|Year : 2015 | Volume
| Issue : 3 | Page : 340-346
Focusing on psychiatric patients' strengths: A new vision on mental health care in Iran
Ali Zargham-Boroujeni1, Jahangir Maghsoudi2, Hamid Reza Oreyzi3
1 Department of Pediatric Nursing, Nursing and Midwifery Care Research Center, Faculty of Nursing and Midwifery, Isfahan University of Medical Sciences, Isfahan, Iran
2 Department of Psychiatric Nursing, Student Research Center, Faculty of Nursing and Midwifery, Isfahan University of Medical Sciences, Isfahan, Iran
3 Department of Education Science, Faculty of psychology and education Science, University of Isfahan, Isfahan, Iran
|Date of Submission||29-Jan-2014|
|Date of Acceptance||10-Dec-2014|
|Date of Web Publication||29-May-2015|
Dr. Jahangir Maghsoudi
Faculty of Nursing and Midwifery, Isfahan University of Medical Sciences, PO Box: 81746-73461, Isfahan
Source of Support: Isfahan University of Medical Sciences, Conflict of Interest: None
Background: Identifying and using the strengths of patients, in practice, is a new territory. Today, the need to educate nurses and psychiatric patients about positive psychology in practice and the importance of understanding and focusing on strengths is clear. However, little is known about the strengths the psychiatric patients use and experience. Thus, this study has been designed and conducted in order to understand how people with psychiatric disorders demonstrate their strengths.
Materials and Methods: In the present study, 13 semi-structured, qualitative interviews with patients and 2 focus groups with nurses were carried out. In addition, a qualitative content analysis was used to identify significant strengths.
Results: Based on the results, the four main strengths consisted of: Finding a meaning in daily living, work as enduring strength, entertaining activities, and positive relationship. Patients also reported that health care providers rarely focused on patients' strengths, and experts confirmed these findings. Our findings indicate that patients' own strengths are a pivotal factor in getting through their illness from their perspective.
Conclusions: Despite the enduring legacy of pessimism regarding psychiatric patients, these people have a repertoire of strengths. Nurses should, therefore, have a greater focus on eliciting and nourishing psychiatric patients' strengths in their care. It is suggested that the theoretical and practical aspects of patients' strengths be incorporated in nursing school curricula.
Keywords: Iran, patient strengths, psychiatric patients, qualitative analysis
|How to cite this article:|
Zargham-Boroujeni A, Maghsoudi J, Oreyzi HR. Focusing on psychiatric patients' strengths: A new vision on mental health care in Iran. Iranian J Nursing Midwifery Res 2015;20:340-6
|How to cite this URL:|
Zargham-Boroujeni A, Maghsoudi J, Oreyzi HR. Focusing on psychiatric patients' strengths: A new vision on mental health care in Iran. Iranian J Nursing Midwifery Res [serial online] 2015 [cited 2020 Feb 27];20:340-6. Available from: http://www.ijnmrjournal.net/text.asp?2015/20/3/340/157832
| Introduction|| |
Recently, there has been a shift in focus from individuals' deficits to exploration of their strengths.  Strength is an ability, skill, or interest that has been utilized before. Focus on resources provides hope that improved functioning is possible.  A study of the history of nursing shows that human strengths have been addressed in some nursing theories.  However, these theories are based on a deficit model rather than on improving the strengths and well-being. 
