Clinical and demographic correlates of stigma in first-episode psychosis : The impact of duration of untreated psychosis

Journal article

Mueser, K. T., DeTore, N. R., Kredlow, M. A., Bourgeois, M. L., Penn, D. L. and Hintz, K.. (2020). Clinical and demographic correlates of stigma in first-episode psychosis : The impact of duration of untreated psychosis. Acta Psychiatrica Scandinavica. 141(2), pp. 157-166. https://doi.org/10.1111/acps.13102
AuthorsMueser, K. T., DeTore, N. R., Kredlow, M. A., Bourgeois, M. L., Penn, D. L. and Hintz, K.
Abstract

Objective
To evaluate the relationships between perceived stigma and duration of untreated psychosis (DUP), demographic characteristics, and clinical and psychosocial functioning in persons with a first episode of psychosis (FEP).

Method
A total of 399 participants with FEP presenting for treatment at 34 sites in 21 states throughout the United States were evaluated using standardized instruments to assess diagnosis, symptoms, psychosocial functioning, perceived stigma, wellbeing, and subjective recovery.

Results
Perceived stigma was correlated with a range of demographic and clinical variables, including DUP, symptoms, psychosocial functioning, and subjective experience. After controlling for symptom severity, perceived stigma was related to longer DUP, schizoaffective disorder diagnosis, more severe depression, and lower wellbeing and recovery. The associations between stigma and depression, wellbeing, and recovery were stronger in individuals with long than short DUP, suggesting the effects of stigma on psychological functioning may be cumulative over the period of untreated psychosis.

Conclusion
The findings suggest that independent of symptom severity, perceived stigma may contribute to delay in seeking treatment for FEP, and this delay may amplify the deleterious effects of stigma on psychological functioning. The results point to the importance of reducing DUP and validating interventions targeting the psychological effects of stigma in people with FEP.

Keywordsstigma; schizophrenia; first-episode psychosis; duration of untreated psychosis
Year2020
JournalActa Psychiatrica Scandinavica
Journal citation141 (2), pp. 157-166
PublisherJohn Wiley & Sons, Ltd
ISSN0001-690X
Digital Object Identifier (DOI)https://doi.org/10.1111/acps.13102
Scopus EID2-s2.0-85074050485
Research or scholarlyResearch
Page range157-166
Publisher's version
License
All rights reserved
File Access Level
Controlled
Output statusPublished
Publication dates
Online11 Oct 2019
Publication process dates
Accepted16 Sep 2019
Deposited29 Jul 2021
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Benjamin E Buck, Neil Hester, Amy E Pinkham, P D. Harvey, Lars F Jarskog and David Penn. (2018). The bias toward intentionality in schizophrenia: Automaticity, context, and relationships to symptoms and functioning. Journal of Abnormal Psychology. 127(5), pp. 503-512. https://doi.org/10.1037/abn0000360
Comparison of early intervention services vs treatment as usual for early-phase psychosis: A systematic review, meta-analysis, and meta-regression
Correll, Christoph U., Galling, Britta, Pawar, Aditya, Krivko, Anastasia, Bonetto, Chiara, Ruggeri, Mirella, Craig, Thomas J., Nordentoft, Merete, Srihari, Vinod H., Guloksuz, Sinan, Hui, Christy L. M., Chen, Eric Y. H., Valencia, Marcelo, Juarez, Francisco, Robinson, Delbert G., Schooler, Nina R., Brunette, Mary F., Mueser, Kim T., Rosenheck, Robert A., ... Kane, John Michael. (2018). Comparison of early intervention services vs treatment as usual for early-phase psychosis: A systematic review, meta-analysis, and meta-regression. JAMA Psychiatry. 75(6), pp. 555 - 565. https://doi.org/10.1001/jamapsychiatry.2018.0623
Which levels of cognitive impairments and negative symptoms are related to functional deficits in schizophrenia?
