The final sample consisted of 28 participants: 9 service users from the inpatient ward, 8 from the rehabilitation day unit, 4 from the day center, and 7 from the community team. The mean age was 43.78 years [standard deviation (SD) = 13.80], and the mean years of using mental health services was 15.08 (SD = 10.20). The majority of the participants were men (56.60 %), single (67.90 %), with vocational education (53.60 %), and unemployed—receiving disability benefits or pension (74.10 %). Nearly one-third (28.60 %) of the participants had a university degree.
In relation to recommendations for a psychosocial intervention, people referred to all identified recovery themes, expected structure, and favorable method of implementation.
The Concept of Personal Recovery
Theme 1 Psychological dimension of recovery. This dimension of recovery was the most frequently endorsed recovery theme. It was reported by a total of 16 focus group participants and consisted of identity transformation, finding a meaning and purpose, emotional well-being and recovery being a journey. Identity transformation referred to a number of processes, which were categorized into the development of the motivation to change, illness awareness and personal growth. Personal growth was the most frequently reported aspect of identity transformation, emphasizing the importance of developing positive self-identity with narratives referring to the acceptance of illness and oneself, the development of self-esteem and self-empowerment, psychological distancing, or stigma management. This reflects the following service user quotation: “Recovery is about not stigmatizing oneself … seeing that I am not the illness itself … [it is] also seeing oneself as a worthwhile person … because I survived this illness … so discovering self-value with self-esteem that relates to these experiences.” Participants also reported that finding the meaning and establishing goals in life was another factor relevant to recovery: “discovering the meaning of life … the purpose of life … leading the life according to good values … discovering the meaning and discovering the values.” The need of discovering the meaning of illness or spiritual development was also a common narrative, e.g. “It depends on one’s worldview but I think, as many of you said, faith and prayer helps a lot.” Goals were described in the context of establishing values, vocational reintegration or leading a responsible life free of debts, problems with the law and correcting problematic behaviors. The subcategory of well-being was reflected by narratives about feeling good with oneself, inner peace and achieving life equilibrium. One of the focus group participants explained that emotional well-being was paramount to medication: “… human well-being is so important … that the person feels good. Medication [can help] but the person has to feel good and this is the most important and this is recovery.” Life equilibrium was attributed to a peaceful life, moderation, having contact with nature, and a life-work balance. Recovery was also described as a long-term process in which the challenges of illness change. This process is not focused on “being cured” but on overcoming illness difficulties as described: “I have been ill for the last 16 years … [at the beginning] I [hoped] that I would be completely cured… but now I think it’s about overcoming the illness … perhaps all my life I will live with it … [I need] to accept it somehow ….”
Theme 2 Relationships with others. Another theme of recovery contained narratives related to relationships with others. A total of 15 participants reported relationship experiences, which were grouped around contacts with people and communication. Some participants expressed that having contact with other people, as well as engaging in social activities were both essential to recovery. Developmental aspects of interpersonal contacts also emerged which was interrelated with personal growth: “Working on what is difficult for me helped me to initiate relations with people … I began to understand more myself … a greater empathy to people was developed, openness, trust.” Regarding communication, some participants underlined its importance in establishing contacts with people. These referred to the importance of talking with people, managing conflicts or the increased sense of connectedness as a result of communicating with others. The following account emphasizes the importance of sharing the experience of illness in contributing to its better understanding: “Well, listening to others… helps in understanding that things like this happen in this illness.”
Theme 3 Wellness strategies. A total of 12 participants reported a range of wellness strategies contributing to recovery, which were categorized into the following subthemes: being active, leading a healthy lifestyle and coping with symptoms. Being active was attributed to motivational aspects as well as leading an active life. Motivation was driven internally and externally. For instance one of the participants underlined the role of self-motivation in dealing with inactivity: “Overcoming inactivity, forcing oneself to be active … simply creating intentions to do something despite difficulties. This motivation is important.” However, another participant underlined the value of participation in activities at the hospital as mobilizing: “Recovery for me [is] maybe when I am a bit more active. Because before I felt like doing nothing, nothing interested me, and I come here and this helps me a bit … this mobilizes me.” Activities described in this subtheme considered daily commitments at the hospital or recreation and activities outside of the hospital, such as going to the cinema, theatre, library, engaging in social relationships, and daily life activities (e.g. cooking, walking a dog or sports). A number of accounts emerged that were categorized as healthy life habits. These were described in terms of eating regularly, taking medication, exercising, praying, developing healthy interests and hobbies, looking after oneself, regular visits to a doctor and following medical advice. Coping with symptoms was mostly attributed to coping with hearing voices and having control over them as well as overcoming fears and having emotional self-control, for instance “For me the element of recovery is … I control the voices, that the voice don’t take control over me … I can separate it … I am aware it is an element of illness.”
