Reciprocity membership: A potential pathway towards recovery from mental illness in a Middle Eastern context

Abstract

While recovery has become a popular framework for mental health services, there is limited understanding of its applicability outside of Western countries. In fact, recent studies in non-Anglophone populations suggest that recovery is contextually dependent and that the implementation of mainstream recovery models risks imposing inappropriate values. We used classic grounded theory to explore the main concerns of mental health service users in a Middle Eastern context and the strategies they use to resolve those concerns. The theory of ‘reciprocity membership’, a process involving ongoing mutual exchange with a group or community, was developed. Reciprocity membership becomes balanced when an individual is satisfied with their ‘contribution to’ the group, the ‘acknowledgement from’ other group members, the ‘expectations of’ the group, and their ‘alignment with’ the values of the group. Balance among these conditions is appraised by a sub-process called ‘valuing’, and developed or maintained by two further sub-processes called ‘positioning’ and ‘managing relationships’. Balanced reciprocity membership seems to be associated with recovery. This study is the first in-depth exploration of people's experience of mental illness in a Middle Eastern context; findings provide evidence for a novel potential pathway towards recovery.

Keywords

grounded theory mentally ill persons Qatar reciprocity recovery social participation

Introduction

Personal recovery in mental illness refers to a person's ability to live a meaningful life regardless of limitations imposed by illness (Anthony, 1993). This concept has origins in a service user movement that started in the 1980s and began as something of a protest against the predominant biomedical focus of symptom resolution through medication (Frese & Davis, 1997). In recent decades, theoretical models of recovery have been incorporated into mental health policy and practice across the globe (Pincus et al., 2016). Common concepts, developed through extensive qualitative studies and service user accounts, include hope, social connectedness, control/empowerment, personal responsibility, finding meaning, and identity (Repper & Perkins, 2003; Slade, et al., 2012; Whitley & Drake, 2010). However, one criticism of personal recovery models is that they been developed largely from monocultural data (i.e., Anglo-Caucasian service users) and may not be transferrable to other population groups (Slade, et al., 2012).

For example, Bayetti, Jadhav, and Jain (2017) caution against the uncritical adoption of Western-biased recovery models in India. The authors write that Indian mental health service users expect their psychiatrist to assume an authoritative role in treatment and that a collaborative recovery approach would be unwelcome to many. The authors also highlight the important role that the family plays in decision-making in Indian culture and fear this may be lost in the mainstream recovery emphasis on self-determination. They also argue that self-determination and self-actualization are inappropriate goals in contexts, such as India, where family and community are viewed as more important than the individual.

In a previous article, we reviewed several Western models of recovery (Andresen, Oades, & Caputi, 2003; Jacobson & Greenley, 2001; Repper & Perkins, 2003; Slade, 2009), contrasted these with the sociocultural context in Qatar, and contextually similar countries, and identified several areas where these models may be incongruent in an Arabic context (Hickey, Pryjmachuk, & Waterman, 2017). These areas included: 1) the importance of autonomy in Western recovery vs. the focus on community inherent in Islamic ethical principles; 2) the collaborative role of the physician in Western recovery-oriented mental health services vs. an expectation for psychiatrists in some Arabic countries to take on a more authoritative role; and 3) biomedical explanations of mental illness vs. a strong belief in the supernatural causation (e.g., black magic, evil spirits) of mental illness found in many Arabic countries. Thus, these elements of mainstream recovery models may at best be ineffective in a non-Western context, and at worst, cause harm by imposing an inappropriate set of values and beliefs into mental health service delivery.

Very few empirical studies on recovery have been conducted outside of a Western context. Those that have suggest that sociocultural context has an influence on recovery. For example, Lapsley and collaborators (2002) examined recovery in Indigenous (Maori) and non-Indigenous New Zealanders. Indigenous participants demonstrated a unique emphasis on traditional healing and ways of understanding the world in relation to their recovery journey. Another study from Taiwan highlights the critical importance of family in the recovery of individuals with mental illness (Song & Shih, 2009). While family support is recognized as important in Western conceptualizations of recovery, it is often secondary to individual priorities. Finally, Leamy, Bird, Boutillier, Williams, & Slade (2011) found that Black and minority ethnic groups placed higher emphasis on spirituality and stigma and often viewed recovery as a collective endeavour rather than an individual one. While these studies highlight potential differences in recovery outside of Anglo-Caucasian populations, there is still a large gap in the literature about recovery in these contexts. Further research is needed in order to better understand the relevance of recovery internationally.