Strassnig, Martin T., Bowie, Carol, Pinkham, Amy E., Penn, David, Twamley, Elizabeth W., Patterson, Thomas L. and Harvey, P. D.. (2018). Which levels of cognitive impairments and negative symptoms are related to functional deficits in schizophrenia? Journal of Psychiatric Research. 104, pp. 124 - 129. https://doi.org/10.1016/j.jpsychires.2018.06.018
Social cognition psychometric evaluation (SCOPE) in people with early psychosis : A preliminary study
Ludwig, Kelsea A., Pinkham, Amy E., Harvey, Philip D., Kelsven, Skylar and Penn, David L.. (2017). Social cognition psychometric evaluation (SCOPE) in people with early psychosis : A preliminary study. Schizophrenia Research. 190, pp. 136-143. https://doi.org/10.1016/j.schres.2017.03.001
Distinct profiles of social skill in adults with autism spectrum disorder and schizophrenia
Morrison, Kerrianne E., Pinkham, Amy E., Penn, David L., Kelsven, Skylar, Ludwig, Kelsea and Sasson, Noah J.. (2017). Distinct profiles of social skill in adults with autism spectrum disorder and schizophrenia. Autism Research. 10(5), pp. 878-887. https://doi.org/10.1002/aur.1734
Psychological well-being and mental health recovery in the NIMH RAISE early treatment program
Browne, Julia, Penn, David L., Meyer-Kalos, Piper S., Mueser, Kim T., Estroff, Sue E., Brunette, Mary F., Correll, Christoph U., Robinson, James, Rosenheck, Robert A., Schooler, Nina, Robinson, Delbert G., Addington, Jean, Marcy, Patricia and Kane, John M.. (2017). Psychological well-being and mental health recovery in the NIMH RAISE early treatment program. Schizophrenia Research. 185, pp. 167-172. https://doi.org/10.1016/j.schres.2016.11.032
A 12-week randomized controlled trial of twice-daily intranasal oxytocin for social cognitive deficits in people with schizophrenia
Jarskog, L. Fredrik, Pedersen, Cort A., Johnson, Jacqueline L., Hamer, Robert M., Rau, Shane W., Elliott, Tonya and Penn, David L.. (2017). A 12-week randomized controlled trial of twice-daily intranasal oxytocin for social cognitive deficits in people with schizophrenia. Schizophrenia Research. 185, pp. 88-95. https://doi.org/10.1016/j.schres.2017.01.008
Comprehensive versus usual community care for first-episode psychosis : 2-Year outcomes from the NIMH RAISE early treatment program
Kane, John M., Robinson, Delbert G., Schooler, Nina R., Mueser, Kim T., Penn, David L., Rosenheck, Robert A., Addington, Jean, Brunette, Mary F., Correll, Christoph U., Estroff, Sue E., Marcy, Patricia, Robinson, James, Meyer-Kalos, Piper S., Gottlieb, Jennifer D., Glynn, Shirley M., Lynde, David W., Pipes, Ronny, Kurian, Benji T., Miller, Alexander L., ... Heinssen, Robert K.. (2016). Comprehensive versus usual community care for first-episode psychosis : 2-Year outcomes from the NIMH RAISE early treatment program. American Journal of Psychiatry. 173(4), pp. 362-372. https://doi.org/10.1176/appi.ajp.2015.15050632
Social cognition in schizophrenia : Factor structure of emotion processing and theory of mind
Browne, Julia, Penn, David L., Raykov, Tenko, Pinkham, Amy E., Kelsven, Skylar, Buck, Benjamin and Harvey, Philip D.. (2016). Social cognition in schizophrenia : Factor structure of emotion processing and theory of mind. Psychiatry Research. 242, pp. 150-156. https://doi.org/10.1016/j.psychres.2016.05.034
Revisiting the validity of measures of social cognitive bias in schizophrenia : Additional results from the Social Cognition Psychometric Evaluation (SCOPE) study
Buck, Benjamin E., Pinkham, Amy E., Harvey, Philip D. and Penn, David L.. (2016). Revisiting the validity of measures of social cognitive bias in schizophrenia : Additional results from the Social Cognition Psychometric Evaluation (SCOPE) study. British Journal of Clinical Psychology. 55(4), pp. 441-454. https://doi.org/10.1111/bjc.12113
Understanding Social Situations (USS): A proof-of-concept social-cognitive intervention targeting theory of mind and attributional bias in individuals with psychosis
