The number of patients with long-term chronic diseases is increasing. These patients place a strain on health care systems and health care professionals (HCPs). Presently, we aimed to systematically review the literature on HCPs’ experiences working with patients with long-term chronic diseases such as type 2 diabetes, chronic obstructive pulmonary disease (COPD), and chronic kidney disease (CKD).A systematic search of papers published between 2002 and July 2019 was conducted in the Embase, AMED, PsycINFO, MEDLINE, CINAHL, and COCHRANE databases to identify studies reporting qualitative interviews addressing HCPs’ experiences working with adults with COPD, CKD or type 2 diabetes. An interdisciplinary research group were involved in all phases of the study. With the help of NVivo, extracts of each paper were coded, and codes were compared across papers and refined using translational analysis. Further codes were clustered in categories that in turn formed overarching themes.Our comprehensive search identified 4170 citations. Of these, 20 papers met our inclusion criteria. Regarding HCPs’ experiences working with patients with COPD, CKD, or type 2 diabetes, we developed 10 sub-categories that formed three overarching main themes of work experiences: 1) individualizing one’s professional approach within the clinical encounter; 2) managing one’s emotions over time; 3) working to maintain professionalism. Overall these three themes suggest that HCPs’ work is a complex balancing act depending on the interaction between patient and professional, reality and professional ideals, and contextual support and managing one’s own emotions.Few qualitative studies highlighted HCPs’ general working experiences, as they mainly focused on the patients’ experiences or HCPs’ experiences of using particular clinical procedures. This study brings new insights about the complexity embedded in HCPs’ work in terms of weighing different, often contrasting aspects, in order to deliver appropriate practice. Acknowledging, discussing and supporting this complexity can empower HCPs to avoid burning out. Leaders, health organizations, and educational institutions have a particular responsibility to provide HCPs with thorough professional knowledge and systematic support.CRD42019119052.PROSPERO number:  With an increasing number of patients with chronic conditions worldwide, a growing number of health care professionals (HCPs) will encounter these patients daily. As patients live longer with chronic diseases, the relationship between HCPs and patients may last for years. In order to provide the best treatment for the growing number of patients with chronic conditions, we need to increase our understanding of how to keep HCPs motivated in their work . This isThe global increase of chronic diseases, often framed as non-communicable diseases (NCDs), has resulted in global strategies within the World Health Organization (WHO) and the United Nations to prevent or delay onset and reduce premature mortality . LifestyFor the past few decades, patients have been encouraged to take responsibility for their health to a greater degree . This isThe patient’s expertise is highly emphasized in patient-centred care, which is defined as care “that is respectful of and responsive to individual patient preferences, needs, and values” and that ensures “that patient values guide all clinical decisions” . This dePolitical statements recommend patient-centered care to a growing population of patients, many with NCDs , 11. At Previous research on HCPs’ experiences of long-term patient–provider relationships is scarce, and often related to professional practice procedures rather than to the HCPs’ individual working experiences in general. How to understand the patient’s experiences is widely researched, but how the HCPs experience the patient–provider relationship, particularly when patients have a chronic disease, appears not to have generated equal interest among scientists. One qualitative study aiming to elicit providers’ perspectives on caring for patients with chronic pain found that HCPs internalized feelings of failure, guilt and discontent. This study highlighted the need for physicians to care not just for their patients but also to adopt self-care strategies to reduce “compassion fatigue” when caring for challenging patients .The present systematic review of qualitative empirical studies aims to provide an in-depth insight regarding how HCPs experience working with patients with chronic diseases. We decided to focus on chronic obstructive pulmonary disease (COPD), chronic kidney disease (CKD), and type 2 diabetes, as these share commonality regarding the continuity of HCP–patient interactions over time and the great impact of lifestyle and self-management on prognosis. However, the three diseases also have clear differences in their treatment, their need for HCP follow up and prognosis over time, making them suitable to contrast the HCP experience. Thereby, we sought new insights that could aid HCPs, policymakers, and educational institutions in reducing the strain on HCPs and preventing burn-out among HCPs. Thus, our aim was to systematically review the literature on HCPs’ experiences working with patients with long-term chronic diseases such as type 2 diabetes, COPD, and CKD.This systematic review was conducted between October 2017 and June 2019. A research group comprising 10 senior researchers (the authors), with a professional background in either nursing or physiotherapy and qualified in realist and interpretive qualitative research methods, conducted a systematic literature review of qualitative papers concerning HCPs’ experiences working with patients with type 2 diabetes, CKD, and COPD. The members of the research group had all worked in clinical and research settings with patients with a range of chronic diseases. Whereas most of the nurses had insider knowledge from their clinical work and research on diabetes, COPD, or CKD, the physiotherapists had an outsider perspective, as their experiences related mainly to chronic musculoskeletal disorders. These differences nurtured our discussions during the whole process. In order to enhance the researcher’s reflexivity, shifting pairs of researchers worked together in all phases of the review process of inclusion/exclusion, appraising the methodological quality, extracting the data for further analysis, and analyzing the data. In the initial phase of the systematic review, a protocol was published in PROSPERO. The review protocol may be accessed via PROSPERO under the registration code CRD42019119052.At beforehand, we decided to include only empirical qualitative studies published in scientific journals, and grey literature, conference proceedings, master and PhD thesis were excluded as they often lack peer reviews. A systematic search strategy was developed and revised in close collaboration among the researchers and with assistance from an experienced research librarian before the final search was conducted. This comprehensive strategy aimed to ensure that relevant peer-reviewed empirical studies were identified in the search. The searches were conducted in six databases: Embase, AMED, PsycINFO, MEDLINE, CINAHL, and COCHRANE. The Medline’s Medical Subject Headings (MESH) terms and additional keywords were used to identify relevant search terms, and the librarian added a study-specific “qualitative filter” to further tailor the search strategy. The search strategy was then adjusted to each other databases. While publication language was not limited, publication dates were limited to between 2002 and 2017. The original search was completed by the 29th of November 2017 and was updated in June 2019 by the same librarian. An example of the search strategy can be found in the Additional file We based our search strategy on the “SPIDER” framework—an acronym for sample, phenomenon of interest, design, evaluation, and research type —to identThe final search strategy identified titles and abstracts. In the screening process, all authors participated in pairs, and the papers were independently screened by title and abstract for eligibility by the two reviewers in each pair, before the pairs met and discussed. Each file represented one diagnosis; one pair sorted through the files for COPD, one pair sorted through chronic kidney disease, and three pairs sorted through the files for diabetes. The inclusion and exclusion criteria were developed a priori but refined to become more precise during the inclusion process. The authors discussed each reference for which initial agreement was not reached, before a final set of references were retrieved and reviewed in full-text to assess whether they met the inclusion criteria. The included papers were then read by new pairs within the group to consolidate the agreement across the reviewers.The included papers were presented in a table drafted by the research group. This table included study specifications , number and gender of participants, characteristics, research purpose, stated theoretical or philosophical perspective, recruitment source, data collection, data analysis, main findings related to our research purpose, and whether the study fulfilled the methodological appraisal.To assess the methodological quality of the studies, the Critical Appraisal Skills Programme checklist (CASP) for qualitative research was chosen as it is not nested to a particular epistemological perspective . In addiAfter the inclusion/exclusion process, the authors read all the included papers in full text in order to identify the data at hand. Our general impression from this reading was that HCPs, in general, were satisfied with their work, but the general outline of several challenges could also be seen. These were discussed by the group. This overall impression guided our further (detailed) analysis of each paper, but it also enabled us to critically appraise whether our initial impression was supported by the data.The detailed, in-depth analysis was performed by groups of two or three members who each independently determined what was relevant in the primary studies’ result section to inform our research question and subsequently to be extracted for further analysis. The extracts were discussed by the pairs until consensus was reached, and thereafter coded manually by the pairs. Metaphors and concepts within the text were identified and used as codes whenever appropriate. We began with papers that we found presenting a richness of information and concepts in accord with what Britten and Pope  call conThe extracts of the next papers were then examined to see whether they could be translated into the codes we used for the previous paper; if not, new codes were developed. This approach was inspired by translational analysis, and thus involved an analytical transfer of concepts and insights between studies , 20. ThrThe extracts and codes were transferred into the NVivo software program. Here, too, all extracts and codes were read and discussed by the group and modified by looking across all the coded papers. This process generated 36 codes (“nodes” in NVivo), which were written on Post-It Notes and attached to a whiteboard. The group then shared, reviewed, and discussed the codes, and finally clustered them into categories. Through discussions and critical appraisals based on the group’s mutual knowledge of the data material but various theoretical perspectives, we gradually developed three main overarching themes.n = 4177 references  and nurses (n = 158). Only two studies included physiotherapists [The included 20 papers concern HCPs’ experiences providing care to patients with CKD (7 papers), COPD (4 papers), or type 2 diabetes (9 papers) Tables . A totalerapists , 33, oneerapists , and fouerapists , 33, 35.Based on our analysis of the results chapters of the included studies, three main themes were identified and developed, each addressing our overall aim to describe HCPs’ experiences working with patients with long-term chronic diseases: individualizing the professional approach within the clinical encounter; managing one’s emotions over time; and working to maintain professionalism Table . Below, This theme comprises three categories illuminating the clinical encounter between the HCP and the patient: “engaging with the patient as a person,” “encountering the chronic condition,” and “facilitating a shared understanding of the chronic condition.”The first category, “engaging with the patient as a person,” describes how many HCPs sought to provide individualized care and find ways to approach each patient’s specific needs , 33. As The second category refers to that, although the HCPs emphasized the importance of seeing and engaging in “the person behind the diagnosis,” they were also obligated to “encounter the chronic condition.” As such, they had to weigh the personal aspects against their professional responsibility and expertise concerning the disease. One challenge for the HCPs, as shown in Tonkin-Crine et al. , was theFurther, the HCPs described feeling responsible for ensuring and strengthening patients’ understanding of their disease in order to motivate them to make the recommended lifestyle changes . DespiteThe third category, “facilitating a shared understanding of the chronic condition” among HCPs and patients,” reflects that long-term chronic diseases lack curative treatment, and much depends on self-management efforts of patients. A lack of understanding among family members may negatively influence the patient’s acceptance of a disease and its severity . RepeatePatients’ specific cultural contexts could also impact their understanding of the chronic disease, which HCPs had to take into account in clinical encounters. This was especially clear in the papers addressing HCPs’ experiences working with ethnic minority groups and indigenous patients , 33. EthThe theme “managing one’s emotions over time” encompasses the following three categories: “the challenges connected to a long-term relationship”; “maintaining professional sympathy,” and “burden of responsibility.”The category “the challenges connected to a long-term relationship” includes both the challenges and the rewards associated with long-term patient–provider relationships. With respect to chronic diseases, HCPs often follow the same patients over a long period of time, often spanning years. Pooley et al.  argued tThe HCPs felt that they had to engage emotionally with their patients, and they largely regarded this as positive. However, a long-term patient–provider relationship could also lead to negative personal relationships with patients . If the . Nevertheless, there was also a risk that this compassion would be diminished. Over time, HCPs could become desensitized to others, and dehumanization could begin as early as, for example, medical school [The category “maintaining professional sympathy” centers around how HCPs deemed emotional engagement, in the forms of professional sympathy and compassion, as necessary for continuing in their work . Neverthl school . There wl school . When thl school .Under the category “burden of responsibility” the HCPs felt highly responsible for their patients’ wellbeing, which they sometimes also experienced as a burden . This waWhile the papers addressed the experiences of HCPs from a range of cultural contexts, working with three different chronic diseases, the HCPs shared the opinion that maintaining professionalism was important. The work maintaining professionals contains the following four categories: “striving to achieve the best for the patient,” “collaborating with other professionals,” “keeping up professional self-esteem,” and “adjusting to health organizational structures.”The category “striving to achieve the best for the patient” includes HCPs’ experiences working to meet ideals embedded in their professional role and practice context , 39. OneWalker et al.  reportedThe category we labelled “collaborating with other professionals” encompasses multidisciplinary support and cooperation with colleagues, as well as the professional loneliness that arises from a lack of cooperation and support. On the one hand, colleagues were described as the most prominent source of support, mainly because they knew the context of care and were easily available for consultation . This suOn the other hand, the absence of support was also highlighted in the included articles, and could result in feelings of professional loneliness. Nurses, in particular, described feeling left alone with extensive responsibility . Also, gThe third category represents “keeping up professional self-esteem.” Positive feedback from others strengthened the HCPs’ self-esteem, and being liked, respected, and valued by colleagues and those in charge in the ward were highlighted as important . PositivThe fourth category was “adjusting to health organizational structures,” and this was connected to nurses’ professional development and career possibilities. Although specialized nursing skills were emphasized within a health organization, it was not always considered essential to support the nurses’ goals of learning and mastering these skills . FurtherThe HCPs’ experiences working with patients with type 2 diabetes, CKD, or COPD presented in the papers included in our systematic literature review are captured by three themes: “individualizing the professional approach within the clinical encounter,” “managing one’s emotions over time,” and “working to maintain professionalism.” Together, these themes describe how clinical encounters with patients depend, to a large degree, on the personal interaction between patient and professional, real clinical practice situations and professional ideals, and contextual support and managing one’s own emotions. In more general terms, this means that clinical working experiences are constituted by the interactions between persons, contexts, organizational structures, and health policy claims. Despite the diversity in the efficiency of interventions, treatment options, and long-term prognosis of type 2 diabetes, COPD, and CKD, in general the HCPs’ working experiences seem to be rather shared.Today, health authorities are governed by ideals such as the patients’ right to receive the best evidenced-based care and the efficiency and cost-effectiveness of the service delivery . At the As the present findings highlight, on the one hand, the patients’ wishes and autonomy must be respected, as they should be considered experts on their own lives, but on the other, patients do not always understand the severity of their disease-related risks, nor do they necessarily make rational decisions. HCPs feel they lack the tools or ability to help patients and family members understand the risks of not following the prescribed treatment plan. In this way, HCPs feel they are to blame by not fulfilling their professional responsibility. This can be particularly challenging when a patient presents a desire for treatment that differs from evidence-based recommendations for best practice. In such cases, HCPs must balance their acting according to patient-centered care and evidenced-based practice models. “Giving up” one’s professional expertise and instead taking on the role of “partner, colleague or co-worker” may be a solution, as described by Alm Andersen . How preFor HCPs, a long-term patient–provider relationship can be both a rewarding and disheartening experience. They may establish a kind of friendship with their patients, and hold significance in their patients’ lives as the one person who shares and can make sense of patients’ disease experiences. As our analysis indicates, this can also be a balancing act, as HCPs know that just as the progression of a disease is uncertain, so is the outcome. HCPs must therefore find the balance between personal closeness to and professional distance from patients, to protect their own emotional vulnerability and maintain a supportive professional role for the patients and their families when patients’ conditions deteriorate, or life ends. There is no formula for how to perform this balancing act in practice, as it is usually individually and situationally determined.In discussing burn-out among HCPs, Dyrbye et al.  point toThe contribution and trustworthiness of our meta-synthesis depends on the quality of the original publications on the one hand, and on the rigor of our own methodological process on the other. One strength of this meta-synthesis is that we conducted comprehensive searches of six databases, and thereby generated a variety of data to be analyzed. By choosing three different chronic diseases on which to focus, we succeeded to find richness and variability in HCPs’ detailed working experiences. Furthermore, the inclusion and exclusion criteria and search terms were decided in advance of the literature search, and the searches were conducted by an experienced librarian. Another strength of our meta-synthesis is that the study selection, study appraisals, extractions of data in primary studies to be analyzed and coding were performed independently by pairs of researchers, and the use of NVivo further ensured a rigorous and systematic process. In this part of the process, we followed procedures to ensure reliability in line with a realist perspective . In the The present study has some limitations that must be noted. Firstly, according to the quality appraisal, as assessed by the CASP and COREQ, the quality of the original articles can be considered high. However, wider methodological orientations or broader philosophical backgrounds were rarely presented or discussed in the included papers. It is also possible that the assumptions made by the authors of the original studies were continued in the meta-synthesis. Secondly, it is noteworthy that although we welcomed both interview studies and observational studies in the meta-synthesis, no observational studies met our inclusion criteria. This implies a knowledge gap, as the HCP–patient relationship and their interactions require research from different vantage points. Thus, further research to examine how clinical practice is performed and contextualized is needed.It is clear from this systematic literature review that HCPs’ experience profound stress in their work with patients with COPD, CKD, or type 2 diabetes. On the other hand, they also experience the creation and maintenance of long-term relationships with patients with chronic conditions as personally and professionally rewarding. As such, HCPs must find the balance between personal closeness to and professional distance from patients. They must also balance providing patient-centered care whilst simultaneously developing and strengthening their professional expertise. This underscores the importance, for HCPs, of having systematic support from colleagues, leaders, educational institutions, and health organizations.Additional file 1. Search terms.Additional file 2. Detailed study appraisal.


