The Effect of Psycho-education Program on the Aliate Stigma in the Caregivers of Clients with Bipolar Disorder

Background Mental health experts believe that stigma is the most challenging issue for caregivers of clients with psychiatric disorders. Therefore, monitoring and assessing the aliate stigma in the caregivers is necessary. This study is aimed to investigate the effect of psycho-education program on the aliate stigma in the caregivers of clients with bipolar disorder. This quasi-experimental study with both intervention and control groups was conducted Ghods Hospital in Sanandaj (n = 64). Psycho-education program was performed for the intervention group for 4 weeks (one session per week for 60 to 90 minutes). Data was collected using the Aliate Stigma Scale before and after intervention (with 4 weeks gap). The results of study showed that there was no difference between intervention and control groups in terms of the distribution of contextual variables. The mean and the standard deviation of the aliate stigma before the conducting the psycho-education program in the control group was (73 ± 14.72), and in the intervention group was (69.63 ± 14.66). After the intervention and administrating the post-test, the results in the control group was (74 ± 14.21) and in the intervention group was (35.06 ± 8.31) which showed a statistically signicant difference (P < 0.001).


Introduction
Bipolar disorder is one of the most common psychiatric disorders (1,2) with a prevalence of about 3% in the general population. It is also the sixth leading cause of disability worldwide (2). This disease has a signi cant impact on the quality of life and various aspects of social and individual functioning (1 and 3), and is considered as an important health problem (4).
Mental disorder is a stressful issue for the patient and the family, because the disease does not only make the patient anxious, but also causes severe distress for the family (5,6). According to the studies, stigma is one of the most common and challenging psychological pressures and the care burden that the caregivers of clients with mental/psychiatric disorders face (5,7). The stigma can be internalized in the labeled person by the society through a process known as the a liate stigma (8). A liate stigma occurs when a person cognitively and emotionally accepts the common negative assumptions and stereotypes in the society, believes in them, and applies them to him/her (9). Mental health experts believe that the most important barrier for treating clients with psychiatric disorders is mental stigma, which also affects health care providers, clients, and caregivers (10). Moreover, the family members of these patients, who play a key role in caregiving of them, limit their social relationships and become isolated due to concerns about this a liate stigma (11).
Studies show that there is a direct relationship between the a liate stigma and the increase of care burden in caregivers of clients with psychiatric disorders (12,13). In addition, the psychological burden imposed by stigma reduces the quality of care provided by the caregivers, and endangers the physical and mental health of the caregivers (10). Studies show that there is a direct relationship between the a liate stigma and the signs and symptoms of depression and suicidal ideation in the caregivers (12,14).
According to the World Health Organization, there are at least 450 million people with mental disorders, and it is estimated that 30% of these patients can be appropriately treated with the effective interventions, including destigmatization of their caregivers and return to the society (15). Therefore, based on what the health experts suggest, one of the ways to treat the clients with bipolar disorder is to increase the awareness and knowledge of their caregivers (16). In addition, since family-centered care is one of the main concepts of nursing, and nurses are in close interaction with the families of clients, thus, they will be able to assess the level of knowledge and awareness of the caregivers, and provide them with the necessary educational tools (17). Studies show that in addition to drug therapy, appropriate interventions for caregivers of clients with psychiatric disorders such as destigmatization training programs will play an effective role for the clients (11). In this regard, psycho-education can be helpful to increase knowledge and destigmatization in the family environment (10).
Psycho-education refers to a set of complementary therapies that are used with a systematic and structured approach in order to raise awareness and change the attitude of families about the nature of the disease, nd a way to treat it, and increase communication skills and problem solving skills (10). Psycho-education is an effective way to help the families of clients to manages the problems caused by family disturbance, and to develop the necessary skills to support the rehabilitation of the patient (18). Therefore, the aim of this study is to investigate the effect of psycho-education on the a liate stigma in the caregivers of clients with bipolar disorder.

Materials And Methods
The present study is a quasi-experimental study with control and intervention groups. The population consisted of all family caregivers of clients with bipolar disorder who referred to Ghods Psychiatric Hospital in Sanandaj in 2019-2020. The inclusion criteria for the caregivers included 18 to 65 years old, spending the most caring time for the client, lack of mental retardation, lack of drug and alcohol consumption, lack of vision and hearing impairment. The exclusion criteria were withdrawal from further research and non-participation in at least two sessions of the training program.
The sample size was measured according to the study of Shamsaei et al. (19), with the reliability level of 95% and statistical power of 80% using the following equation, and taking into account the 10% drop-out in the samples size, 32 people was considered in each group (total sample size was 64).
After receiving the code of ethics (IR.MUK.REC 1398.151), obtaining the executive license and coordination with the o cials of Ghods Psychiatric Hospital, the sampling procedure was performed on all wards of the hospital and the outpatient clinic based on inclusion criteria. In order to prevent any major intervening variable, the sampling was performed rst for the control group and then for the intervention group. After recruitment of subjects of the control group as well as the intervention group, psycho-education presented to the intervention group.
Because the selection of the control and intervention groups was done simultaneously from one medical center, rst the control group and then the intervention group were examined, so that the data collection would not be biased. Both groups completed the demographic questionnaires and the A liate Stigma Scale in two intervals. The pre-test was administered at the beginning of the study and the post-test was administered four weeks after the pre-test.