Fiszdon, Joanna M., Roberts, D. L., Penn, David, Choi, Kee Hong, Tek, Cenk, Choi, Jimmy and Bell, Morris D.. (2016). Understanding Social Situations (USS): A proof-of-concept social-cognitive intervention targeting theory of mind and attributional bias in individuals with psychosis. Psychiatric Rehabilitation Journal. 40(1), pp. 12 - 20. https://doi.org/10.1037/prj0000190
Intact implicit processing of facial threat cues in schizophrenia
Shasteen, Jonathon R., Pinkham, Amy E., Kelsven, Skylar, Ludwig, Kelsey, Payne, B. Keith and Penn, David L.. (2016). Intact implicit processing of facial threat cues in schizophrenia. Schizophrenia Research. 170(1), pp. 150-155. https://doi.org/10.1016/j.schres.2015.11.029
Lexical characteristics of emotional narratives in schizophrenia : Relationships with symptoms, functioning, and social cognition
Buck, Benjamin and Penn, David L.. (2015). Lexical characteristics of emotional narratives in schizophrenia : Relationships with symptoms, functioning, and social cognition. The Journal of Nervous and Mental Disease. 203(9), pp. 702-708. https://doi.org/10.1097/NMD.0000000000000354
Self-reported comfort treating severe mental illnesses among pre-doctoral graduate students in clinical psychology
Buck, Benjamin, Harper Romeo, Katy, Olbert, C and Penn, David. (2014). Self-reported comfort treating severe mental illnesses among pre-doctoral graduate students in clinical psychology. Journal of Mental Health. 23(6), pp. 297 - 302. https://doi.org/10.3109/09638237.2014.924048
Metacognitive functioning in individuals at clinical high risk for psychosis
Barbato, M, Penn, David, Perkins, D, Woods, Scott, Liu, Li and Addington, Jean. (2014). Metacognitive functioning in individuals at clinical high risk for psychosis. Behavioural and Cognitive Psychotherapy. 42(5), pp. 526 - 534. https://doi.org/10.1017/S1352465813000167
An investigation of the relationship between therapist characteristics and alliance in group therapy for individuals with treatment-resistant auditory hallucinations
Harper Romeo, Katy, Meyer, P, Johnson, David and Penn, David. (2014). An investigation of the relationship between therapist characteristics and alliance in group therapy for individuals with treatment-resistant auditory hallucinations. Journal of Mental Health. 23(4), pp. 166 - 170. https://doi.org/10.3109/09638237.2013.869568
Theory of mind and social judgments in people at clinical high risk of psychosis
Healey, Kristin M, Penn, David, Perkins, Diana, Woods, Sue and Addington, Jean. (2013). Theory of mind and social judgments in people at clinical high risk of psychosis. Schizophrenia Research. https://doi.org/10.1016/j.schres.2013.08.038
Psychosocial treatments for schizophrenia
Mueser, Kim T., Deavers, F., Penn, David and Cassisi, J E.. (2013). Psychosocial treatments for schizophrenia. Annual Review of Clinical Psychology. 9(1), pp. 465 - 497. https://doi.org/10.1146/annurev-clinpsy-050212-185620
Context influences social cognitive judgments in paranoid individuals with schizophrenia
Pinkham, Amy E., Hopfinger, J. B. and Penn, David. (2012). Context influences social cognitive judgments in paranoid individuals with schizophrenia. Schizophrenia Research. 135(43891), pp. 196 - 197. https://doi.org/10.1016/j.schres.2011.11.024
Attention shaping as a means to improve emotion perception deficits in outpatients with schizophrenia and impaired controls
Combs, D, Chapman, Dustin, Waguspack, J, Basso, M and Penn, David. (2011). Attention shaping as a means to improve emotion perception deficits in outpatients with schizophrenia and impaired controls. Schizophrenia Research. 127(2016-03-01), pp. 151 - 156. https://doi.org/10.1016/j.schres.2010.05.011
Intranasal oxytocin reduces psychotic symptoms and improves Theory of Mind and social perception in schizophrenia
Pedersen, Cort, Gibson, Clare, Rau, Shane, Salimi, Kayvon, Smedley, Kelly, Casey, Robin, Leserman, Jane, Jarskog, Lars and Penn, David. (2011). Intranasal oxytocin reduces psychotic symptoms and improves Theory of Mind and social perception in schizophrenia. Schizophrenia Research. 132(1), pp. 50 - 53. https://doi.org/10.1016/j.schres.2011.07.027
The relationship between neurocognition and social cognition with functional outcomes in schizophrenia: A meta-analysis
