Since the aim of the present study was to qualitatively explore the experience of Greek- Cypriot individuals living with mental illness, it should be noted that this is the first study, to our knowledge, which investigates this issue within the cultural context of Cyprus, both prior to and after deinstitutionalization. In particular, this study took place under the recent psychiatric reform in Cyprus, which resulted in a change in the type, number and staffing of mental health services. The main findings of the study regard: a) the meaning of mental illness as an unbearable, suffering disease, b) the perception of the self during the illness and how this is associated with adherence to pharmacotherapy and subsequent clinical outcome of the disease, c) the perception of different phases of the illness in time, d) perceptions about the effectiveness of pharmacotherapy, e) social and personal consequences for the participants following the diagnosis of mental illness and related social stigma, f) the different phases of the therapeutic relationship between patients and mental health nurses in time, and g) the quality of provided mental health services as perceived by people living with mental illness.
The meaning of mental illness, its therapy and perception of the self
With regard to the meaning of mental illness, a painful, suffering and multifaceted experience was described herein by the participants, congruent to previous studies [
54,
103‐
107]. Participants clearly described two distinguished sources of suffering; firstly the distressing experiences stemming from the pathophysiology of the disease and side effects of pharmacotherapy and secondly social stigma associated with mental illness and psychotropic medication. The unbearable and multisided pain following the onset of mental disorder symptoms has also been previously described in international literature as a catastrophic experience which interrupts one’s life [
108‐
112]. However, the concrete differentiation among the main sources of suffering reported herein has not been formerly discussed in depth in the literature, and may further be useful in education of healthcare professionals regarding the recovery model and its implementation to mental healthcare [
113], as well as in the way recovery-oriented psychotherapeutic interventions may be organized. For example, a key target of such approaches may be the alleviation of distress following SMI diagnosis and possible consequences of relevant trauma, as well as the empowerment of people living with SMI through the periods of suffering [
114]. An additional group of interventions may encompass pharmacotherapy-related psychosocial techniques and the effective management of its adverse events under the scope of patients’ wishes and needs [
115,
116].
Most importantly, these findings reveal the limited implementation of recovery-oriented approaches in the healthcare system in Cyprus, since the participants appeared to suffer strongly due to their illness, while their re-engagement into everyday routine seemed to be only partially achieved [
117]. In contrast, the key principles of recovery-oriented healthcare systems determine that individuals living with SMI are viewed as facing chronic, rather than acute, problems which necessitate long-term support with emphasis on recovery management rather than disease management [
117]. The focus is on the enhancement of a positive self-image and self-determination, remission of symptoms and systematic empowerment for a normal and qualitative way of living. Overall, recovery-oriented approaches focus on inspiring hope in people living with SMI and their families, person-centered care and finally the needs and perspectives of mental health services consumers [
118].
The lack of recovery-oriented system in mental healthcare in Cyprus may also explain the way the participants perceived themselves during the illness [
119]. The descriptions they chose to portray themselves were mainly negative ones, for example “bad person” or “tormented person”. Such descriptions seem to reflect the participants’ diminished self-esteem, stemming probably from inadequate implementation of interventions which aim to enhance their resilience and positive personal identity traits. [
114] One may argue, by contrast, that negative self-image may also rise from the common universal stereotypes often attributed to mentally ill people, such as “dangerous” or to their disease as “untreatable” or “bizarre” [
68]. Research shows that most of the times the public describes the majority of chronic illnesses, such as cancer or heart failure, as “bad situations”, giving emphasis on the condition related to the disease [
105], as opposed to mental disorders, where emphasis is given on the person suffering from it. This discrimination gives ground to labeling and social stigma, consequently affecting the self-image of individuals living with mental illness [
67,
105].
