Dynamics of recovery in psychosis, stigmatization, and microaggressions in mental healthcare: a qualitative study of service users' narratives

BACKGROUND: Collaborative care relationships form a key component of recovery-oriented mental healthcare, but can be disrupted if service users feel judged by professionals. Professionals can express stigmatizing attitudes through microaggressions, i.e. subtle forms of discrimination that have a negative cumulative effect. People with psychosis have been found to regularly experience overt and subtle forms of stigma in mental healthcare. This study aims to expand our understanding of the various forms and consequences of microaggression from a service user perspective. METHODS: In this qualitative study, we analysed narratives of people with psychosis purposefully selected from two collections of Dutch patient-authored stories ('Verhalenbank psychiatrie' and 'Patientervaringsverhalen'), including two books and nine transcripts of low-structured interviews. We performed thematic analysis to identify different forms of microaggression and additionally used narrative analysis to gain insight into the experienced consequences for recovery. RESULTS: We identified three main forms of microaggression: microaggressions that dehumanize; microaggressions that disregard service users' perspectives; and microaggressions that convey hopelessness. Experienced consequences of microaggression included feelings of loneliness, powerlessness and uselessness, acts of despair, resistance or withdrawal, and disengagement from services. Microaggressions were found to create additional recovery needs that were often addressed outside mental healthcare. CONCLUSION: Our findings illustrate the gap between ideals concerning collaborative care relationships and the everyday experiences of service users. Service users often experienced an absence of relationship-building in mental healthcare, with negative consequences for their recovery process. Our identification of different forms of microaggression can raise awareness and effectuate behavioural change in professionals and contribute to the emancipation of people with psychosis.