Frontiers’ 2020 Call for Papers on “Stereotypes and Intercultural Relations: Interdisciplinary Integration, New Approaches, and New Contexts,” my paper integrates the scientific study of stereotypes with a literary-theatrical exploration of stereotyping. The focus is on Tibor Egervari’s post-Auschwitz adaptation of Shakespeare’s anti-Semitic comedy The Merchant of Venice, with a very brief look at his related work on Christopher Marlowe’s The Jew of Malta and his 1998 collaboration with conductor Georg Tintner on a touring production of composer Viktor Ullmann’s and librettist Peter Kien’s one-act opera, The Emperor of Atlantis, or Death’s Refusal, composed in the “model” concentration camp Terezín (Theresienstadt), in 1943–1944. Egervari’s theater art critically deconstructs what he calls “the Old Jew” stereotype in specific ways highly readable using the Stereotype Content Model (SCM) and Behavior from Intergroup Affect and Stereotypes (BIAS) map. Theater performance can sometimes embody the forceful dynamic traced by the BIAS map, from cognition to affect to behavior. Egervari’s original adapation, which sets The Merchant of Venice in Auschwitz, reveals this dynamic clearly. My interdisciplinary study of Egervari’s theatrical-cultural work validates the SCM and BIAS map for literary studies and interprets the Shylock stereotype in the terms of those models and through the lens of Egervari’s anti-Nazi adaptation of Shakespeare’s Merchant.In response to  The genocide of six million European Jews during the Second World War involved deliberate intensification of a pre-existent Jew stereotype. The study of stereotyping is urgent for this reason alone, but there is more. In ways that people might never have imagined, understanding stereotyping is crucial if we are to end political polarization and together build a sustainable global culture. Fortunately, stereotypes have for decades been the focus of convincing research in psychology, and are now much better understood than they were in the 1930s. The Stereotype Content Model SCM; , originaIn theater studies too, advances have been made with respect to stereotyping. In Canada today, public performance serves to negotiate differences and identities among First Nations, between First Nations and settler/invader cultures, between French and English, and among successive waves of migrant and displaced populations , p. vii.The Merchant of Venice, setting it inside a prison inside the Auschwitz death camp, he felt that for the first time in his life, he could talk openly about the Shoah  stereotype, which prompts the behavior of passive facilitation and active harm, and•the importance and the failure of empathy.I argue that the SCM and BIAS Map predict the plays’ violence – even the extreme violence of Egervari’s adaptation, which pales only against the reality that was.Stereotypes are collective cognitive entities  and inflThe Merchant of Venice: Shylock is a figure closely bound up not only with the fictionalized landscape of anti-Semitism on the page but also with its lived history off of it. The Merchant of Venice has furnished notable turns of anti-Semitic phrase, foremost among them the term “Shylock” which has come to describe a cut-throat type of Jewish profiteer. This play and its Jewish moneylender [tend] to bleed messily off the page into historical actuality [....]. , James Shakespeare and the Jews (1996), Janet Blood Relations: Christian and Jew in The Merchant of Venice (2008), and David Anti-Judaism: The Western Tradition (2013). Schools of thought across the Humanities – New Historicist, Psychoanalytic, Post-Colonial and more – have worked to understand the charisma of the character Shylock and the uses to which he has been put.Since the war, the topic of Shylock and anti-Semitic and anti-Judaic stereotyping has received significant attention. Outstanding monographs dedicated to this work include John Gross’s The Jew of Malta, and early modern Europe’s violent religious and economic conflicts. It is thought that both Marlowe and Shakespeare drew on “older (non-Jewish) European traditions of hate literature” . He cites Jean-François Lyotard:It might seem to be simple common sense to break apart naive mimetic association between real Jews and the stereotype; yet, John Drakakis, discussing a 1990 essay by Stephen Greenblatt, suggests that the “shift in much of contemporary criticism of ent one” , p. 29. One converts Jews in the Middle Ages, they resist by mental restriction. One expels them during the classical age, they return. One integrates them in the modern era, they persist in their difference. One exterminates them in the twentieth century.” , p. 29To argue that Jews are what “cannot be domesticated” potentially returns us to a naive mimetic realism that has been rightly problematized. It is necessary to better understand what stereotypes actually are, how they are formed, of what they consist: their being, their ontology – a task undertaken by scientific research.In their 2019 paper on discrimination against immigrants, [Over evolutionary time a] cognitive mechanism […] evolved to detect coalitional alliances via the categorization of the social world into “Us” versus “Them”; this is what ultimately predisposes humans to discriminate in favor of their ingroup and against the outgroup. For the human mind, ethnicity, cultural group, or race is simply one historically contingent subtype of coalition because through a long human story, they have been an ecologically valid predictor of people’s social alliances and coalitional affiliations. : in the listings for that year The Merchant held twenty-first place, just ahead of The Merry Wives of Windsor. There were still nine new productions during the 1933-4 theatre season, but numbers dropped to usually one or two for the following seasons (Eicher 304). Thomas Eicher attributes these declining numbers to systematic interventions by the administration, claiming that the play was in effect “stopped.”8 9 On the other hand, the stance of the Nazi bureaucracy and of cultural makers was not as straightforward as we might have thought; Ackermann characterizes it as “twisted”  stereotype and the envious prejudice it generates can play a role in outbreaks of so-called ethnic cleansing and genocide. Amy Cuddy, Susan Fiske and Peter Glick discuss envious prejudice and the history of the Jew stereotype Interpreting this scene through the lens of the SCM, we can affirm that the stereotyped subject articulates in detail the behavioral consequences of his perceived status as a highly competent and very cold person in the eyes of his Venetian interlocutors. He specifies the contradiction inherent in Antonio’s passive facilitation and active harm. Antonio, however, remains committed to the abusive behaviors that flow from his prejudiced beliefs.14 or shared ingroup status, which broadly speaking implies seeing things from a shared perspective. It seems reasonable to suggest that the Shakespearean sense of “kindness” is not far from what we mean today by empathy.Another feature of the SCM that is captured by Shakespeare’s play involves the primacy of warmth and the potentially transformative role of empathy and perspective taking. The negotiation of the contract between Shylock and Antonio involves a three-way conversation and interchange of views that could have moderated the evolving hostility. Antonio unkindly and recklessly refuses an offer of “kindness” from Shylock, who in turn suggests a contract that is anything but kind. In Shakespeare’s English, the word “kind” is layered and polyvalent, suggesting not only niceness, or generosity, as the word is used today, but also including the etymological sense of kinship,Following Antonio’s rebuff, the exchange ends with the contract involving the pound of flesh:JEWWhy, look you, how you storm.I would be friends with you and have your love,Forget the shames that you have stained me with,Supply your present wants and take no doitOf usance for my moneys, and you’ll not hear me.This is kind I offer.BASSANIOThis were kindness.JEWThis kindness will I show.Go with me to a notary, seal me thereYour single bond, and, in a merry sport,If you pay me not on such a day,In such a place, such sum, or sums, as areExpressed in the condition, let the forfeitBe nominated for an equal poundOf your fair flesh, to be cut off and takenIn what part of your body pleaseth me.ANTONIOContent, in faith: I’ll seal to such a bondAnd say there is much kindness in the Jew.(1.3.133–149)The passive facilitation cued by the ambivalent LW/HC stereotype can take the form of mercantile patronage, and such is the case here. Shylock recognizes the mixed consequences of his outsider stereotyped status, and his daughter Jessica, too, acknowledges her outsider status. She, however, “may still identify with aspects of the societal reference group” , p. 78, Empathy and perspective taking counteract negative stereotyping  and its SALARINOWhy, I am sure, if he forfeit, thou wilt not take his flesh: what’s that good for?JEWTo bait fish withal; if it will feed nothing else, it will feed my revenge. He hath disgraced me, and hindered me half a million, laughed at my losses, mocked at my gains, scorned my nation, thwarted my bargains, cooled my friends, heated mine enemies, and what’s his reason? I am a Jew. Hath not a Jew eyes? Hath not a Jew hands, organs, dimensions, senses, affections, passions? Fed with the same food, hurt with the same weapons, subject to the same diseases, healed by the same means, warmed and cooled by the same winter and summer as a Christian is? If you prick us do we not bleed? If you tickle us do we not laugh? If you poison us do we not die? And if you wrong us shall we not revenge? If we are like you in the rest, we will resemble you in that. If a Jew wrong a Christian, what is his humility? Revenge. If a Christian wrong a Jew, what should his sufferance be by Christian example? Why, revenge! The villainy you teach me I will execute, and it shall go hard but I will better the instruction. (3.1.46–66)Empathy continues to be at issue in the courtroom scene in Act 4: appeals for kindness and perspective are tossed back and forth. Portia, in her cross-dressed role as the “young doctor of Rome” (4.1.151–152) delivers a celebrated set speech in praise of mercy:PORTIAThen must the Jew be merciful.JEWOne what compulsion must I? Tell me that.PORTIAThe quality of mercy is not strained:It droppeth as the gentle rain from heavenUpon the place beneath. It is twice blest:It blesseth him that gives and him that takes.’Tis mightiest in the mightiest; it becomesThe throned monarch better than his crown.