In line with the above, we also suggest that the fact that the majority of the participants chose a common Greek-Cypriot name or surname as a pseudonym may to a degree reflect on the participants’ need not to aspire to the identity of the mentally ill person. Hence, their illness would be perceived as a common one, unable to influence their personal identity and esteem in a negative way. Prior literature illustrates the need of mentally ill people to preserve their self-identity prior to illness, and consequently their uniqueness and individuality beyond the psychiatric diagnosis [
24,
116]. Moreover, data shows that loss of self-identity is strongly connected to the onset of mental illness, and intensified by social and self stigma [
120,
121]. The study by Wisdom et al. [
111] exploring identity-related themes in individuals living with SMI revealed that these people experience loss of their self due to the onset of mental illness, having the sense that they are either dead or that they have lost a particular part of their identity, mostly connected with their social roles e.g. being a parent. Additionally, Wisdom et al. [
111] reported that people living with mental illness often describe their self as a stranger when they refer to their existence during the illness, while they also mention a perception of duality of self in terms of the sick and the healthy self. Based on the results of the present study and related literature, we propose that interventions targeted at helping people maintain positive self-identity and self-appraisal through the different phases of mental disease is of utmost importance.
The way mentally ill people internalize their self during the illness and the degree to which this perception influences their self-esteem and self- image appears to be a really important issue, since it seems to be related to adherence to therapy, both psychosocial and pharmacological and subsequently to clinical outcomes [
103,
122]. Based on such data, the findings of the present study highlight the need for recovery-oriented approaches focused on the enforcement of positive personality values, such as positive self-appraisal, motivation and hope in order for the Cypriot consumers of mental health services to gain the desired quality of life [
122]. In more detail, the participants of the current study described that the symptoms of their disease had affected their existence negatively. They also stated that it was mainly through pharmacotherapy that their symptoms had gone away, and hence were able to attend rehabilitation programs and further reintergrate into society, gaining a perception of positive self-value. Overall, one may argue that participants’ need to preserve a positive self-perception was both the main buffer against the negative effects of pharmacotherapy and the ultimate means of adhering to pharmacotherapy, as they did not mention any psychotherapeutic approaches provided to them towards this goal. In contrast, along with the effectiveness of pharmacotherapy, the participants underlined personal initiative and effort against the limitations set by the illness as a prerequisite for recovery.
At the same time, participants described that engagement into pharmacotherapy was also associated with demeaning self-appraisal, mainly due to social stigma and subsequent self- stigma. As a result, participants described an ongoing struggle to accept the effectiveness of medication, however, without, mentioning any kind of support through this process. This ongoing struggle was supported by the positive effects of pharmacotherapy on self-perception and functionality, as well as stigmatization and social withdrawal. Participants characterized stigmatization as an important consequence of being prescribed psychotropic medicines, which caused their transition into the group of “sick people”. It seemed that pharmacotherapy in some way evoked the formation of the identity of “mental health patient” for the participants, a fundamental reason for them to drop out of therapy. Based on the above, one may underscore the lack of interventions to effectively address issues associated with sigma within the Cypriot cultural context, both social and healthcare related, in order for people living with SMI to achieve quality of life [
123].
Nonetheless, the necessity of medication to control symptoms, improve cognitive functioning, prevent relapse and promote recovery has been stressed in international literature [
73,
120,
121,
124‐
127]. However, this requires effective management of pharmacotherapy and relevant adverse effects, and, mainly, participation of mental health services consumers in the development of the therapeutic plan [
99]. Interestingly, Piatt et al. [
36] underlined medication as a means of transformation of self and further as a major component of recovery, although they did not address the way medication may empower self-view and self-appraisal throughout the different stages of ill health. Furthermore, there are studies with contradictory findings on this subject. For example, according to Mansell et al. [
125], pharmacotherapy is described as a way for “blurring the water”, since individuals under medication are not able to differentiate between their true self and their self under medication, hence unable to attribute their behavior to their personal characteristics or to antipsychotic medication [
125]. In addition, in the study of Spaniol et al. [
57], pharmacotherapy was interpreted as a means of remaining enslaved in mental health system. In conclusion we suggest that all these issues need to be taken under consideration when interventions are targeted on the empowerment of people living with SMI.
Moreover, despite the fact that in the present study, acceptance of pharmacotherapy was an important element in participants’ recovery, there is no data, even anecdotal, to support the issue that medication management approach by mental health professionals in Cyprus is in line with the recovery model. In particular, in Cyprus, as well as in Greece [
128] there still exists the physician centered culture, hence the consumers of mental health services are not actively involved in decision-making processes regarding their medication. As a result, medication is usually prescribed with little or no consultation and often, without consideration of the individual's wishes and experience, affecting one's willingness to accept medication or even to comply with instructions given by a mental health prescriber. Based on that, the present study highlights the importance of the implementation of the recovery model and patients’ participation in decision making, not only in Cyprus, but in all those countries which still hold a physician centered approach and power relations between mental health professionals and patients.