The importance of human strengths has been emphasized in psychology theories. The belief that human beings have the strength for goodness is the base of humanistic theories. According to these theories, through therapy, clients explore their abilities to develop self-worth.  Positive psychologists believe that treatment also consists of developing the patients' abilities. They claim that strengths are buffers against mental disorders.  Focusing nursing care on a person's strengths, as a complement to the traditional approach of deficit-based nursing, may improve health and wellness.  Research has revealed a number of important links between strengths and valued outcomes (e.g. life satisfaction and achievement).  It has shown that strength-based reports result in better academic, social, and overall outcomes for clients with mental health disorders, as compared to traditional socio-emotive reports that focused on the deficits that students were facing.  Studies have found a relationship between strengths and well-being.  Studies also indicate an association between strengths and hope for recovery, a productive and satisfying life, the ability to buffer suicide risk, survivorship, and resilience. ,,, The outcomes of developing and identifying strengths are change in the client's self-image and improvement of self-esteem.  Worldwide studies showed that half to two-thirds of people diagnosed with schizophrenia and other major mental disorders significantly improve or recover.  However, much of the research on clients' strengths has been conducted on disciplines other than nursing. Furthermore, the participants recruited were survivors, children, families, students, and women. In Iran, a few studies have also been conducted on clients' strengths. Rahimian and Asgharnejad found that resilience and ego-resiliency were significantly related to mental well-being. Higher levels of resiliency had positive outcomes in adult survivors of the earthquake of Bam, Iran. In this study, samples consisted of both men and women. Their average age was 37 years (ranging from 18 to 54 years).  Researchers found that hardiness was negatively correlated to mental disorders. Results of other studies also provided support for the hypothesis that subjective well-being and strengths are related.  Nursing researchers have studied inner strength in healthy women, women with breast cancer, and men with AIDS.  Although these studies were not exactly the same as the present study, they illuminate the background of this study. A conceptual analysis of health assets revealed the five core dimensions of mobilization, motivational, relational, volitional, and protective strengths.  Rotegå rd et al. described the nurses' perceptions and experiences of cancer patients' health assets. In this qualitative study, 26 expert nurses in cancer care participated in focus group interviews. When the data were subjected to thematic analysis, three new core dimensions of cognitive, emotional, and physical strengths were revealed.  Eloranta et al., in their study, describe the personal resources of old clients in Finland. The data were collected by unstructured interviews with 21 elderly home care clients. Inductive content analysis was used to analyze the data. A sense of control over one's life and a determination to remain active were the resources of these clients. Factors enhancing older people's resources were their involvement in leisure activities and social networks. The results revealed that professionals still do not have sufficient skills and abilities to identify and support older people's existing resources. In addition to having access to necessary resources, it is also crucial that people know how to use them. 
Resiliency resources can be a valuable mechanism for maintaining the well-being and understanding differential resistance to, and recovery from ill-health in later life. 
Mental health care in Iran is completely deficit-based. Therefore, there is little known about the strengths of psychiatric patients. Understanding and supporting psychiatric patients in using their repertoire of capacities to help them manage their illness, engage in positive health behavior, and live well is important.  Thus, further research on the personal strengths of mentally ill patients is necessary. Findings of this research may enrich our understanding of psychiatric patients' strengths and how they are used to improve their well-being. The present study seeks to understand how psychiatric patients describe their experiences and perception of the strengths needed or used by them or supported by their care providers.
| Materials and Methods|| |
This is a qualitative study. We used descriptive and exploratory approach because it best fits the aim of this study to uncover all aspects of psychiatric patients' strengths and to gain understanding of their strengths.
Data were collected using individual, semi-structured interviews with psychiatric patients, and expert panel. We chose these methods because interview is one of the most commonly used strategies for collecting qualitative data,  and expert panel is an effective tool to validate the results. 
Moreover, mainly to assess the quality and significance of data which support the validity of the results, we used expert panel approach as an effective and inexpensive tool. The experts chose to represent all points of view. They were asked to examine all the data, and then, to highlight consensus on the conclusions, particularly on the answers to evaluative questions.
The clinical context chosen for this study was two psychiatric settings including mentally ill patients and mental health team. For gathering qualitative data, we used purposive sampling to seek participants (patients) according to two criteria, experiential fit and good informant. Samples included individuals of both sexes with psychiatric illness. Head nurses of the hospitals were asked for help in selecting participants. Participants were recruited by some criterion such as age, sex, and diagnosis that ensured variation in the sample.  Inclusion criteria were that the patient had a current or previous mental disorder diagnosis, was older than 20 years, was able to communicate and understand Persian, and was willing to describe his/her experiences from his/her personal strengths in her/his life with mental illness and healing process.
We formed two expert panels from two clinical fields at the psychiatric clinics and psychology departments of two university hospitals. Each session lasted for 2 h. Each panel had 5-7 participants, for a total of 12 experts, including men and women. For the first panel, we recruited seven psychiatric nurses. All of them were faculty members in Isfahan University of Medical Sciences, Iran. They had extensive experience in the field of mental health. Only one expert had 6 years of experience. The other members had 25 years of clinical teaching experience in psychiatric-mental health nursing practice. They were introduced by the director of psychiatric nursing department. The second panel had five experts: One clinical psychologist with over 20 years of experience in psychiatric clinics, one associate professor in psychology, two PhDs in nursing with 6 and 25 years of experience in nursing, respectively, and two psychiatric (MSN) nurses with 25 years of experience in psychiatric nursing.