Fett, A. K., Viechtbauer, W., Dominguez, M-D, Penn, David, van Os, J and Krabbendam, L. (2011). The relationship between neurocognition and social cognition with functional outcomes in schizophrenia: A meta-analysis. Neuroscience and Biobehavioral Reviews. 35(3), pp. 573 - 588. https://doi.org/10.1016/j.neubiorev.2010.07.001
An examination of social cognition, neurocognition, and symptoms as predictors of social functioning in schizophrenia
Combs, D. R., Waguspack, J., Chapman, Dustin, Basso, M R. and Penn, David. (2011). An examination of social cognition, neurocognition, and symptoms as predictors of social functioning in schizophrenia. Schizophrenia Research. 128(43891), pp. 177 - 178. https://doi.org/10.1016/j.schres.2010.11.019
Antipsychotic medication and social cue recognition in chronic schizophrenia
Roberts, D. L., Penn, David, Corrigan, P., Lipkovich, I., Kinon, B and Black, R A.. (2010). Antipsychotic medication and social cue recognition in chronic schizophrenia. Psychiatry Research. 178(1), pp. 46 - 50. https://doi.org/10.1016/j.psychres.2010.04.006
The virtual doppelganger: Effects of a virtual reality simulator on perceptions of schizophrenia
Kalyanaraman, S., Penn, David, Ivory, J. D. and Judge, A. (2010). The virtual doppelganger: Effects of a virtual reality simulator on perceptions of schizophrenia. Journal of Nervous and Mental Disease. 198(6), pp. 437 - 443. https://doi.org/10.1097/NMD.0b013e3181e07d66
Social cognition: The key factor predicting social outcome in people with Schizophrenia?
Harvey, P. D. and Penn, David. (2010). Social cognition: The key factor predicting social outcome in people with Schizophrenia? Psychiatry (Print). 7(2), pp. 41 - 44.
Comparison of social cognitive functioning in schizophrenia and high functioning autism: More convergence than divergence
Couture, S. M., Penn, David, Losh, M., Adolphs, R, Hurley, R and Piven, J. (2010). Comparison of social cognitive functioning in schizophrenia and high functioning autism: More convergence than divergence. Psychological Medicine. 40(4), pp. 569 - 579. https://doi.org/10.1017/S003329170999078X
Treatment approaches with a special focus on social cognition : Overview and empirical results
Wolwer, W, Combs, D, Frommann, N and Penn, David. (2010). Treatment approaches with a special focus on social cognition : Overview and empirical results. Key Issues in Mental Health. 177, pp. 61 - 78. https://doi.org/10.1159/000284379
Psychological well-being among individuals with first-episode psychosis
Uzenoff, S. R., Brewer, K. C., Perkins, D. O., Johnson, D P., Mueser, Kim T. and Penn, David. (2010). Psychological well-being among individuals with first-episode psychosis. Early Intervention in Psychiatry: the development, onset and treatment of emerging mental disorders. 4(2), pp. 174 - 181. https://doi.org/10.1111/j.1751-7893.2010.00178.x
Upward spirals of positive emotions counter downward spirals of negativity: insights from the broaden-and-build theory and affective neuroscience on the treatment of emotion dysfunctions and deficits in psychopathology
Garland, E. L., Fredrickson, B. L., Kring, A. M., Johnson, D P., Meyer, P and Penn, David. (2010). Upward spirals of positive emotions counter downward spirals of negativity: insights from the broaden-and-build theory and affective neuroscience on the treatment of emotion dysfunctions and deficits in psychopathology. Clinical Psychology Review. 30(7), pp. 849 - 864. https://doi.org/10.1016/j.cpr.2010.03.002
Social skill and social cognition in adolescents at genetic risk for psychosis
Gibson, Clare, Penn, David, Prinstein, M, Perkins, D and Belger, A. (2010). Social skill and social cognition in adolescents at genetic risk for psychosis. Schizophrenia Research. 122(1-3), pp. 179 - 184. https://doi.org/10.1016/j.schres.2010.04.018
Transportability and feasibility of Social Cognition and interaction Training (SCiT) in community settings
