for the intervention group. Table 4. Comparison of Total ISSMI Scores and Mean Subscale Scores Obtained by Intervention and Control Patients Before and After Pyschoeducation (N = 47). Scale 1st Week 7th Week Analysis result Alienation intervention 14.75 ± 4.17 11.95 ± 3.31 T = 3.644, p = 0.001 Control 12.65 ± 3.74 11.95 ± 2.99 T = 1.400, p = 0.175 Approval of stereotypes Intervention 15.95 ± 3.48 12.33 ± 3.05 T = 4.479, p = 0.000 Control 13.60 ± 2.93 13.21 ± 3.94 T = 0.536, p = 0.597 Perceived discrimination Intervention 12.08 ± 3.33 9.79 ± 2.90 T = 3.743, p = 0.001 Control 11.43 ± 3.62 10.13 ± 3.29 T = 2.328, p = 0.030 Social withdrawal Intervention 15.00 ± 3.63 11.83 ± 3.86 T = 4.190, p = 0.000 Control 13.47 ± 4.09 12.86 ± 4.35 T = 1.203, p = 0.242 Resistance against stigmatization Intervention 12.08 ± 2.63 10.62 ± 2.77 T = 1.886, p = 0.072 Control 10.95 ± 2.88 10.26 ± 2.68 T = 1.590, p = 0.126 Total ISSMI Intervention 45.70 ± 12.24 35.29 ± 10.57 T = 5.821,p = 0.000 Control 40.21 ± 12.52 37.91 ± 13.10 T = 1.332, p = 0.197