Between Acceptance and Concealment: Living with Bipolar Disorder in Southeastern Iran

Bipolar disorder is one of the most disabling chronic psychiatric conditions worldwide, yet the way patients experience and interpret their illness is profoundly shaped by culture. A new qualitative study from Kerman, a city in southeastern Iran, offers a rare window into how adults living with the disorder perceive their condition, think about treatment, and navigate the dense web of family and social expectations that surrounds them. Published in BMC Psychiatry, the research by Behshid Garrusi of the Neuroscience Research Center at Kerman University of Medical Sciences, sociologist Saideh Garousi of Shahid Bahonar University of Kerman, and psychiatrist Farzaneh Raaii of Shahid Beheshti Hospital, reveals a lived experience organized around a continuous tension between acceptance and concealment, and between support and control.

The team used a descriptive phenomenological approach, a method designed to capture the essence of lived experience as participants themselves describe it. Between October 2024 and May 2025, the researchers conducted in-depth, semi-structured interviews with twelve adults, six women and six men aged 22 to 41, recruited from six specialized mental health clinics in Kerman. Every participant met DSM-5 criteria for bipolar disorder, had experienced at least two mood episodes requiring treatment, and was in remission at the time of the study. The interviews were analyzed using Colaizzi’s seven-step method, a rigorous qualitative framework that moves from reading raw transcripts to extracting significant statements, formulating meanings, clustering themes, and finally describing the fundamental structure of the phenomenon. Saturation, the point at which no new information emerges, was assessed through team discussions based on code repetition across consecutive interviews.

Four major themes emerged from the analysis. The first describes the psychosocial process of adaptation, a trajectory that begins with denial of the diagnosis, passes through a difficult period of acceptance, and can end in what the authors call legitimation, the point at which a person comes to see their condition as a legitimate part of their identity rather than a shameful secret. This progression is not automatic or linear. Participants described oscillating between acknowledging their illness and pushing it out of awareness, a dynamic that directly affected whether they sought care, stayed on medication, and disclosed their diagnosis to others.

The second theme concerns the individual meaning-making structures through which participants explained why they had become ill. The researchers identified three distinct types of attribution: moral, supernatural, and contextual. Some participants framed their disorder in moral terms, as the consequence of personal failings or wrongdoing, a framing that carried heavy self-blame. Others reached for supernatural explanations, reflecting cultural and religious frameworks in which affliction can be understood as spiritual in origin. Still others offered contextual accounts, locating the cause of their illness in life circumstances, stress, and social conditions. These explanatory models matter clinically, because what a person believes caused their disorder shapes what they think will cure it, and whether a mood stabilizer seems like a rational answer at all.

The third theme, conflict with the treatment system and society, captures the ambivalence many participants felt toward psychiatric medication and the pressure they experienced toward what the authors describe as forced normalization. Ambivalence toward medication is a well-documented phenomenon in bipolar disorder research, but here it acquired a distinctive cultural texture. Participants weighed the benefits of pharmacological stability against concerns about dependency, side effects, and the social meaning of taking psychiatric drugs in a community where mental illness is heavily stigmatized. Forced normalization refers to the societal expectation that patients should appear normal, conceal their condition, and conform to social norms, regardless of their actual wellbeing. The pressure to perform normality, the study suggests, can itself become a barrier to honest engagement with treatment.

The fourth theme maps the context of interpersonal and social relationships, and it is here that the study delivers some of its most striking findings. Family emerged as a double-edged institution, simultaneously the most important source of support and a significant source of restriction. In collectivistic settings such as southeastern Iran, the family is the primary safety net for people with chronic illness, monitoring medication, accompanying patients to clinics, and providing economic and emotional backing. Yet the same closeness enables surveillance and control. Participants described family members who restricted their autonomy, made decisions on their behalf, and treated the diagnosis as a family secret to be guarded rather than an illness to be managed openly. The paradox of support and control, the authors argue, is a defining feature of the lived experience of bipolar disorder in this context.

Gendered pressures added another layer of complexity. Women and men encountered different expectations about how their illness should be expressed, concealed, and accommodated, and these expectations shaped their social functioning and their willingness to disclose. The study also found that participants’ support networks were fragile, often limited to immediate family and vulnerable to rupture. Because stigma operates at the level of the family as well as the individual, a diagnosis could affect marriage prospects, family reputation, and social standing, giving relatives strong incentives to enforce concealment. The result is a support system that is indispensable and constraining at the same time.

Running through all four themes, the researchers identified a single fundamental structure that unifies the lived experience of their participants: a continuous dialectical tension between acceptance and concealment, the paradox of support and control, and the interplay between individual agency and social structure. Patients are constantly negotiating how much of themselves to reveal, to whom, and under what conditions. Social stigma, the authors conclude, is the central and pervasive force that binds these tensions together, shaping participants’ identities, their relationships, and their engagement with treatment. Stigma is not an external add-on to the illness experience in this setting; it is woven into every decision about medication, disclosure, marriage, work, and friendship.

The clinical implications are significant. The authors argue that interventions in this context must be culturally sensitive, targeting stigma reduction, family education, and structured support systems rather than the individual patient alone. Because families function as both caregivers and gatekeepers, educating relatives about the nature of bipolar disorder could transform them from instruments of concealment into partners in care. Because explanatory models are moral and supernatural as well as biomedical, effective treatment engagement requires clinicians to understand and work with patients’ own causal beliefs rather than dismissing them. The study’s authors call for future models of care that integrate biomedical approaches with community-based mechanisms tailored to the cultural realities of southeastern Iran, a region where specialized mental health resources are concentrated in urban clinics and where the social costs of a psychiatric label remain high.

For the international research community, the study is a reminder that bipolar disorder is never experienced in a cultural vacuum. Most of what psychiatry knows about illness perceptions and treatment adherence comes from Western, individualistic societies, where the dominant model assumes an autonomous patient making independent decisions about care. This research from Kerman shows what happens when that assumption fails: the patient is embedded in a family and community whose interests, fears, and reputations are entangled with the illness itself. Understanding recovery in such settings means understanding the dialectic the researchers describe, in which every step toward acceptance is shadowed by the pull of concealment, and every offer of support carries the possibility of control. The twelve voices captured in this study suggest that improving outcomes for people with bipolar disorder in collectivistic cultures will depend less on new medications than on changing the social conditions under which the illness is lived.

Subject of Research: Illness perceptions, treatment attitudes, and social relationships among adults with bipolar disorder in southeastern Iran

Article Title: Illness perceptions, treatment attitudes, and social relationships among clinic-attending adults with bipolar disorder in Kerman, Iran: a qualitative study

Article References: Garrusi, B., Garousi, S., & Raaii, F. (2026). Illness perceptions, treatment attitudes, and social relationships among clinic-attending adults with bipolar disorder in Kerman, Iran: a qualitative study. BMC Psychiatry. https://doi.org/10.1186/s12888-026-08722-6

Image Credits: AI Generated

DOI: 10.1186/s12888-026-08722-6

Keywords: bipolar disorder, qualitative research, illness perceptions, social stigma, cultural psychiatry, Iran, family relationships, treatment attitudes, phenomenology, mental health, collectivism, medication adherence