The current study explores people's experience of mental illness and recovery in a Middle Eastern context. The study was conducted in Qatar, a rapidly developing country bordered by Saudi Arabia and the Persian Gulf. Qatar aims to develop an ultramodern society while maintaining its traditional values, which are rooted in Islam and their nomadic background (Kronfol, Ghuloum, & Weber, 2013; Lustig, 2011). However, some would argue that many aspects of traditional life are changing and this creates tension between modernization and traditional values (Fellow, 2013; Teller, 2014).

Collectivism is seen as one important aspect of Qatari culture (Hofstede, 2001). Collectivism places an emphasis on the group over the individual (Oyserman, Coon, & Kemmelmeier, 2002). Within this structure, the extended family forms the basic societal unit and its members are socially and economically interdependent (El Haddad, 2003). However, extended family can be both detrimental and beneficial to recovery. In some cases, extended families provide practical, emotional, and spiritual support (Bilal, Kristof, Shaltout, & El-Islam, 1987; El-Islam, 1982). In others, they are a source of stress and a trigger for substance abuse and suicide (Al-Nahedh, 1999; Suleiman, Nashef, Moussa, & El-Islam, 1986).

Although collectivism and extended family remain important, the rapid economic development in Qatar and other countries in the region is challenging traditional values and institutions (Fellow, 2013). For example, economic prosperity has led to the widespread use of foreign nannies and maids who have taken on many of the traditional roles of mothers and grandmothers (Bennet, 2009). Perhaps as a result of having domestic help, many women in the region have begun to enter the workplace (Willen, Perniceni, Lohmeyer, & Neiva, 2016). This is generally seen as a positive change. However, it has created a shift in some women's roles, responsibilities, and decision-making within the home (Alsharekh, 2012). Additionally, urbanization and digital connectedness have led to social interactions outside of the extended family or tribe, which is another departure from traditional extended family life (El Haddad, 2003).

Religion is an important influence on Qatar's sociocultural context. Most Qataris belong to the strict Wahabi sect of Islam (Lustig, 2011) and religious ceremony and observance are evident in day-to-day life. Residents are woken at dawn each morning with the call to prayer being broadcast from loud speakers mounted on the thousands of mosques across the city, men and woman dress modestly in long robes (Abayas for women; Thobes for men) and head coverings, much of the local architecture has incorporated Islamic symbols and principles, and there is a strong belief in the healing power of prayer and the Quran.

Religion is widely, but uncritically, acknowledged as an important source of support for people with mental illness in the region (Hickey, Pryjmachuk, & Waterman, 2016). Articles on mental illness from Qatar and nearby countries often presume the supportive role of religion without having adequate data to back up the claims. In a review of the literature that we conducted (Hickey, et al., 2016), only one study examined the role of religion on recovery and found it to be both a source of support and a source of distress for women with obsessive compulsive disorder (Al-Solaim & Loewenthal, 2011).

The Qatari Government has recently put plans in place to scale up mental health services in the country. At the time of writing, the only adult inpatient treatment centre had 63 beds. This service has not kept pace with the rapid population growth. In 2005, there were .97 beds for every 10,000 people in the country (World Health Organization, 2005 ). In 2017, this number had decreased by 75% to .24 beds for every 10,000 people in the country. There is also a public outpatient service that offers a clinic, outreach and day programs. Several private hospitals offer limited psychiatric outpatient consultation.

The current study was developed in response to a call within Qatar's first National Mental Health Strategy for better contextual understanding about people's experience of mental illness (Supreme Council of Health, 2013). This strategy incorporates a focus on recovery but acknowledges the lack of local research data to support such an approach. Thus, this study aims to explore service user's experience of mental illness and recovery in Qatar.

