The stigma associated with mental illness, especially psychosis, has been around for a long time. In the past, psychiatrists were called alienists, most of them working in asylums for the insane (or “others”) in isolated rural locations. Even the contemporary term psychiatry is mysterious enough, translating to “medical treatment of the soul” (Lieberman and Ogas, 2015). What is a soul anyway? We fear what we don’t know. What do these terms and associated geographical and conceptual distances imply about the nature of mental illness and those who suffer from it?
Previously, Arguelles Bullon blogged about a qualitative study exploring the stigma associated with psychosis experienced by those with ethnic minority backgrounds in the United Kingdom (Arguelles Bullon 2022). Further, Steele has blogged about the impact of stigma on those at risk of psychosis (Steele 2021a) and the promising findings related to the efficacy of the Ending Self-Stigma intervention (Steele 2021b). Unsurprisingly, the findings from these studies suggest that stigma has negative impacts at multiple levels (individual, family, and community), and current service provision and interventions are probably not fully addressing the issue.
To date, there remains limited evidence concerning the experience of stigma in specific contexts and in relation to specific ethnic communities. With reference to the experience of psychosis among people from Middle Eastern ethnic backgrounds, Tabar et al. (2025) conducted a systematic review to answer the following three questions:
- What is the experience of people with psychosis and their families/carers of Middle Eastern ethnicity regarding the stigma of psychosis?
- What are the attitudes of psychosis in people with Middle Eastern ethnic backgrounds?
- What evaluations of anti-psychosis stigma interventions have been carried out with people of Middle Eastern ethnic backgrounds?
Until now, we’ve known little about stigma in Middle Eastern psychosis; this study starts to fill that gap.
Methods
The authors conducted the systematic review following the Preferred Standards for Systematic Reviews and Meta-Analysis (PRISMA) guidelines. Due to the diversity of the methodologies used in the studies, they utilised the mixed methods appraisal tool to assess the quality of the included studies. Similarly, the authors opted to conduct a narrative synthesis to answer each of the three questions above. These decisions allowed for a much broader exploration of the questions examined.
Of particular note, the authors reported their positionality in the method section. We have noticed that this practice is being used increasingly in academia. To align with the trend, we will also briefly describe our backgrounds. SS is of East Asian descent, was educated mainly in Aotearoa New Zealand, and has only ever worked in Australia. Currently, he works exclusively as a Psychiatrist for an Aboriginal Community Controlled Health Organisation. He does not identify with any particular ethnicity or culture. JPT is of Southeast Asian descent, received his training and education in the United Kingdom and Australia, and currently works as a Psychiatrist for a statewide Transcultural Mental Health Service.
Results
What is the experience of people with psychosis and their families/carers of Middle Eastern ethnicity regarding the stigma of psychosis?
The review found eight studies (participants ranging from 16 to 28) addressing this question.
The six key themes generated from the included studies were:
- rejection,
- oppression,
- isolation,
- lack of awareness,
- negative labels, and
- the burden of schizophrenia and its impact on functioning.
What are the attitudes of psychosis in people with Middle Eastern ethnic backgrounds?
The review found six studies (participants ranging from 104 to 718) that addressed this question.
The five key themes generated from the included studies were:
- closeness versus distance,
- employability/reluctance to work with someone with schizophrenia,
- rejection of close relationships,
- negative labels, and
- aetiology.
What evaluations of anti-psychosis stigma interventions have been carried out with people of Middle Eastern ethnic backgrounds?
The review found four studies (participants ranging from 60 to 278) that addressed this question. All the studies used different outcome measures, with two focused on the effect of anti-stigma interventions on people with schizophrenia, while the other two looked at the impact on medical students and general practitioners. All the included studies showed promising outcomes in terms of reducing the level of stigma associated with psychosis.
Overall, the results from this review suggest that:
- The stigma associated with psychosis is a prominent issue among people with psychosis and their families/carers of Middle Eastern ethnicity.
- The attitude toward psychosis in people with Middle Eastern ethnic backgrounds (including health professionals) was largely negative.
- A small body of evidence suggests that anti-psychosis stigma interventions may be effective in reducing stigma among people of Middle Eastern ethnic backgrounds.
Stigma deeply affects people with psychosis and their families in Middle Eastern countries.
Conclusions
The authors concluded:
it is understood that stigmatising beliefs, actions, and attitudes towards psychosis are prevalent in the Middle East, often displaying negative attitudes which can affect people with psychosis, family members, and caregivers.
They also added that the study findings:
can be used as a foundation to inform future practice by improving overall mental health literacy and addressing the negative associations to psychosis in a sensitive manner, while also improving the social integration of people with psychosis and increasing personal contact.
Cultural sensitivity and better mental health literacy are vital to reducing psychosis stigma.
Strengths and limitations
The authors should be congratulated for systematically combining the existing knowledge about this important yet under-researched area of psychosis. We also admire them for being open about potential personal biases through the positionality statement and reflections on positionality. It is humbling to acknowledge that nothing we do in research (or life, for that matter) is entirely objective. We all bring our own biases and prejudices to our work regardless of our creed or ethnicity, especially in a field as interesting as Psychiatry.