Roberts, D. L., Penn, David, Labate, D., Margolis, S A. and Sterne, A. (2010). Transportability and feasibility of Social Cognition and interaction Training (SCiT) in community settings. Behavioural and Cognitive Psychotherapy. 38(1), pp. 35 - 47. https://doi.org/10.1017/S1352465809990464
Neuropsychological profile of autism and the broad autism phenotype
Losh, M., Adolphs, R., Poe, M. D., Couture, S M., Penn, David, Baranek, G T. and Piven, J. (2009). Neuropsychological profile of autism and the broad autism phenotype. Archives of General Psychiatry. 66(5), pp. 518 - 526. https://doi.org/10.1001/archgenpsychiatry.2009.34
Loving-kindness meditation to enhance recovery from negative symptoms of schizophrenia
Johnson, D. P., Penn, David, Fredrickson, B. L., Meyer, P, Kring, A M. and Brantley, M. (2009). Loving-kindness meditation to enhance recovery from negative symptoms of schizophrenia. Journal of Clinical Psychology. 65(5), pp. 499 - 509. https://doi.org/10.1002/jclp.20591
Social cognition and interaction training (SCiT) for outpatients with schizophrenia : A preliminary study
Roberts, D. L. and Penn, David. (2009). Social cognition and interaction training (SCiT) for outpatients with schizophrenia : A preliminary study. Psychiatry Research. 166(43892), pp. 141 - 147. https://doi.org/10.1016/j.psychres.2008.02.007
Perceptions of hostility by persons with and without persecutory delusions
Combs, D. R., Penn, David, Michael, C. O., Basso, M R., Wiedeman, R, Siebenmorgan, M and Tiegreen, J A.. (2009). Perceptions of hostility by persons with and without persecutory delusions. Cognitive Neuropsychiatry. 14(1), pp. 30 - 52. https://doi.org/10.1080/13546800902732970
Stability and generalization of Social Cognition and interaction Training (SCiT) for schizophrenia: Six-month follow-up results
Combs, D. R., Penn, David, Tiegreen, J. A., Nelson, Andre, Ledet, S N., Basso, M R. and Elerson, K. (2009). Stability and generalization of Social Cognition and interaction Training (SCiT) for schizophrenia: Six-month follow-up results. Schizophrenia Research. 112(43891), pp. 196 - 197. https://doi.org/10.1016/j.schres.2009.04.010
The effects of task engagement and interpersonal rapport on WCST performance in schizophrenia
Roberts, D. L. and Penn, David. (2009). The effects of task engagement and interpersonal rapport on WCST performance in schizophrenia. American Journal of Psychiatric Rehabilitation. 12(1), pp. 57 - 72. https://doi.org/10.1080/15487760802615798
The effects of antipsychotic medications on emotion perception in patients with chronic schizophrenia in the CATiE trial
Penn, David, Keefe, R. S., Davis, Stephen, Meyer, P, Perkins, D O., Losardo, D and Lieberman, J A.. (2009). The effects of antipsychotic medications on emotion perception in patients with chronic schizophrenia in the CATiE trial. Schizophrenia Research. 115(1), pp. 17 - 23. https://doi.org/10.1016/j.schres.2009.08.016
An investigation of the relationship between activation of a social cognitive neural network and social functioning
Pinkham, Amy E., Hopfinger, J. B., Ruparel, K and Penn, David. (2008). An investigation of the relationship between activation of a social cognitive neural network and social functioning. Schizophrenia Bulletin. 34(4), pp. 688 - 697. https://doi.org/10.1093/schbul/sbn031
Social cognition training for individuals with schizophrenia: Emerging evidence
Horan, William P., Kern, R. S., Green, M. F. and Penn, David. (2008). Social cognition training for individuals with schizophrenia: Emerging evidence. American Journal of Psychiatric Rehabilitation. 11(3), pp. 205 - 252. https://doi.org/10.1080/15487760801963652
A preliminary trial of adherence-coping-education (ACE) therapy for early psychosis
Uzenoff, Sarah R., Perkins, Diana O., Hamer, Robert M., Wiesen, Christopher A. and Penn, David L.. (2008). A preliminary trial of adherence-coping-education (ACE) therapy for early psychosis. Journal of Nervous and Mental Disease. 196(7), pp. 572-575. https://doi.org/10.1097/NMD.0b013e31817d01a5
Social cognition in schizophrenia: An overview
Penn, David, Sanna, L. J. and Roberts, D. L.. (2008). Social cognition in schizophrenia: An overview. Schizophrenia Bulletin. 34(3), pp. 408 - 411. https://doi.org/10.1093/schbul/sbn014