The data reported herein with regard to the way participants experience their living with the illness and subsequent therapy, call for the reorganization of the culture of mental healthcare policy in Cyprus towards a more recovery-oriented approach in both community and hospital organizations. Empowerment of the resilience of people living with SMI, participation in decision-making and planning for their own care, along with effective management of pharmacotherapy, need to be the ultimate focus of mental health services [
119,
123]. Unfortunately, within the mental healthcare system of Cyprus there still exists disease – centered approaches, characterized by limited involvement of mental health services consumers in the design of the therapeutic plan [
61].
According to international literature, transformation of mental health services towards a recovery-oriented system of care requires the collaborative work of all organizations involved in mental healthcare in order to articulate a framework and a mandatory strategy for recovery and well-being in relation to mental health problems. The proposed policy needs to address future healthcare plans, hospital accreditation standards and annual objectives for hospital and community mental health services [
123]. The objectives should include: a) empowerment of individuals living with mental illness and their families, in order to be able to participate in designing their own care, as well as meet their everyday life needs in a culturally competent manner, b) promoting self-determination in people living with SMI, and c) educating healthcare professionals about the principals of recovery-oriented healthcare systems [
35,
114,
117,
123].
According to Park et al. [
123] such an effort may include a) quantitative and qualitative research to assess the knowledge and relevant attitudes regarding recovery and recovery-oriented practices of both healthcare professionals and consumers of mental health services, b) collaboration between consumers of mental health services and the heads of mental health professionals, as well as policy makers to develop Recovery-in-Action Initiatives to meet the needs and resources of all partners in the project and c) a systematic theory-based assessment of transformation of attitudes and practices among all groups of partners in order to identify relevant barriers and supports within the local context [
123].
Another negative influence on ones’ self-appraisal necessitating the transformation of the culture of organization and provision of care in mental health services was the participants’ tragic experience upon their hospitalization in the State psychiatric hospital of Cyprus (Athalassa hospital) where involuntary hospitalization was applied during the acute phase of mental diseases. In particular, the descriptions of the participants highlighted experiences of human rights violation, even in relation to basic hygiene. Moreover, the main sources of dissatisfaction were the quality of the facilities and relationships with healthcare professionals. These findings partially support the data reported by Johansson & Lundman [
129], which underscore the experience of being subjected to involuntary care as a case of restricted autonomy, violation of physical integrity and devaluation of humanity. Interestingly, it has been reported that hospitalization in acute care settings was associated with a negative impact on one’s perception on self- identity due to self- stigma [
67,
69,
72,
103]. These findings support the need for interventions to improve conditions prevailing in the Athalassa hospital, as well as reform the way mental health services are provided in both hospital and community setting, in order for the consumers of mental health services to preserve a positive personal identity [
113,
123,
130].
Proposed interventions
The importance of the proposed interventions is supported by evidence which shows that negative self-appraisal in people living with mental illness may be related to poor hope regarding recovery and social interaction and subsequent self stigma. In particular, such data illustrate that people exhibiting high degree of self-stigma and at the same time a high level of insight report poor hope regarding recovery, low self-esteem and limited social interactions compared to people with high insight and low levels of self-stigma [
103]. Based on these findings, interventions targeted at social stigma arising from mental illness, and empowerment of mentally ill patients’ self-esteem seem relevant, along with interventions aiming to alleviate self-stigma. Additionally, the participants in the present study emphasized the therapeutic influence of the community mental health services on their existence in terms of socialization, creativity and rehabilitation and subsequently on the development of a positive self-view. Similar findings were presented in the study by Sun Kyung & Eun Hee [
109], where attending a clubhouse enhanced patients’ sense of belonging and their recovery.