(4.1.178–186)caritas, or God’s unbounded love (4.1.257). This is interesting in relation to Luther’s implication about competing for that love, as there is no point in competing for what is unlimited. Caritas plausibly directs us away from prejudice and toward the variety of Christian humanism that saw all human beings as equal; however, theology no doubt takes my argument too far afield. The critical point is that, however it is named, empathy and perspective taking – and reason – are refused on all sides, and a dangerous and angry dehumanization of a stereotyped subject is unleashed. The play acts out what happens when empathy is denied. It shows the workings of social prejudice based on stereotyped intergroup and interpersonal perceptions, and it shows how the destructive dynamic could have been, but was not, interrupted by empathic perspective taking.Portia frames her legal arguments by the Christian theological concept of mercy, which she subsequently identifies with charity, Latin Scholars and artists, including Egervari, have vehemently drawn out the profound failure of empathy in this play, noting that in spite of her beautiful words, Portia not only refuses empathy, but is the most cruel:Portia’s – or Shakespeare’s – behavior toward Antonio is in fact as cruel as anything Shylock does. The scene is drawn out excruciatingly, and its theatrical power has much less to do with the quality of mercy than with the pleasure of sadism on the one hand and revenge on the other. , p. 159us to have our revenge”:Stephen Orgel points out that the “old law that Portia suddenly invokes allows … for ex post facto law, which applies only to Shylock, and has been invoked – indeed invented – solely to put him at the mercy of the court. This is a striking example of the play’s tendency toward overkill, because the forgotten law is Shakespeare’s invention, appearing in none of the sources, and quite unnecessay to the plot. , in 1943–4. Costuming and theatrical transformations dramatically expose the reality that the human beings are Jews, in the costumes of the Häftlinge; the Emperor singing the aria is a Jew. Egervari’s directorial style draws on intensifying techniques learned from Japanese Noh and the theater work of Luigi Pirandello, Antonin Artaud, Bertolt Brecht, Jerzy Grotowski, and others . As a survivor and an artist, his ongoing implication with the trauma of Auschwitz is expressed through theater, and his “Merchant” is an extraordinary accomplishment.For over two decades, Egervari wrote, adapted and directed theater projects staging the deconstruction of the stereotype of the “old Jew” (to use his term). “Egervari’s “Merchant” harnesses the power of Shakespeare’s, following through, as Shakespeare does, with Shylock’s defeat. The difference is that Egervari’s “Shylock” is a Nazi commander/actor-director who is staging the play in order to prove the reality of the toxic Jew stereotype that justifies his mass murders. The dramatic deconstruction of the anti-Semitic stereotype “Shylock” is founded in the first place on the theater basics of costuming and acting, and the play’s success as an anti-Nazi work is founded on theater’s power to change minds.How is this work readable using the SCM and BIAS map? As discussed above, the SCM identifies warmth and competence as universal dimensions of social perception, and posits that warmth and competence judgments are based on the socially contingent and temporally mutable antecedents of competition and status. “People viewed as competitors are judged as lacking warmth, whereas people viewed as non-competitors are judged as warm; people viewed as high status are judged as competent, whereas people viewed as low status are judged as incompetent” , and with respect to his choice to play the hated Jew, he will explain. The SCM can offer another reason: his appropriation of the role reflects the envy he feels toward the Jew stereotype because of his prejudiced belief in the exaggerated competency of the Jews as powerful conspirators , while he crucially affirms that the stereotype is the true Jewish “identity.” His envious need to assert himself in relation to the Jew stereotype, suggested by his initial decision to play Shylock, is exposed as well by his belief that he alone can reveal, through the power of theatrical performance, the truth of the prototypical exemplar:SHYLOCK Jessica!JESSICA Good morning, sir.SHYLOCK I am your father!JESSICA Yes, in the play, but …Mein Kampf?  to consequences, Cuddy, Fiske and Glick ask how warmth and competence judgments affect the ways that targets are treated. They propose that perceptions of warmth and competence elicit predictable, differentiated patterns of social emotions, behaviors and attibutions. People perceived as incompetent and not warm elicit contempt and disgust, and those perceived as competent but cold, e.g., in this case, Jews, elicit envy , p. 102.Cognition → Affect → BehaviorLow Warmth/High Competence Stereotype → Envy → Passive facilitation and Active HarmA significant lack of warmth, particularly in stressful social conditions, could create “a relatively urgent need to react,” and perhaps to react violently . However, anger has been shown to mediate the link from envy to activation 15 In this context, the words become even more ironic and meaningful than they are in the Shakespearean text. They signify the moral humanity of the Jewish prisoners, which is also expressed in their dignified behavior throughout.With this claim to a patient and quiet spirit, Antonio verbally places himself on a higher moral plane than Shylock, a move that accords with the SCM’s theory that envy is always directed upwards, toward that target the perceiver supposes to be superior. Antonio frames the situation such that he is the superior. It is interesting that Egervari retains this passage in his adaptation (p. 171); therefore, a doomed Jewish prisoner (an incarcerated lawyer), acting the role of Antonio, speaks these words to the “Duke” who is in fact the depraved SS officer who will shortly murder them all, with the exception of “Shylock,” who is murdered by the real Jews.Merchant and even more strikingly in Egervari’s adaptation, where he is killed. One possibility has to do with the theory that whereas warmth judgments are other-oriented, in that they reflect how others perceive the subject, competence judgments “rebound” on that stereotyped subject (As far as I know, the SCM and BIAS map does not explicitly address what might happen under conditions of stress when a subject targeted by the LW/HC stereotype is perceived to lose competence. Shylock loses his status/competence in  subject , p. 89 –Shylock is on his knees and the others surround him. As he is reciting his lines, GRATIANO grabs him by the throat and shakes him. Surprised, SHYLOCK drops his knife, which ANTONIO picks up. They all stop for a moment, and then they all jump on top of SHYLOCK. He is killed on the spot before TUBAL has time to get his weapon. , p. 182In terms of the SCM, the knife is a crucial resource, and “status assesses the capability of groups to control resources” , p. 94. 16 This instability is a feature of Egervari’s adaptation but not, perhaps, of Shakespeare’s play. Cuddy, Fiske and Glick make the important point that envious stereotypes, such as “Shylock,” although they are ambivalent across the dimensions of warmth and competence, are psychologically consistent for perceivers who do not experience the psychological tension that was classically assumed to be integral to ambivalence (A final argument about this moment in the adaptation. When the Nazi commander transforms into the enemy “Shylock,” the world of the play becomes volatile and extremely stressed. The resulting mental conflict in the local environment of the prison on the set is destabilized by profound incongruence between the varied elements of cognitive perception and their affective consequences. The situation can be interpreted using another psychological model, that of affective incoherence, which I understand to be debilitating cognitive-affective incompatibility .16 This ivalence . p. 76. I have shown that Shakespeare’s Shylock and Egervari’s post-Holocaust “Shylock” are readable using the SCM and Bias map. My interdisciplinary reading validates the SCM and BIAS map for work in literature, and offers a fresh interpretation of Tibor Egervari’s anti-Nazi Shakespeare adaptation. I hope to have demonstrated the value of interdisciplinary work in such diverse fields of the arts and sciences.17The SCM and BIAS map are a powerful model for understanding the dynamic dance that begins with perception and cognition, then moves to affect and emotion, to sometimes end – at the far right edge of the map – in the worst violence possible, beyond imagining. If the model can help us to discover ways to dissolve a murderous and obdurate ethnic stereotype, that is a goal worth pursuring, as Cuddy, Fiske and Glick themselves affirm , p. 129.The archival approach developed by The SCM shows that warmth judgments are not founded on actual niceness, morality, or warmth, but by the presence or absence of social competition, which may be entirely social and structural; that competency judgments are not determined not by true competency, agency or ability, but by social status, which well be inherited or faked . This coA Midsummer Night’s Dream, the Amazon Queen Hippolyta speaks of theater’s capacity to “transfigure minds all together”18 – a psychological notion that suggests a kind of collective cognitive evolution for the better. For millennia, humanity believed in the gravity and importance of the arts. The role of the arts in relation to the evolution of the mind will, I hope, attract more scientific and interdisciplinary study in the future.Drawing on his experience as a Hungarian Jewish child caught up in the Nazi Holocaust, Tibor Egervari turned to the ancient theater arts of narrative, costume, mask, make-up, choreography and acting in order to effect the collective transformation of mind of which theater is sometimes capable. His work reminds us of theaters’ precedence in human societies as a means of representing and working through intercultural violence. In Shakespeare’s The original contributions presented in the study are included in the article/supplementary material; further inquiries can be directed to the corresponding author.The author confirms that she is the sole contributor to this work and has approved it for publication.The author declares that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


Fictional portrayals of illness and medical management in film and television can reflect and perpetuate cultural stereotypes about illness. The aim of this study was to analyse fictional depictions of gout in contemporary film and television.n=44).We conducted a search for English language depictions of gout in film and television since 1990 using the Internet Movie Database (IMDb), other internet media databases, and member suggestions from the Gout, Hyperuricemia and Crystal-Associated Disease Network (G-CAN). Film and television episodes with gout content were analysed for depictions of characters with gout, causal factors, and management strategies , and portrayals of biological causes were infrequent (12%). Common management strategies were change in diet (36%) and short-term pain relief (32%), with only one mention of urate-lowering therapy (5%). The majority of films and television episodes depicted gout as humorous (59%) and embarrassing (50%).In contemporary film and television, gout is portrayed as a humorous and embarrassing condition, caused by dietary indulgence. These depictions may reinforce inaccurate beliefs about the causes of gout and its management.The online version contains supplementary material available at 10.1186/s41927-020-00174-z. Gout is a chronic disease of monosodium urate (MSU) crystal deposition that presents as recurrent flares of painful and disabling arthritis . The disConsistent with depictions of the illness in historical art and literature , gout isFilm and television reach a broad range of society and therefore have the potential to contribute substantially to illness beliefs. Analysis of fictional medical dramas on television has shown that these programmes depict a wide range of common medical conditions . HoweverWe conducted a content analysis of gout depictions in film and television. The “Internet Movie Database” (IMDb), which has been used to identify content in other scientific studies , 19, wasRequests to nominate films and television episodes were posted on the IMDb community pages and emailed to experts from the international volunteer organization Gout, Hyperuricemia and Crystal-Associated Disease Network (G-CAN) via the G-CAN mailing list.Films and television episodes were included in the analysis if they were fictional, released after 1990, produced in English, and had content related to gout in humans. Documentary and reality films and television episodes were excluded.Each film or television episode was watched in full by two researchers (CD and RM). Where available, films and episodes were watched with closed captions. All text relevant to gout was extracted and transcribed in script form with relevant time stamps by one of the two researchers and was checked by the other researcher.The films and television episodes were coded by both researchers at the time of viewing, and relevant text extracts were reviewed. The following data were collected: media type (TV/film), genre , setting , year of production, country depicted and characteristics of the affected person . When the same character with gout appeared in more than one television episode, each episode was coded individually. The character’s experience of gout  was also recorded. Causes of gout were recorded and classified into biological factors (such as genetics and kidney dysfunction), ageing, obesity, and overindulgence of food, alcohol and sugary drinks. Management of gout was recorded and coded into urate-lowering therapy, serum urate monitoring, pain medication, anti-inflammatory medication, and dietary strategies. Reference to gout as a humorous topic and as a source of social embarrassment was