The present study was approved by the Medical Ethics Committee, Isfahan University of Medical Sciences. Then, we referred to the two psychiatric sites of Isfahan, Iran. The researchers worked collaboratively with the personnel of psychiatric clinics to recruit people with psychiatric disorders and conduct individual interviews with (participants) patients from July 2012 to December 2012.
Interviews were conducted face-to-face in the education room of psychiatric wards. It was hoped that interviewing participants in a familiar, comfortable, and convenient environment would reduce anxiety and produce more informative interviews. All interviews were conducted by the first author. The interviews lasted for approximately 45 min to 1 h, were audio-taped, and later transcribed verbatim. Before the interview began, the aim of the study, the voluntary quality of participating, protection of confidentiality, and participants' rights to leave the interview were explained for each participant. The interview was ended when no new data was obtained.
The following questions guided the interviews:
- What you think are your important personal strengths?
- Can you give experiences from your life describing your strengths?
- Can you talk about experiences in which your significant other talked about your strengths?
The results of qualitative analysis were presented to the expert panel. The panels were convened in the Nursing and Midwifery Council room, where the heads of departments usually meet. The researchers welcomed the experts, and presented the aim of the study and the results of interview analysis. The panels were guided by this question:
What are the most important strengths of people with mental disorders based on the data?
The panel discussions were audio-taped, imaged, and transcribed verbatim. To improve the accuracy of transcripts, researchers completely checked a subset of all completed discussions. A note taker was present at the panel discussions. The panel discussions lasted for approximately 2 h.
Data analysis was performed concurrently with data collection. We chose the widely used method of content analysis. , To analyze the text transcribed from the individual interviews, three steps were followed. First, in this study, the first author read the transcripts several times to obtain a sense of the whole. The analysis started by identifying the units of meaning that could be extracted from the statements. Then, the analysis proceeded with line-by-line coding, and noting initial explicit and implicit results for each interview. Second, the initial findings were reviewed to develop initial codes, which were then systematically applied to the data set to identify all data extracts related to these codes. Then, the codes were compared and unified. Codes with similar meanings were combined into an associated theme. Finally, the emerged theme was given a final definition and a name that reflects its content. Final themes were prepared to be presented in expert panels. The themes gained from analysis of interviews and the most important strengths from review of literature were presented to expert panels. The experts freely discussed their perspectives. We looked for a critical, common sense understanding of psychiatric patients' experiences of their personal strengths. 
Furthermore, the text resulting from expert panel discussions and the notes were read several times, and an overall impression was recorded. The texts were systematized and interpreted. According to expert panel's views, the most important strengths were organized.
Credibility was established through member checking, peer checking, and prolonged engagement. Through prolonged engagement with the subject matter, and returning a full transcript of their coded interview and a summary of the emergent categories to the informants to see whether they recognized the findings of the study, we increased the credibility of the findings. In addition, two expert supervisors and one doctoral student of nursing carried out the peer-checking.
To achieve conformability, we recorded the analytic process including the evidence and thought processes.  Using multiple strategies for gathering data, we tried to improve the objectivity of the study, to confirm the results, and to gain a more holistic description of the patients' strengths. 
We used expert panels and looked for strengths in literature. Finally, after analyzing the data, we presented the results to a committee composed of three independent researchers of nursing school to obtain their comments and discuss the results.
| Results|| |
We conducted 13 individual interviews with 7 women and 6 men with an average age of 37 (range: 24-47) years and 2 expert panel groups ([Table 1] for additional background information). In total, 21 strengths were identified. Themes and quotations were translated by an English-speaking nursing teacher. For brevity, we discussed the main strengths identified. These strengths were shown to be important to all those interviewed, mental health professionals, and expert panel groups. Based on the results, the four main strengths consisted of finding a meaning in daily life, work as enduring strength, entertaining activities, and positive relationship.
Finding a meaning in daily life as strength
Many participants frequently highlighted the impact of becoming involved in an activity as a powerful source of energy. Sometimes participants identified valued activities that gave their lives a sense of direction, meaning, and purpose. These useful activities raised the self-esteem and helped to reduce symptoms, avoid hospitalization, and/ or spending time. For instance a participant found that:
"Through participation in some activities, we are entertained and we may earn income. Our lives will become organized. I wake up in the morning and look for goals and activities. I do not feel I am sick. I am no longer jobless." (No. 3, male participant).