That said, there are some limitations. As the authors point out, the Middle East is not a homogenous culture. The review started by including 19 different countries in the inclusion criteria, only to obtain data from six countries (Iran, Turkey, Oman, Jordan, Saudi Arabia, and Afghanistan) with most (15 out of 18 included studies) of the included data coming from Turkey (7), Jordan (5), and Iran (3). For example, it would be difficult to argue that the findings of the current study are generalisable to other Middle Eastern countries like Iraq and the United Arab Emirates.
Further, the review did not include any study that explored the questions in the setting of the Western culture (e.g. people of Middle Eastern heritage in the United Kingdom). The experiences of those in their home countries would likely be vastly different from those who have moved to, or whose parents have moved to a new country. Given that migration may be a risk factor for psychosis (Selten et al, 2020), the study questions asked in this review in the setting of those with a Middle Eastern heritage living in Western Culture would have specific importance and implications.
The study findings mostly reflect experiences in Turkey, Jordan, and Iran; limiting their relevance to the wider, culturally diverse Middle East.
Implications for practice
We fear what we don’t know. Cultural factors and social context are critical in understanding the psyche. Is it surprising that psychosis remains stigmatised given how little we really know about the experience? We suspect similar investigations would reveal findings that are not much different in more Western cultures.
Psychosis, by definition, is the loss of contact with reality, be it in thoughts (i.e. delusion) or perception (i.e. hallucination). The experience does not have to be pathological – over 5% of people without mental illness have psychotic experiences at some point in their lives (McGrath et al, 2015). But how much do we know about the aetiologies of psychosis? Not much. We are not always good at differentiating psychotic experiences in the clinical context, let alone in the non-clinical or cultural context. When are psychotic experiences pathological, and when are they not?
Psychosis (and schizophrenia) is often thought of as a biological abnormality. Accordingly, we may have under-valued non-biological factors in this area. By doing so, we may be missing something. To quote from a recent editorial from Jarvis (2025):
[the] cultural shaping of psychosis depends on psychiatric contexts, as well as relational, social structural, traumatic, and spiritual frameworks. Culture and context create the language and concepts that determine which of the symptoms and behaviours associated with psychosis are considered salient, important, and worthy of clinical assessment and intervention.
It is also important to remind ourselves that there are always at least two cultures at play; that of the patient (which we almost always recognise, at least superficially), but also that of the “culture of psychiatry” (which we often miss); usually Western prototypes of psychic nosology (Jarvis 2025). Perhaps the very nature of subjectivity in understanding intra-psychic states, including psychosis, necessitates an approach informed by qualitative and phenomenological methods (including that of lived experience), which is key to broadening the evidence base of psychotherapeutic research (Levitt et al., 2024). Understanding may not be the same as cure, but it may point the way forward in such endeavours.
We have come a long way in psychiatry, but still have a long way to go. We do not hide people away in asylums anymore, and we actively promote mental health literacy. Knowledge is power because it casts a light in the darkness of uncertainties. We need to keep listening to progress towards a better future. Maybe one day, we will find out what a soul is.
Understanding psychosis requires both cultural humility and questioning psychiatric norms; we must keep listening.
Statement of interests
No conflicts of interest to declare.
Links
Primary paper
Tabar P, Lloyd-Evans B, Low J, et al. (2025) A Systematic Review and Narrative Synthesis of the Stigma of Psychosis in Middle Eastern Populations. Stigma and Health. Advance online publication.
Other references
Arguelles Bullon A. “I feel inferior and ashamed”: the stigma of psychosis in ethnic minority groups. The Mental Elf, 22 August 2022.
Jarvis GE. (2025) Cultural variations in psychosis: Recent research and clinical implications. Transcultural Psychiatry. 2025;0(0). doi:10.1177/13634615251324088
Levitt HM, Hamburger A, Hill CE, et al. (2024) Broadening the evidentiary basis for clinical practice guidelines: Recommendations from qualitative psychotherapy researchers. Am Psychol. 2025 Apr;80(3):389-410.
Lieberman J, Ogas O. (2015) Shrinks: The untold story of Psychiatry. Little, Brown and Company.
McGrath JJ, Saha S, Al-Hamzawi A, et al. (2015) Psychotic Experiences in the General Population: A Cross-National Analysis Based on 31,261 Respondents From 18 Countries. JAMA Psychiatry. 2015 Jul;72(7):697-705.
Selten JP, van der Ven E, Termorshuizen F. (2020) Migration and psychosis: a meta-analysis of incidence studies. Psychol Med. 2020 Jan;50(2):303-313.
Steele D. Stigma and discrimination in people at risk of psychosis. The Mental Elf, 21 January 2021.
Steele D. Ending self-stigma: not at all straightforward. The Mental Elf, 8 June 2021.