recorded. Discordant coding between the two researchers  was resolved by discussion and review with a third author (ND).Analysis was primarily descriptive. Percentages for the numerical coding were calculated. In addition to all content, depictions in historical and modern-day settings are reported separately.Figure There were 37 depictions of people with gout Table . The majGout was depicted as painful , affecting mobility , as a reason or excuse to prevent attendance at social functions or activities  and as affecting work ; for example, in Doctors, Charlie was unable to attend an audition due to a gout flare, “Ow! It’s painful … This toe will not be tapping today” .Gout was commonly used to set the scene of nobility, particularly in historical settings. In Vatel, the Prince has an attack of gout just as the King arrives to visit: “We have to be perfect! Go, go, go, go”, Vatel: “The Prince’s gout is bad. Tell Dr. Bourdelot” . The association of gout with nobility was used for humorous effect in some modern-day depictions, such as in Keeping Up Appearances, where it was used to demonstrate Hyacinth’s desire to be seen as part of the upper classes, as she convinces her husband to pretend to have gout rather than a fungus infection as it is “an affliction acceptable in the very highest circles.” .Having gout was also used as a method of emphasising character flaws such as weakness, greed and overindulgence. In Game of Thrones, the character with gout, Prince Doran, is murdered by Ellaria, who says “When was the last time you left this palace? You don’t know your own people, their disgust for you … Your son is weak, just like you. And weak men will never rule Dorne again.” .Gout was used as a plot device to explain a character’s absence from important events. An example of this is in The Favourite, where the Queen is portrayed as a self-indulgent and weak ruler, trying to avoid her responsibilities. She does not attend important meetings with officials due to attacks of gout, causing others to use her absence to advance their political ambitions: “Might I remind you you’re not the Queen?” Sarah: “No, she has sent me to speak for her. She’s unwell.” . This device is also used in Marco Polo where Kublai Khan can’t attend a feast due to an attack of gout, sending his son in his place, Jingim: “Hobbled by gout … He sends his regrets and me in his stead.” .Causes with examples are shown in Table Specific foods portrayed as associated with gout are shown in Table Management strategies for gout with examples are shown in Table Analgesia was mentioned as a management strategy in 7/22 (32%) of films and television episodes depicting the treatment of gout, such as Doctors: “Can you inject him with something to numb it? Then we can cram his foot into his shoe” , and  anti-inflammatory medications in 3/22 (14%), such as Dr. Ellingham in Doc Martin: “Yes, well, I’ll prescribe you naproxen to dull the pain” . Urate-lowering therapy and serum urate monitoring were mentioned in no depictions of gout in historical settings of gout and once in a modern-day setting.Gout was portrayed as humorous in 7/20 35%) of depictions in historical settings and 19/24 (79%) of depictions in modern-day settings, such as in Gut Punch: Webster: “I thought only sailors get gout”, Scooter: “No, that’s scurvy. Gout’s a fat person disease” . In Bleak House, Lawrence Boythorn is amused by his neighbour’s gout: “Sir Arrogant Numskull is here, laid up with the gout! Ha, ha, ha, ha, ha, ha … serves him right.” . It was shown as embarrassing in 11/20 (55%) of historical settings and 11/24 (46%) of modern-day settings . These portrayals fit with the historical narratives about gout as a disease of the upper classes and associated with overindulgence [Gout was commonly utilised as a plot device to explain the absence of characters from events, to set the scene of nobility and to explain the absence of characters from important social events or work. This is an accurate portrayal of the real-life experience of patients with gout, as absence from important events or work is frequently described by patients in qualitative studies , 21.This study aligns with the results of a previous study from our group analysing descriptions of gout in contemporary newspaper articles, which similarly showed that gout was portrayed as a self-inflicted condition associated with lifestyle choices . There iLimitations of the study include restricting the content to English language films and television episodes that aired from 1990. The study findings may not be generalisable to depictions of gout in non-English speaking countries. The time period was chosen to allow analysis of contemporary depictions that may influence current views about the illness. However, it is possible that content aired in earlier decades may influence the views of older people about the gout. The search term ‘gout’ may not have identified all depictions of gout; in order to maximise search results, film and television episodes were found through several methods including searching the Internet Movie Database, a Google search, and seeking recommendations from the Gout, Hyperuricemia and Crystal-Associated Disease Network (G-CAN). The films and television episodes were coded by two researchers to improve accuracy and discordant coding was solved by discussion with a third coder.This study has shown that in contemporary film and television, gout is portrayed as a humorous and embarrassing condition, caused by dietary over-indulgence. Aligned with causal factors, dietary change and short term medication are portrayed as the major management strategies. These representations may influence societal beliefs about the illness, and reinforce inaccurate beliefs about the causes of gout and its management.The present study identified that in contemporary film and television, gout is portrayed as a humorous and embarrassing condition, caused by dietary indulgence. These depictions may reinforce inaccurate beliefs about the causes of gout and its management.Additional file 1. Television episodes included in analysis.


Psychiatric inpatients receive a multidisciplinary treatment approach, covering psychiatry, nursing, occupational therapy, and psychology. Research findings reveal that the effectiveness of any treatment is associated with three types of factors: specific , common  and extra-therapeutic. However, there is little published research on the factors and events which inpatients themselves consider to be beneficial .N = 107) of a psychiatric clinic completed a questionnaire to elicit their appraisal of beneficial moments. A qualitative content analysis was applied. The coding procedure was conducted independently by two authors.Inpatients (N = 204), positive relationships (N = 140), clinical setting and environment (N = 52), inpatients’ new insights (N = 36), and factors unrelated to either therapy or the clinic (N = 30). In total, 44% of the quotations were related to specific factors, 49% to common factors, and 7% to extra-therapeutic factors.Self-appraised beneficial moments were found in five areas: therapy-specific components  than appraised by patients in our study . Our study underlines the importance of a patient-centred care approach as well as shared decision making and patient-clinician communication. For clinical practice, knowledge of inpatients’ perspectives on beneficial moments is crucial in order to reinforce precisely these therapeutic components. Psychiatric inpatients participate in a wide array of multidisciplinary treatments: inpatient care usually involves psychiatry, nursing, occupational therapy, and psychology . DetermiHowever, how the effectiveness of a psychological intervention is achieved still needs to be clarified. Since the late 1940s, psychotherapy research aimed to uncover the effect of ‘specific factors’  which rely on a specific psychotherapy theory . Beyond their specific components, different psychotherapy approaches typically share a variety of so-called ‘common factors’  patientsBeyond the theory-driven discussion of whether and how much specific, common and extra-therapeutic factors contribute to treatment effectiveness, qualitative examinations give an insight into what patients themselves find helpful for their symptom relief. Accordingly, a broad spectrum of themes has been examined in significant events research , which rIn the context of psychiatric inpatient care, qualitative examinations typically focus on the satisfaction with services , inpatieThe aim of this study was therefore to explore inpatients’ experiences of beneficial moments during their stay at an inpatient psychiatric clinic. We decided to examine subjective experiences of a good treatment in clinical practice rather than focusing on the criteria of efficacy, effectiveness, or efficiency that are typically applied in quantitative studies. Furthermore, we investigated whether the reported beneficial moments were associated with specific or common therapeutic factors, or extra-therapeutic factors, associated with the multidisciplinary treatments delivered in the clinic.The data are from a single Swiss clinic with 70 beds, located in a rural setting, for acute psychiatric disturbances with special focus on treatment of affective disorder and adjustment disorder, but no patients with drug dependency or schizophrenia. The treatment is multimodal with a focus on drug treatment and on psychotherapy including individual treatment (120 min/w direct contact) as well as several group therapies. The individual treatment is conducted by medical specialists. Furthermore, mindfulness-based body therapies  as well as creative therapies  are offered in individual as well as group settings. Nursing is provided on an individual basis and the interaction with the patient group is structured according to the concept of milieu therapy.The sample was drawn from all inpatients admitted to the clinic between January 1 and May 31, 2016. There was no selection or exclusion made. Of the 176 eligible inpatients, 107 patients (61%) filled out the questionnaire and participated in the study. All of these patients had a minimum stay of 4 weeks at the psychiatric clinic and were in the final stage of their stay.magische Momente”) to explore events that are associated with a healing process during patients’ stay at the clinic. Similar terms have also been applied in psychotherapy research ..magischeThe questionnaire measured inpatients’ self-appraised beneficial moments during their stay at the psychiatric clinic. An open question format was chosen. The use of open-ended questions in a questionnaire is suitable for first insights into a novel research field , 33. TheThe questionnaire consisted of additional quantitative questions  that focused at the following constructs: relationship with the medical specialists, plausibility of the treatment, expertise of the medical specialists, and personal involvement in the treatment process. The results of these questions are not reported in this qualitative study: The quantitative questionnaires were collected for internal clinical purposes and made it possible to obtain an initial rough overview.The data collection was completely anonymous and participation was voluntary. All patients were considered to have full control over the extent to which they wanted to participate. The second author (RM) was responsible for patient recruitment. Patients received the questionnaire at the end of their stay at the clinic. The completed questionnaire was brought by the patients to the last appointment with the treating medical specialist. The questionnaire was reviewed by the Local Ethics Committee, Zurich, Switzerland. The project did not fall within the scope of the Human Research Act (HRA) and no consent was required because no health-related data were assessed.https://atlasti.com) was used. The structuring content analysis was chosen since it is suitable for summary, structure, evaluation and analysis of large datasets.The data has been evaluated by applying the structuring content analysis developed by Mayring . For datThe summary is one of the elementary components of the qualitative content analysis. It focuses on the identification of people’s key messages by reducing them to major subjects. In detail, we classified identical and similar passages by topic and then combined similar factors into major categories. This allowed us to identify the main