Finding a meaning in daily life was accepted as a main strengthening factor.
Another participant pointed out thus:
"In doing the everyday action of life, I feel I am serving my family and reaching goals. So, I'm not feeling empty." (No. 7, female participant).
Work as enduring strength
Almost all the participants raised the issue of work as the essence of human dignity. For one research participant, work not only made life hectic but also filled her life with the eternal asset:
"Work is a recreation. If I wasn't working, my life would be absurd. I must stay in the hospital. I will be ill and need medicine. I cannot handle my life. But since I'm working and I'm busy, I do not think and I've not been sick. I've made a lot of progress in my life. Go work; don't ask 'what is work?' (Persian poetry) Work is something eternal." (No. 9, male participant).
One participant said:
"We worked. My husband too tried to help us and we have shown adaptability and, thus, made our lives." (No. 4, female participant).
All members of the panel agreed that work is an important strengthening element.
Entertaining activities as strength
All the research participants stated that some activities may lead to gaining personal strengths and promote wellness. Many activities, such as following diet recommendations, doing artwork, bathing, exercising, spending time with family, having intimate relationships, fishing, reading newspapers, completing crossword tables, shopping, being with friends, sleeping, walking along the river, and talking on the phone, were mentioned by participants. For example, one participant stated:
"When I exercise, my mood is better, my sleep is regulated, I can establish a better relationship with others, and will continue to live with greater power." (No. 6, female participant).
Another participant stated:
"If I don't work and have no entertainment, I feel under the weather. I like to read newspapers. I am interested in planting flowers." (No. 11, male participant).
Activities, as strength, had earned a high score and were chosen by the expert panel groups as a major strengthening factor.
Nearly half of the participants mentioned strengths they experienced through positive relationships with others. This included positive regard and trust in significant others, being seen and accepted by friends and family members, and fellowship with peers. These traits were highlighted and valued. Significant others with such qualities inspire courage and trust. Such qualities may help the patients to relax and let go of some control. One of the participants stated:
"I have confidence in those around me. My family and friends listen to me and express their concerns about events affecting me.…. My father is an honest man and loves me. This behavior creates trust." (No. 9, female participant).
Another participant said:
"If you do not have a relationship with other people, you will be corrupted. There is no life without relationship with others. When you have a relationship with siblings and relatives, you will be happy." (No. 13, male participant).
Furthermore, the positive relationship component was chosen by the expert panel as a major strength, and its effect on mental health of clients was emphasized.
| Discussion|| |
The aim of the present study was to explore psychiatric patients' experiences and perception of their strengths, and mental health professionals' views about these strengths. The results revealed that psychiatric patients possess a repertoire of strengths. Some of these strengths were actively used and others were considered as important during their illness and healing. Studying the strengths of individuals with psychiatric disorders as represented in their first-person accounts is the positive aspect of this study. There appears to be four main strengths that are important to consider. They consist of finding a meaning in daily life, work as enduring strength, entertaining activities, and positive relationships. The varied emphasis that the participants placed on these four areas indicates the critical role of strengths in patients' life journey.
The findings from this study highlight the positive impact of assessing the capabilities of psychiatric patients, evident from their eagerness to talk about their abilities instead of deficits. Overall, the present study both adds support and is supported by the literature on existing strengths, although the current study indicates that there are some more novel aspects to psychiatric patients' strengths.
These findings are largely consistent with the results of the study by Young and Ending. Working hard, having courage, being honest with self and others, being able to take care of oneself, exercising, connecting with others (including friends, family, and community), searching for meaning or purpose in life, and positive focus were the main components of the recovering model.  Finding a meaning in daily life, work, entertainingactivities, and positive relationships can help patients increase their well-being. Meaning in life is gained when people perceive that they can effectively manage their lives so that they feel they have control over their lives. 
Meaning as an independent component of well-being is associated with life satisfaction and happiness, and a lack of meaning is predictive of depression and disengagement. , Presence of meaning in life helps to eliminate depression and anxiety.
Work is an involvement that is positively related to well-being. During work, the participants attached themselves to the work environment because it strengthens their sense of control.  Findings of a study indicated that mental well-being is associated with activity, better health, and mobility status, which should become targets for preventive measures.  Making use of meaningful work is a way to overcome self-harm and suicidal impulses in mental health clients. 