Theme 4 Clinical understanding of recovery. The clinical understanding of recovery was reported by a total of 9 focus group participants. Narratives reflecting this theme included a lack of symptoms, return to a former state of health, attitude towards medication, and a lack of difficulties related to illness. One of the most debated aspects of this pertained to medication. Most of the participants underlined the necessity of taking medication, while emphasizing that pharmacotherapy had to be carefully managed. One of the participants stressed that the right kind of medication is crucial in recovery: “I would insist however … it is important the prayer, eating well and all that [are important], but in this illness well-prescribed medication is 80 % of success.” However, another participant clarified that medication does not prevent relapse: “I take medication … and despite taking medication I relapse, completely out of nowhere … I take medication regularly, at the same hour, I care so much about being healthy and functioning normally, but despite this, the illness comes back.”
Theme 5 Support systems. Five participants reported that access to supportive systems fosters recovery. This was attributed to a secure livelihood and satisfactory psychiatric mental healthcare. Matters of livelihood considered difficulties in navigating and obtaining information within the support system but also stressed the importance of the security of accommodation, food, and economic stability in recovery as depicted in the following quotation: “Livelihood matters are important, to have something to eat and security of accommodation … financial stability is important as well.” The subcategory of psychiatric mental healthcare referred to the availability of mental health services and the quality of relationships with mental health professionals. The need of treatment from the outside of the hospital emerged: “… as it is known I cannot go to hospital all my life, to be sick in a hospital … but a doctor that comes to you privately and will advise on medication or something.” Participants also described a number of experiences referring to the quality of contact with mental healthcare staff. These included accounts about the openness of contact, acceptance, partnership, and friendliness of these relationships. One person underlined the role of partnership in managing medication: “If I tell him, that I react badly to this drug then he will decrease the dose and prescribe another drug, or we will just talk and he will suggest something …a good doctor with whom you can talk.”
Intervention Recommendations
The exploratory focus group study revealed a number of recommendations within each recovery theme. With regards to the psychological dimension of recovery participants’ recommendations covered the majority of identified recovery elements, that is transformation of identity, finding the meaning and purpose in life and achieving life-balance with the aspect of positive identity development being the most widely supported. The theme relationships with others reflected the need of communication and having contact with people; however, the importance of other people involvement in the process of recovery also emerged, for instance: “When I get worse I need a kind of … friend or someone from family who will visit me in the hospital.” As to wellness strategies participants recommended living outside the hospital, fulfilling daily activities and managing symptoms; however, symptoms management such as development of criticism towards symptoms was the most common narrative, for example: “… when I relapse I need someone … to tell me that what I think does not exist.” Regarding support systems participants underlined the need of information provision about available financial support when feeling ill as well as having a good quality and regular contact with mental healthcare staff, for example: “Sessions with a psychologist … once every 2 or 3 weeks, sometimes once a week…it gives me a sense of security.” Lastly the need of continuation with well managed medication was underlined, as in the following example: “Now that I have well-prescribed medication I can balance everything. I have time for prayer, eating, and earning some money.” In addition to the identified recovery themes participants suggested that the intervention should be individualized in the sense of considering individual capabilities, pace, and not being imposed in any way. “It has to be adjusted to the specific phase of recovery … as it can be hurtful … if someone is too ill [they]cannot participate in this intervention.” There were also views indicating that treatment should be conceptualized as a personal development process and that it would be unconstructive if it reinforced peoples’ feeling about being ill: “… a kind of developmental coaching … showing people possibilities [in life] … if you fear something you don’t have to focus on the fear and take the pill …” or “It depends on the people that surrounds us … the belief that we are not normal … it would be a negative intervention.”