The graduated recovery intervention program for first episode psychosis: Treatment development and preliminary data
Waldheter, E., Penn, David, Perkins, D. O., Mueser, Kim T., Owens, L W. and Cook, E. (2008). The graduated recovery intervention program for first episode psychosis: Treatment development and preliminary data. Community Mental Health Journal. 44(6), pp. 443 - 455. https://doi.org/10.1007/s10597-008-9147-6
Social functioning in individuals at clinical high risk for psychosis
Addington, Jean, Penn, David, Woods, Scott W., Addington, D and Perkins, D O.. (2008). Social functioning in individuals at clinical high risk for psychosis. Schizophrenia Research. 99(43891), pp. 119 - 124. https://doi.org/10.1016/j.schres.2007.10.001
Adherence-coping-education therapy for early psychosis
Penn, David and Uzenoff, S. R.. (2008). Adherence-coping-education therapy for early psychosis. Journal of Nervous and Mental Disease. 196(10), p. 780. https://doi.org/10.1097/NMD.0b013e318187bfff
Facial affect recognition in individuals at clinical high risk for psychosis
Penn, David, Addington, Jean, Woods, Scott W., Addington, D and Perkins, D O.. (2008). Facial affect recognition in individuals at clinical high risk for psychosis. British Journal of Psychiatry. 192(1), pp. 67 - 68. https://doi.org/10.1192/bjp.bp.107.039784
Neural bases for impaired social cognition in schizophrenia and autism spectrum disorders
Pinkham, Amy E., Hopfinger, J. B., Pelphrey, K. A., Piven, J and Penn, David. (2008). Neural bases for impaired social cognition in schizophrenia and autism spectrum disorders. Schizophrenia Research. 99(43891), pp. 164 - 175. https://doi.org/10.1016/j.schres.2007.10.024
Brief report: Feasibility of social cognition and interaction training for adults with high functioning autism
Turner-Brown, L. M., Perry, T. D., Dichter, G. S., Bodfish, J W. and Penn, David. (2008). Brief report: Feasibility of social cognition and interaction training for adults with high functioning autism. Journal of Autism and Developmental Disorders. 38(9), pp. 1777 - 1784. https://doi.org/10.1007/s10803-008-0545-y
Predictors of the therapeutc alliance in group therapy for individuals with treatment-resistant auditory hallucinations
Johnson, D. P., Penn, David, Bauer, D. J. and Meyer, P. (2008). Predictors of the therapeutc alliance in group therapy for individuals with treatment-resistant auditory hallucinations. British Journal of Clinical Psychology. 47(2), pp. 171 - 183. https://doi.org/10.1348/014466507X241604
Assessment of social judgments and complex mental states in the early phases of psychosis
Couture, S. M., Penn, David, Addington, Jean, Woods, Scott W. and Perkins, D O.. (2008). Assessment of social judgments and complex mental states in the early phases of psychosis. Schizophrenia Research. 100(43891), pp. 237 - 241. https://doi.org/10.1016/j.schres.2007.12.484
Social cognition in schizophrenia: An NiMH workshop on definitions, assessment, and research opportunities
Green, M. F., Penn, David, Bentall, R., Carpenter, W T., Gaebel, W, Gur, R C., Kring, A M., Park, Sung-Yun, Silverstein, S M. and Heinssen, Robert. (2008). Social cognition in schizophrenia: An NiMH workshop on definitions, assessment, and research opportunities. Schizophrenia Bulletin. 34(6), pp. 1211 - 1220. https://doi.org/10.1093/schbul/sbm145
Attentional-shaping as a means to improve emotion perception deficits in schizophrenia
Combs, D. R., Tosheva, A., Penn, David, Basso, M R., Wanner, J L. and Laib, K. (2008). Attentional-shaping as a means to improve emotion perception deficits in schizophrenia. Schizophrenia Research. 105(43891), pp. 68 - 77. https://doi.org/10.1016/j.schres.2008.05.018
Recognizing and responding to early psychosis: A qualitative analysis of individual narratives
Judge, A., Estroff, Sue E., Perkins, D. O. and Penn, David. (2008). Recognizing and responding to early psychosis: A qualitative analysis of individual narratives. Psychiatric Services. 59(1), pp. 96 - 99. https://doi.org/10.1176/appi.ps.59.1.96