Generally, the emerging strengths from this study were partly similar to the components of other studies about the strengths of patients that were identified by researchers in different regions across the world. For instance, the existing literature has described positive relationships, trust, hope and optimism, commitment to worthy goals, and protection as strengths.  To rebuild networks and relationships with loved ones was important to psychotic patients.  Another study showed that empowerment, connections to others, meaning of work, and vocational future are the main components of recovery.  Based on the aforementioned findings, it can be concluded that psychiatric patients in different areas of the world have a similar perception of their strengths with almost similar components.
Although the strengths, finding a meaning, work, entertaining activities, and positive relationships, that emerged in the present study were mostly found in other studies, it is noted that the data provided by the participants of this study provided unique and specific ideas in regard to these strengths. This study also found new strengths, for example, entertaining activities.
In addition, our study found several new aspects of strengths in psychiatric patients not previously identified in the literature. Review of literature showed that the majority of researches on strengths have been conducted in women, children, and adolescents or in a public health context. However, our study focused on the experiences and strengths of adult psychiatric patients of both sexes. Our study on psychiatric patients, therefore, found strengths not previously mentioned and is particularly relevant for mental health care.
However, an important finding in this study was that the clients seem unaware of, and do not focus on, their own strengths in their care. The experiences of study participants showed that professionals did not investigate, discuss, or use their strengths.
The few studies that have focused on strengths in mental health care have mainly used patients with schizophrenic, depressive, and bipolar mood disorder (BMD), or substance abuse disorders as participants. Our study included patients of both sexes with schizophrenia, BMD, obsessive-compulsive disorder (OCD), depression, substance abuse, and schizoaffective disorder. Moreover, we conducted expert panels to ensure that the study reflected the diverse views on patients' capabilities, thus providing richer insights into mentally ill patients' perceptions of internal strengths across different groups. Furthermore, our study indicates that there are individual differences and that sex differences may exist, findings that need to be explored further in future research.
This study has a number of implications which are particularly relevant to nursing. These included the importance of promoting and encouraging personal strengths by patients and professionals who are able to engage in identifying patients' strengths. The following part of the essay provides suggestions for ways of addressing strengths, and how practitioners can actively facilitate the strengths perspective.
Strengths have practical applications for people with psychiatric disorders.
The concept of strengths might be a helpful way to create a new strategy in caring for these groups of patients. People could be taught to identify their strengths and to create "power statements" in order to convey the importance of potentials to health care practitioners. The findings of this research invite the patients to share resources. Mental health care providers should consider this when working with the mentally ill by working more holistically and being mindful of the importance of strengths. The present study demonstrates a need for greater attention to patients' capabilities and greater access to alternative options of care based on these strengths. This could include enabling professionals, patients, and families to assess the strengths, and the interventions that might best suit their strengths. Information could be on hand to facilitate discussions about patients' strengths. A teaching curriculum must be designed around what educators hope to achieve from strengths. It should be noted that this study was carried out with a limited number of participants in Isfahan. Therefore, the wide transferability of the results needs further investigation by future studies with a large group of participants, and if necessary, with quantitative studies.
| Conclusion|| |
The present study reaffirms that psychiatric patients possess a repertoire of strengths that should be assessed and used in care plans. This study gives further evidence that providing insight into the strengths of patients will facilitate the process of care and healing in this population.
In order to identify the strengths and enhance patients' quality of care, it is important for nurses to address their strengths. This point has particular significance for psychiatric nursing and other mental health care professionals as they are well placed to assess and offer patients with specific information and encouragement on a variety of strengths and design care strategies to help the development of the care process. More emphasis could be placed on the possibility of strengths, generally, offering the patients a much more hopeful care. For example, nurses could demonstrate more strength-focused practice. This emphasis will be of great value in enhancing the quality of care. In this regard, it is suggested that strengths be included in nursing courses and that nursing school curricula incorporate the theoretical and practical aspects of patients' strengths.
Hopefully, the benefits of strengths will become more widely accepted and produce changes in service delivery, and this will cut to the heart of issues that are important to psychiatric patients, dispelling the preconceived beliefs of mental health professionals.
| Acknowledgment|| |
This article was derived from PhD dissertation of J. Maghsoudi with project number 391208, Isfahan University of Medical Sciences, Isfahan, Iran. The authors wish to sincerely thank all the patients and experts who participated in this study and Clinical Research Centers of Noor and Farabi hospitals for their cooperations.
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