Intervention
The psycho-education program for the intervention group was performed for 4 weeks, one session per week for 60 to 90 minutes. The training sessions were held in groups of 4 to 5 participants, several times a week, according to the request and conditions of the caregiver through group discussion. At the end of the psycho-education program, the post-test was administered for the intervention group.
The implementation of the psycho-education program, the number of sessions, and the general framework of the educational content were as follows: The rst session started with the introduction of the individuals and the researcher stated the purpose of the study. Then the researcher discussed about the disease and its treatments, and the way of caring the ill member.
The second session started by reviewing the previous session. Then, continuing by the explaining of the concept of stigma and the strategies to cope with it for the caregivers. Also the participants shared their experiences of being labeled by those around them because of their client's disorder and mentioned how they coped with the situation.
At the beginning of the third session the concept of stigma and its coping strategies reviewed. Then, the session continued with a discussion of life skills and how they can use that skills in their life in order to live better.
The fourth session was a continuation of practice on life skills. Then the educational content of previous session reviewed. At the end, the whole necessary educational content was presented to the participants as booklet and pamphlet. Table 1 shows the headings of the educational content for each session.

Instruments
The demographic questionnaire: This questionnaire consist of information about the caregivers, including age, gender, marital status, education, job, economic status, the number of family members, caregiver-client relationship, the history of patient's disease, the family history of the disease and the number of times of the previous hospitalization. Cronbach's alpha coe cient at 0.94 (19).
To ensure the reliability of the questionnaire, it was administered to fteen caregivers of clients who were not part of the research community. They had similar characteristics to this population. Employing the internal consistency method, the calculated Cronbach's alpha coe cient for this questionnaire was 0.85, which indicates the optimal reliability for this tool. The data were analyzed through SPSS-22 using descriptive statistics and inferential statistics.

Results
Demographic characteristics: The total sample included 64 caregivers of clients with bipolar disorder; most of them were women (54.7%), and married (73.4%). The mean age of the caregivers was 41.48 ± 10.16 years, the most of them were spouses of the clients (29.7%), and were self-employed (28.1%), and had moderate economic status (64.1%). In terms of education the most of caregivers had diploma degree (31.3%). The majority of the participants did not have a family history of the disease (62.5%). Mean duration of the disease was 4.61 ± 2.97 years with the mean of 4.67 ± 3.23 times of previous hospitalizations ( Table 2).
A liate stigma: According to Table 3, the mean scores of a liate stigma was 73 ± 14.72 in control group and was 69.63 ± 14.66 in intervention group, respectively. No signi cant difference was found between the two groups at baseline (P = 0.36), and all of them had moderate level of a liate stigma. After 4 weeks, the score of the post-test of a liate stigma in the control group was 74 ± 14.21, and in the intervention group was 35.06 ± 8.31, which showed a statistically signi cant difference (P< 0.001).
The comparison of the a liate stigma scores in the pre-test and post-test stages, in each group separately, shows that the a liate stigma scores in the pre-test and post-test stages in the control group were not statistically signi cant (P = 0.17), while, there was a statistically signi cant difference in the post-test stage compared to the pre-test in the intervention group (P <0.001) and the level of a liate stigma was decreased (Table 4).

Discussion
The literature indicates that one of the problems and challenges of the caregivers in life with a psychiatrically disordered patient is stigma (23 − 20), and a liate stigma can lead to destructive effects on caregivers, and the consequences of it intensify when the caregivers endorse or accept the negative attitude they perceive (shi 2018). The results of this study in the pre-test stage in both control and interventionj groups that showed a moderate a liate stigma in the caregivers, con rms this point. the society on caregivers leads to a negative attitude towards mental illness, feeling ashamed of having such a patient in the family, trying to hide and eventually ignoring the ill member (21, 24, 25 and 26).
Considering that the stigma related to mental illness is a global health problem (27), and destigmatization in psychiatric disorders is one of the main goals of WHO programs (28), therefore this study was conducted to investigate the effect of psycho-education program on the a liate stigma of the caregivers of clients with bipolar disorder. For this purpose, the educational session were arranged to conduct a psycho-education program to the caregivers and the results showed the effectiveness of that, after the psycho-education program, the parents of the clients did not blame themselves for their child's mental illness (19). Bernhard et al. (2006) and Young et al. (2014) also noted that the psychoeducation programs, which improved the level of knowledge and attitudes of caregivers about mental illness led to a positive attitude in caregivers towards the clients and their illness and has a signi cant impact on the recovery of clients with psychiatric disorders (33, 34).

Conclusion
The present study showed that stigma is one of the problems of caregivers of clients with bipolar disorder. Due to the key role of the caregivers in the caring process, the follow-up investigation, and the constant treatment of clients, it should be noted that the lack of su cient knowledge and awareness about the concept of stigma may reduce the quality of care provided by the caregivers and endanger their physical and mental health. Therefore, monitoring and examining the perceived stigma in caregivers seems to be vital and necessary.
Based on the ndings of the present study, it can be said that one of the destigmatization strategies in the caregivers of clients with bipolar disorder is conducting the psycho-education program in parallel with the others therapies; therefore, it is suggested that more attention should be paid to this educational intervention.
One of the limitations of the present study is the short duration of the psycho-education program, because it seems that the long-term training is more effective in improving the quality of the intervention. Another limitation was the lack of follow-up investigation about the effectiveness of psycho-education in the periods of 1, 3, 6, and 12 months after performing the psycho-education program. Despite the above limitations, the ndings of the present study provided signi cant empirical evidence on the effectiveness of psycho-education program on the a liate stigma of the caregivers of clients with bipolar disorder.