themes. Hence, we preserved the original content while producing an inductive summary at a higher level of abstraction. After identifying the main themes, we grouped them in accordance with the contextual model, i.e., whether they represent specific, common or extra-therapeutic factors in the treatment process .Two of the authors (CL and RM) were involved in the analysis. The first author (CL) holds a PhD in clinical psychology and psychotherapy. The second author (RM) is a medical specialist in psychiatry and psychotherapy. The authors share research interests on the impact of common factors on intervention effects. Using constructive feedback loops during the analytic process, the authors worked on minimizing the potential dominance of either professional background on the study results. In a first step, we analysed the transcripts independently  and identified the main themes and factors. In the next step, we compared the two coding schemes, debated disagreements, and reached consensus on one scheme.A total of 107 patients (68% women and 32% men) completed their inpatient treatment in the clinic during data collection and were evaluated for this study. Patients had a mean age of 54.4 years. The profile of respondents was similar to the clinic patients as a whole.The patients’ responses varied in form and length. Some provided lists of one-word responses, while others answered in whole sentences or narrative phrases. They included one to three factors per answer, and there were no missing responses to the question we were analysing. Occasionally, patients used punctuation or underlined words for emphasis.Specific therapy componentsPositive relationshipsThe setting and the environment of the clinicInpatients’ new insightsFactors unrelated to either therapy or the clinicTwenty-one factors were generated from the beneficial moments which respondents noted. Our data showed that patient-appraised beneficial moments could be described by five main themes:After identifying our main themes, we classified the factors in accordance with the contextual model, i.e., whether they represent specific, common or extra-therapeutic factors in the treatment process see Fig. . Five faN, is given in parentheses. The total number of quotations overall is N = 462.In the following subsections, we provide more details about the factors which influenced patient-appraised beneficial moments. The factors are grouped according to the themes above, with up to two quotations illustrating each factor. For each theme and factor, the total number of quotations, Numerous comments revealed that patients emphasize the impact of specific therapy components. Patients suggested a broad range of specific treatment approaches that are appraised as beneficial:Examples: “Perceiving the body in a new way ”, “Getting to know relaxation techniques ”.Many patients emphasized that a particular alternative therapy/therapist  or a general alternative approach  was associated for them with the experience of a ‘beneficial moment’. Examples: “To find mindfulness in everyday life”, “The fact that mindfulness permeates everything, coupled with mindfulness meditation, I have learned a great deal”.Respondents outlined that beneficial moments did occur when they payed attention to the present moment and the current experience. Examples: “The Quality of Life and Burnout Seminars where the knowledge and context of my illness was explained to me”, “Depression Seminar: I felt well and understood”.The patient’s participation in discussion-related group seminars as well as gaining knowledge about one’s own disease state through the communication during the seminar have been described as beneficial moments. Examples: “[…] that I managed to utilize the positive effects of lithium”, “Drugs despite initial negative attitude”.Patients also acknowledged that the pharmacological therapy that has been provided by the medical specialist is an important component of the therapeutic process. Aspects like the establishment, modification, or discontinuation of psychotropic drugs or other medications  were mentioned. Participating in sports therapies  of the psychiatric clinic were highlighted as a crucial therapy component.Examples: “The sports offer of the psychiatric clinic gave me great pleasure and motivated me to schedule some time for sports in the future”; “The group sports and game was much fun and a welcome distraction.”Another dominant view was that the experience of a positive relationship forms the basis of a beneficial moment. Notably, the majority of responses highlighted that a good relationship with fellow patients is a central element during the stay at the clinic:Examples: “Fellow patients: Reflection of behaviour and unvarnished, but respectful feedback among each other”, “The exchange with other fellow patients, the deep relationships during this time”.Several patients highlighted that the establishment of relationships with one or more fellow patients was indispensable for trust building and a ‘beneficial moment’ in itself. Examples: “Consultations with medical specialists”, “The medical specialist has accompanied and assisted me. Furthermore, he believed that I will make it”.Furthermore, respondents emphasized the importance of establishing a relationship with the medical specialists. Beyond the experience of being understood, they also found the conversations with the medical specialists helpful for information transfer. Examples: “Relationship, trust, understanding of […] the nursing staff”, “Consultation with the nursing staff: The professional’s support was outstanding. She [the nurse] challenged me regularly with her targeted questions and specific hints; the contact with her influenced the therapeutic success substantially”.Finally, some patients highlighted that the nursing staff enabled them to establish a trust-based relationship. Besides conversations, patients also mentioned the impact of nonverbal interactions with the nursing staff. Examples: “The feeling of getting help and being saved when needed”, “The trust that I could have already gained after a few days. […] this trust has made everything possible: Openness, to allow being helped, hope, patience, new recognition and insights”.Some patients did appreciate the genuine experience of an authentic relationship and the feeling of belongingness. Patients described the importance of openness and authenticity in relationships as well as the consequent feeling of a sense of belonging to a more superordinate social context. In contrast to the categories above, these patients did not refer to a specific person . Examples: “Conversation with relatives”, “The conversation with the medical specialist and my partner: we found a good solution for the topic holidays at home”.Two respondents mentioned that the conversation with their relatives under the guidance of the medical specialist was a ‘beneficial moment’ during their stay at the clinic. Examples: “Getting to know both medical specialists as highly competent”, “Competent professionals at all levels”.Notably, two patients appreciated that the professionals had a substantial expertise in their field. Patients emphasized that this provided the basis to resolve their problems. In this category, the expertise was named in the context of the therapeutic relationship. Implications of the setting and the environment of the clinic for patient care received considerable attention, and a mixture of opinions were offered about potential places for the experience of beneficial moments:Examples: “Feel-good factor: Location of the clinic”, “Beneficial moments in nature as well as with the beautiful animals everywhere around the clinic ”.Interestingly, a considerable number of patients mentioned that the landscape of the clinic was a beneficial moment for them. More generally, some also mentioned that the atmosphere of nature  around the clinic area was unique and healing for them. Examples: “Retreat to this quiet, beautifully situated place”, “In fact only the absolute peace”.Respondents acknowledged that the tranquillity as well as the silence of the clinical area was crucial for their own healing process. Examples: “The very attentive and helpful house cleaning team”, “The delicious food, the extremely friendly and fast service”.A few patients mentioned that the service and the hospitality of the clinic staff  were important aspects during their stay. Examples: “The opportunity to retire into a beautiful room, […], the aesthetics of the architecture and the furniture, the pleasant collective lounges ”, “The retreat: The cosy, spacious room with high ceilings, pleasant colours and the big bed”.The aesthetic style and ambience of the psychiatric clinic as well the area was highlighted by four patients to be an important part of their treatment success. A number of respondents commented on the association between new insights and the experience of beneficial moments; for example:Examples:“Understanding the cause of illness with the help of consultations with medical specialists and caregivers”, “Understanding the triggers and consequences of the depression and uncertainty”.Interestingly, some patients stressed that it was healing for them to find a functional explanation for their illness. Their original explanation changed through therapy into a functional explanation. Examples: “To get an external view of the situation and my life”, “To perceive myself as me and to be perceived as such, not as a role of ‘wife’, ‘pastor’s wife’, or ‘mother’”.Ten respondents highlighted that they were able to self-reflect their situation with the help of the therapy and that this was a crucial aspect for their individual healing process. They stated to perceive thoughts and feelings more consciously. Examples: “Self-help and self-therapy”, “Finding again my joie de vivre  after approximately 1.5 weeks after intake”.Two patients acknowledged that they experienced a reduction in demoralization in the first phase of the therapy. They started to believe in their own problem-solving abilities. Furthermore, the therapy helped them to acknowledge that external and troubling factors are changeable. Examples: “Feeling ready to go home.”, “I am looking forward to being at home and expect being able to transfer all that I have learned into my daily life”.Two respondents also stated that the therapy helped them to expect that the symptoms will decrease and will be manageable. They described a general increase in their quality of life and/or an increased resilience to recurrences. Some comments suggested that beneficial moments take place outside the therapeutic context itself; for example:Examples: “Room of Tranquillity, encounters with God”, “[…] and knowing to be supported in it by God, because he loves me and wants me to love myself”.The two pastors working in the clinic are employed and paid by the Protestant and Catholic churches respectively, and are not part of the therapeutic services of the clinic. A number of patients emphasized that the spiritual experience, the contact with the pastor of the clinic, or an inner experience triggered by spirituality or religiosity were important aspects of their healing process. Examples: “Regular jogging every day, linked with a daily sense of achievement and new confidence in one’s will”, “Sport is always healing for me”.Some patients stressed that some type of sport or physical movement was associated with a beneficial moment for them. In all cases, the patients practiced sports outside the therapy schedule. We set out to explore inpatients’ experience of beneficial moments during their clinical stay via a questionnaire. Furthermore, we intended to assess the distribution of specific, common and extra-therapeutic factors related to inpatients’ experience of beneficial moments. To the best of our knowledge, this is the first study focusing on events which patients themselves appraise as healing while classifying them as either specific, common, or extra-therapeutic.N = 204) like common factors such as positive relationships, inpatients’ new insights, as well as the setting and environment of the clinic (N = 228). Extra-therapeutic factors had almost a negligible association with beneficial moments during inpatients’ stay at the psychiatric clinic (N = 30). On the one hand, specific factors such as therapy components and expertise were commonly mentioned by inpatients during their clinical stay. Notably, alternative