International literature supports the implementation of specific types of psychotherapy addressing self-identity issues in order to assist people living with SMI towards recovery. For example, the study by Bargenquast & Shweitzer [
108] provides evidence for the effectiveness of Meta-cognitive Narrative Psychotherapy regarding self-appraisal issues during the process of recovery. Meta-cognitive Psychotherapy is an innovative type of psychotherapy developed by Lysaker et al. [
110], where meta-cognition is a means to understand how one goes from discrete perception into an integrated representation of self and others [
131]. As for people living with SMI, it is proposed that this type of psychotherapy may empower the ability for self-reflection, decrease hallucinations and delusions and improve insight [
103,
131‐
133]. Moreover, therapeutic recreation is a proposed model of therapy aiming to enhance the level of self-determination in individuals living with SMI [
114]. Self-determination refers to the motivation of an individual influenced by three psychological needs: a) competence (feeling of success or optimal challenge), b) autonomy (provided choice and control over a particular behavior) and c) relatedness (feeling socially connected to others). Overall, self-determination requires the satisfaction of all the aforementioned needs in order to be developed. Medication adherence is strongly related to self-determination [
114].
Another type of therapy proposed is the model of Acceptance and Commitment Therapy (ACT). The aim of this therapy is to achieve a balance between acceptance of what is thought to be impossible to change and commitment to actions, a process which could support individuals living with SMI in transforming their goals and finding meaning beyond the consequences of sustained symptoms and impairments [
122]. Moreover, mental healthcare professionals are expected to support individuals living with SMI in overcoming obstacles and deciding on their values.
In terms of enhancement of adherence to therapy, both pharmacological and psychosocial, literature provides substantial evidence for the effectiveness of psychosocial interventions [
133] by educating patients and their families on both disease pathophysiology and the effective management of the adverse side effects of medication [
134,
135]. Such studies address people with mental illness, as well. In addition, there is empirical evidence that supports the implementation of Cognitive Behavioral Therapy psychotherapeutic interventions to promote adherence to pharmacotherapy and psychosocial functioning [
136,
137]. The main issues that are usually addressed include: a) a broad discussion about the reasons behind patient’s acceptance or refusal to take medication and the advantages and disadvantages following his/her decision, b) reattribution of patients’ thoughts to hallucinations believed to enhance acceptance and adherence to medication, and c) the involvement of patient in decision-making [
138].
Facilitators of recovery
A well described facilitator of recovery by the participants regarded the effective and therapeutic relationship between patients and mental health nurses, the importance of which is underlined in many studies. The significance of empathic and supportive relationships between consumers of mental health services and health professionals lies on evidence which shows that these qualities enhance understanding of healthcare professionals and reassurance towards people living with SMI. This in turn seems to make patients feel accepted, facilitating their social integration [
54,
124,
139‐
143]. Overall, empathy, respect and availability provided by health professionals have been described in international literature as basic elements of the therapeutic relationship [
47,
67,
104]. On the contrary, unavailable and depersonalized mental health professionals have been described as a barrier to recovery [
143]. More importantly, the participants in the present study described the particular phases of the relationship between them and mental health nurses as a dynamic process, while mutual acceptance and empathic understanding were crucial in maintaining a positive self-image by both sides.
Additionally, education of healthcare professionals in order to apply recovery-oriented models of therapy is needed. There are particular objectives mentioned in the literature that need to be supported through the implementation of the recovery model by mental healthcare professionals, especially nurses, such as: a) navigation of people living with mental illness on their journey to recovery, b) believing in the support and recovery of people living with mental illness [
47,
144], and c) provision of information, choice, practical support on financial matters and employment of people living with SMI.
However, international literature [
35,
145], underlines a lack in the training of mental health nurses when it comes to applying the recovery model, although they seem to have the knowledge to implement it [
35,
145]. Furthermore, while mental health nurses show confidence in their understanding of the importance of the recovery model [
145], they are uncertain about providing practical support for employment and helping mentally ill patients find a house or manage their own symptoms [
35,
145], areas where more education is necessary.
Another important finding, although beyond the scope of the present study, was the therapeutic effect of the research interview for the participants. It seemed that participants considered the interview to be ‘redemptive’, since they used phrases such as “I expelled some residues off me, which were useless’. The therapeutic effect of the phenomenological research interview has been considered in previews research [
146]. In particular, studies underline the importance of the research interview for the development of trust and rapport between the researcher and the participants in order for the latter to be able to disclose their pure experience with the phenomenon under study. This dynamic seemed to endorse the participants of the present study to reflect on the way mental illness and its therapy made them feel, a procedure which proved to be therapeutic [
147]. Nevertheless, the ultimate goal of phenomenological research is for the participants to be encouraged to relive their personal experiences in order to acknowledge their inner meanings and reflections [
147].