therapies such as Shiatsu, Yoga, and Qi-Gong were by far the most frequently used content categories. This is in line with recent meta-analyses in various mental disorders, indicating that alternative approaches have a significant treatment effect, especially when compared to waiting lists or treatment-as-usual controls [To date, psychotherapy research is often divided into two kinds of models – the medical model that stresses the necessity of specific factors in the treatment procedure, and the contextual model, which defines psychotherapy as a therapeutic process . In our controls , 36. On controls , 38.both competent and empathic [Gained insight through self-reflection states that “In several therapies, there were repeatedly moments when I was in balance, where I felt centred. I felt myself at the moment and it was good that way”.Furthermore, the results from our questionnaire can be compared with meta-analytical research findings  regardinempathic . Hence, The finding that there are marked differences between patients and researchers/practitioners in the ranking of how important different factors are in the inpatient care is not new. For example, Dowds and Fontana  examinedWe would like to acknowledge some limitations of this study. First, there was a selected enrolment into the study as only inpatients with affective and adjustment disorders were analysed. It might be that different results would be found in different settings with other diagnoses. For example, patients with anxiety and depressive disorders differ in terms of their treatment goals . Second,more important than specific factors in therapy improvement and that extra-therapeutic factors matter as well. Also, we recommend that practitioners should be open about their own personal expectations with the given treatment and ask about the inpatients’ idiosyncratic perspectives. This will increase the shared understanding of factors contributing to treatment improvement as well as the treatments’ credibility and plausibility. Third, for the clinical context, it could be beneficial to reinforce the interplay between specific techniques and common factors. For example, an emotionally warm and empathic style and a good relationship could be obtained during the specific treatment or through a specific method by that inpatients have the feeling of being understood and cared for. Fourth, qualitative investigations should be regularly consulted in clinical practice. Finally, future studies should focus on outpatients, where factors outside the therapy might have a greater impact on perceived beneficial moments.Several conclusions can be drawn. First, our findings indicate that a good treatment in clinical practice should acknowledge that patients have their own definition of what is important in a therapeutic process and, moreover, that their perspectives might differ from research findings. Second, from an ethical point of view, inpatients should be informed about research findings which indicate that common factors are Future studies should assess beneficial moments also six or 12 months after discharge to explore the retrospective and long-term sense of beneficial moments. Our results are drawn from a specific clinic with a focus on psychotherapy and an intense multimodal treatment; therefore, studies in other psychiatric clinics could enrich our understanding of the effects of therapeutic environment on inpatients’ subjective experience on beneficial moments. Furthermore, there has been an increased interest on the use of patient characteristics in order to match patients to the treatments that might be most suitable to them , 44. Her


The role and experience of non-abusing concerned family members (CFMs) in elder family financial exploitation (EFFE) is largely unexplored. This paper examines the experience of “trying to do the right thing,” focusing on what CFM’s were trying to accomplish , and resulting outcomes utilizing data from a qualitative study of 28 CFMs . Five common goals appear to be motivating CFM involvement, driven by a priority to ensuring the victim’s quality of life, as well as the desire to honor and respect the victim’s wishes, protect the victim’s financial well-being, preserve family relationships, and deal with the perpetrator(s). CFM help-seeking resulted in a wide range of outcomes, from making a difference by connecting victims to supportive services and interrupting the financial exploitation, to mixed results, and in other cases frustration with no desirable outcomes.


Background: Many studies indicate that men are more reluctant to seek help for mental health problems than women. Traditional ideas of masculinity are often seen as a cause of this phenomenon. However, little is known about the diversity of experiences during the processes of help-seeking and service use among men with depression who have already utilized mental health services. This study aims to explore men's experiences and attitudes toward depression, help-seeking, and service use in order to develop gender-sensitive services.Methods: Narrative-biographical interviews were conducted with men treated for depression (n = 12). Interview topics included individual experience with depression, help-seeking behavior, and mental health service use. Transcripts were analyzed using qualitative content analysis.Results: Before seeking treatment, men's help-seeking behavior was negatively affected by internalized masculine norms. However, findings indicate a change of attitudes toward depression after mental health service use. Men with depression emphasized a salutogenic perspective toward mental health problems and critically reflected on masculine norms. The positive function of men-only groups were described as key for successful service use.Conclusions: Men with depression reported experiences toward help-seeking and service use on four different levels: (i) attitudes toward depression, (ii) perception of societal views on depression, (iii) experiences within the family context and (iv) experiences with mental health services. Interventions to reduce the stigma of being “unmanly” and to improve men's capacity to cope with being unable to work should be developed. Peer-led men-only groups may increase participants' self-esteem and assist in disclosing weaknesses. In the context of GPs' mediating role, training for health professionals concerning the impact of masculine norms on mental health is recommended. There is broad evidence of men's reluctance to seek help for mental health problems. Studies support the generally-held assumption that men are less likely than women to get assistance from mental health professionals for problems . A body Further studies of a systematic review refer to the adverse effects of male role expectations and social pressures to perform well as family providers and fathers with consequences for help-seeking behavior. Depression was frequently perceived as a threat to men's roles as family provider and many participants reported feelings of inadequacy and incapability compared to their situation before depression . CompareIn addition to the impact of expectations regarding male roles on help-seeking behavior, studies revealed positive as well as negative experiences of  health service use among men with depression. A recent qualitative study referred to conflicts that men experienced in relation to antidepressant use . On the Even though traditional masculine norms play an important role in reinforcing men's reluctance to seek help, qualitative studies showed that some men seemed to benefit from just the same norms by perceiving these ideals as a healthy resource . While sDespite emerging evidence for the diversity of men's experiences of help-seeking and service use, many studies provide a one-dimensional understanding of mental health behavior among men with depression, including reduced service use. Beyond this, there is a lack of knowledge on how men's specific needs in cases of depression are addressed by mental health services. Moreover, the impact of norms concerning traditional masculine roles for men with depression who have already utilized mental health services is unclear. Previous studies on mental health professionals' view about the impact of male gender for the treatment of men with depression stress the need to develop gender-sensitive services . On the This qualitative investigation is part of the mixed-methods study “Constructions of Masculinity and Mental Health Behavior of Men with Depression” (MenDe) funded by the German Research Foundation. The study aims for a comprehensive analysis of men's constructions of masculinity and the consequences for their mental health behavior. Through an analysis of the diversity of concepts of masculinity, the study contributes to a more detailed picture of depression among men.In the first step, based on a sample of 250 men with depression, a latent class analysis was performed and three types of a combination of masculinity orientation and job-related attitudes were identified . In the Participants were recruited both inside and outside healthcare settings in Southern Germany. Eligible patients were asked by doctors or other clinical staff about their willingness to participate in the study. After expressing their willingness to participate, research workers contacted the patients, informed them about the aims of the study and verified the patients according to the following inclusion criteria: patients must be male, aged between 18 and 64, diagnosed or self-identified as having depression and sufficient German language skills. The study's exclusion criteria were organic mental disorder, dementia, anorexia with body mass index (BMI) <17, addiction and bipolar disorder or schizophrenia.We conducted narrative-biographical interviews  in whichTwelve interviews were conducted by a researcher (TS) between March and June 2018. The place for the interviews was chosen by the respondents. Interviews took place either at home or in the facilities of Ulm University, from which audio was recorded, transcribed verbatim, and anonymized. The duration of the interviews was between 27 and 133 min, with a mean of 75 min. Respondents were asked to answer socio-demographic questions at the end of the interview.Interview transcripts were analyzed using qualitative content analysis  via the n = 12) are presented in Interviewees' characteristics  attitudes toward depression; (ii) perception of societal views on depression; (iii) Family environment: between role expectations and social support; and (iv) experiences with mental health services . These mThe majority of interviewees reported that masculine norms influenced their attitudes toward depression as well as their decision to seek help. Some of them reported having “trivialized” their symptoms in terms of a “temporary” condition, which was expected to return quickly to a normal state of health: “It's a bit difficult at the moment, but it'll be fine again soon” . Most participants reported having tried to solve mental health problems on their own instead of seeking mental health services. Along these lines, some interviewees described their own as well as men's socialization in general as having an emphasis on avoiding feelings, appearing strong and never crying. One participant reflected masculine norms meant that he never disclosed mental health problems, saying that “[…] it doesn't exist among men. Men are the breadwinners, the problem solvers, the doers” . In order to meet traditional masculine norms concerning societal roles, respondents decided not to disclose their mental health problems and to post-pone their own needs:You have to play your part in the world of business. This means you can rarely be honest anywhere. That's the main thing, not to actually show how you're really doing .Interviewees explained low levels of help-seeking behavior as being a means of maintaining their employability as well as to safeguard career options. Therefore, one respondent reported that shortly after being admitted to a psychiatric ward due to a mental breakdown, he asked to be discharged “in order to go to work” . In line with a critical stance toward masculine norms, the analysis indicates a change in attitudes toward mental health problems during recovery processes. Interviewees emphasized a salutogenic perspective on depression and help-seeking. Respondents perceived having depression as an important “life experience”  or a “necessary wake-up call” . This perspective awakened them to the need to change harmful attitudes toward work and life: “Before my illness, work came first. And now I have to say I'm the top priority and I only do what is good for me” . Some participants viewed their depression primarily as a chance to reflect on their attitudes, which led to positive coping strategies in everyday life . Due to their critical stances toward masculine norms, interviewees recommended being “more sensitive to looking after oneself and noticing these warning signs earlier” . Others suggested detaching oneself from traditional masculine norms that inhibit help-seeking and service use for depression: “This kind of thing, of ‘I cannot show weakness, I cannot be sick’ should be avoided” .Participants referred to a variety of gender-related stigma experiences which could be classified into two categories: firstly, participants reported being assessed as incapable to adequately cope with mental distress. Depressive symptoms were not taken seriously by others who alleged that mental disorders are a result of an inability to deal with distress: “I've often heard people say ‘Get a grip! Don't make such a fuss’” . Secondly, stigma experiences were related to the failure to fulfill norms relating to work. One respondent reported that he had been shunned by workmates and management due to his failure to cope with mental health problems: “They said I didn't appear to be sick and that they had never been sick in their lives” . The analysis revealed that “not being sick” was associated with attributes of being strong, successful and self-reliant conveyed by the employment environment. In contrast, mental health problems in the workplace left interviewees feeling weak and vulnerable. Thus, they reported that their depression-related incapacity to work made them feel stigmatized by other colleagues. Participants were labeled “loser,” “lazy,” or “incapable” . Along with these experiences, respondents on sick leave reported being afraid that “outside my house somebody could ask me ‘What are you doing for work these days?’”  Some participants developed strategies in order to meet work-related norms, e.g., by telling people “I'm a freelancer. I'm working from home at the moment” . Against this background, respondents stated that seeking help continues to be viewed negatively as it is connected with the inability to cope with mental distress: “It's certainly still the case that people say, ‘Oh, he needed help, he can't do it himself’” . Interviewees perceived little understanding of what it means to have a depressive disorder and seek help within different social and job-related contexts. Some respondents reported fears of being stigmatized, which led to them rejecting inpatient services:The goal is under no circumstances to check into a clinic, because then the stigma is even bigger. That means you can't hide it any more, either at work or in your private life .However, some participants perceived a slowly growing societal acceptance for professional help-seeking. One respondent noted that “People used to be locked up. All psychiatric institutions used to be completely closed off, and in the last 15 years they've become much more open” .Participants reported both negative and positive experiences within their familial context during the help-seeking process. Some men perceived a loss of empathy that might be related to the duration of mental health problems: “I feel like I can't really mention my depressive symptoms at home anymore, because obviously it's annoying [for my family]” . Participants described a lack of understanding regarding their depression and their “inability” to recover:The worst thing is my environment: “You've been to the hospital twice now, you are taking the medication and you have been on holiday, you must be healthy now” .Others reported that the diagnosis of “depression” was not taken seriously by family members but seen as a pseudo-problem . Within the familial context, paternal role expectations were an important issue for some participants: “My family couldn't understand that I, a father, didn't go to the hardware store today, because I didn't feel good. It was never really recognized” . In contrast, an open-minded and appreciative family environment was seen as assisting in the seeking of professional help . Further findings underlined the supportive role of the partner as the “rock”  in the help-seeking process: “Without my wife, I wouldn't still be sitting here. I wouldn't have accepted any help, and I would be sitting somewhere in a clinic where I wouldn't be able to open the door by myself” .Participants described both negative and positive experiences with  health service use. Some respondents reported a lack of interest as well as a downplaying of depressive symptoms by GPs which led to them no longer seeking help:The GP said, “Yeah, my God, I'm seeing you again? So, what have you got? Problems at work? So, a lot of people have problems. Don't get so upset!” .In some men's views, GPs tended to relativize depressive symptoms and recommended calming oneself down. In contrast, other interviewees reported the role of GPs as being a gateway to mental health services and being generally supportive and encouraging as well: “I told him everything. And then he pressed a note into my hand and said I had to go to the clinic immediately” . Alongside structures of formal service use, interviewees pointed out the positive role of other informal service users' social support during and after inpatient services. They reported the key role of a face-to-face exchange with fellow service users, especially those with a similar illness-related background, which was described as a supportive feature during the help-seeking process. Respondents felt accepted without being questioned by others: “There was no question of why… just this listening and sympathy and being there for you” . In particular, group counseling for men with depression was perceived as facilitating the disclosure of weaknesses. For this reason, interviewees preferred approaches that enabled them to address anxieties in a group of fellow service users who identify with the same gender. Relatedly, participants highlighted the familiarity of men-only groups in the context of inpatient services: “You can really show your true self. You can show weakness and it won't be interpreted negatively. Nobody laughs at you” . Because of societal expectations due to masculine norms as well as perceived stigma of being “unmanly,” some participants defined inpatient services as a sheltered space: “You're in a kind of cocoon, where you're protected, where you feel really comfortable. Where you're doing well” . Others described inpatient services as being their first opportunity to open up to someone else: “That was the first time I was able to be open about my problems like that” . These interviewees perceived inpatient services as being a protection against external expectations which they were unable to meet due to mental health problems. Instead of having to meet the expectation of being active and responsible, service users are allowed to be “passive” recipients:I really appreciate the clinic. To be free of my responsibilities for a while. In a clinic, you're completely relieved of it. You're given a plan to work through .Consistent with the change in attitudes toward mental health-related help-seeking, interviewees described their experiences of inpatient services as an “educational resource”, where they could benefit from fellow patients' life experiences and learn how to cope with depressive symptoms: “I learned a lot through meeting people with the same problems. That makes you smarter, when you know how to deal with it” .The objective of our study was to explore experiences and attitudes toward depression, help-seeking and service use in a sample of men undergoing treatment for depression. Our findings suggest that men with depression retrospectively give both negative and positive experiences of help-seeking and service use. On the one hand, they report the adverse impact of masculine norms as well as stigma experiences. On the other hand, results indicate a transformation of their attitudes toward traditional masculine norms by critically reflecting on non-help-seeking behavior as well as maladaptive work patterns. In this regard, peer-led men-only groups were seen as assisting the disclosure of anxieties.Retrospectively, the interviewees perceived that they trivialized and downplayed their symptoms, which they justified using the societal role of caring for their family or to meet career-related expectations. This is in line with previous studies showing that men who suffer from depression have difficulties disclosing their mental health problems, reasoning that traditional masculine norms such as being strong, successful, and self-reliant inhibit help-seeking behavior . FurtherAdditionally, our findings also report on stigma experiences, which relate to the inability to cope with mental distress as well as to perform expected job- and family-related roles. The concept of mental illness stigma describes a process that involves labeling, stereotypes, separation, loss of status, and discrimination , 22. TwoSome interviewees indicated negative experiences in seeking GPs' help for depression, whereas other participants pointed out the importance of GPs as gateways to mental health services. This discrepancy is in line with results from a qualitative study that identified positive factors that may assist men's help-seeking decisions . These fContrary to the power of traditional masculine norms as an obstacle to seeking help, our findings indicate a change of attitudes toward service use during the participants' recovery processes. Our qualitative analysis pinpointed a critical stance toward masculine norms as well as a salutogenic perspective on depressive illness and service use experiences among interviewees after seeking help. In contrast to the assumption that psychiatric service use contradicts masculinity , our resBecause study participants had used mental health care services prior to the study, results only refer to participants who had successfully sought help. Therefore, our findings are not able to explain reasoning processes in men who have never sought help for mental health problems. Another limitation is the small sample size as well as participants' high age (mean = 52), which means it is not possible to reveal age-related differences in help-seeking attitudes and behavior. However, there may be variances of dealing with depression in the light of society's expectations, e.g., relating to the male “breadwinner” role. Alongside the need for age-differentiated analyses, future studies could focus on fathers with depression to explore the meaning of fatherhood for coping with depression. While most of the reviewed literature demonstrated how masculine norms create barriers in seeking help for depression, more evidence on preferred types of service use is needed, e.g., in terms of the role of GPs as a potential point of contact for further information about mental health services. Furthermore, other findings suggest that the educational level is associated with the rigidity of gender roles, i.e., that a low level of education corresponds to rigid gender roles. Future research could focus on differences between milieus and along socio-demographic factors  to examine these hypotheses. Finally, our results show that it would be of great interest to conduct quantitative studies examining mental health needs among men with depression in a broader population. Although our study did not reveal any impact of socioeconomic status (SES) to masculinity orientations and service use behavior quantitative studies should include measurement of SES.Real Men. Real Depression.” campaign that aimed to increase public awareness and help other men recognize depression . The patients/participants provided their written informed consent to participate in this study.SK, RK, HG, TB, and PB proposed the project idea. SK supervised the project. KF, MP, MSc, HG, and PB helped with participant recruitment. TS, AM-S, MSt, and SK undertook literature research and conducted and analyzed the interviews. TS drafted the manuscript. All authors contributed to and approved the final manuscript.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.