Methods

In Qatar, service users have had limited input into the development of service and policy and the National Mental Health Strategy acknowledges a need for additional service user perspective (Supreme Council of Health, 2013). We chose a Classic Grounded Theory (CGT) approach (Glaser, 1978; Glaser & Strauss, 1967) to address our research aim because of its focus on the concerns of participants. CGT is an exploratory methodology that is used to develop a mid-range theory of social processes that are grounded in participants' experiences. Thus, it allowed us to explore people's experience of mental illness and, in so doing, to examine the applicability of recovery as a concept in Qatar.

This study received ethical approval from Hamad Medical Corporation's Medical Research Council (15259/15), University of Manchester's University Research Ethics Committee (ethics/060515), and University of Calgary's Conjoint Health Research Ethics Board (REB15-2555). All participants provided audio-recorded verbal informed consent. We obtained this consent after the study had been explained and understanding had been verified through a brief set of questions about the main aspects of the study (e.g., purpose, voluntariness, etc.). All names used in the results section are pseudonyms.

Participants

We used purposive sampling to recruit service users with a range of psychiatric diagnoses with the intention of developing a grounded theory that would be useful to front-line staff working with a diverse patient population. We also attempted to recruit similar numbers of male and female participants because previous literature from the region favoured males by a ratio of 2:1 (Hickey, et al., 2016) and we felt this would lead to a more equitable grounded theory.

Inclusion criteria for participants included: 1) aged 18 or older; 2) able to converse in Arabic or English; 3) not repatriating after discharge (in the case of non-nationals); 4) diagnosis of any mental illness; 5) capable of providing informed consent; and 6) willing and physically able to participate in an interview. Participant characteristics are presented in Table 1.

Table 1.

Participant characteristics (N=21).

Characteristic	n	%
Religion
Muslim	19	91
Christian	2	10
Gender
Male	12	57
Female	9	43
Marital Status
Unmarried	11	52
Married	10	48
Employment
Employed	11	52
Unemployed	10	48
Age
21–29	11	52
30–39	7	33
40–47	3	14
Nationality
Qatari	8	38
Egyptian	3	14
British, Canadian, Indonesian, Iranian, Lebanese, Omani, Pakistani, Pilipino, Saudi Arabian, or Tunisian	10	48
Place of birth*
Qatar	14	67
Outside of Qatar	7	33
Diagnosis**
Depression	9	48
Bipolar disorder	6	29
Substance abuse	3	14
Anxiety disorder	2	10
Post-partum depression	2	10
Schizophrenia	2	10
ADHD	1	5
Eating disorder	1	5
Post-traumatic stress disorder	1	5

Being born in Qatar does not result in citizenship.

n/% add to more than 21/100% because some participants had multiple diagnoses; Diagnosis based on self-report.

Recruitment and data collection

Recruitment and data collection were led by the primary author of this article, a White male nursing instructor at a local university. Six undergraduate nursing students, fluent in English and Arabic and familiar with the local culture, were engaged as co-researchers in the study and contributed to data collection under direct supervision of the primary author. These students had completed course work and a clinical placement about mental disorders and had experience communicating with mental health service users. All received additional training in research methods (e.g., ethics, including eliciting informed consent, interviewing, data collection, transcription, translation and dissemination) as part of their participation in this project.

The primary method of recruitment was to approach inpatients at the public psychiatric hospital. This was done by the primary author and a student co-researcher after an initial discussion with the unit psychiatrist or charge nurse to identify potential participants, and after an introduction was made by a member of the staff. We also used word-of-mouth as a secondary method of recruitment in order to access potential participants who were not currently engaged with mental health services.

Open-ended interviews were conducted in either Arabic or English, depending on the preference of the participant. These interviews were audio recorded. We used several open-ended questions to begin the interviews, “Please tell me about yourself” and “Please tell me about your illness”. We then used prompts to encourage elaboration. In keeping with CGT methods, data collection and analysis were conducted concurrently.

When concepts began to emerge during analysis, we began to follow broad, initial questions with more focused questions about those concepts. In this way, we were able to elicit a wide range of information and also gain a deeper knowledge of certain topics. Near the end of data collection, no new concepts were emerging, so we began to focus more on saturating our knowledge of the main concepts. Follow up interviews (n = 7) with key informants (n = 3) were particularly useful in this regard.

We conducted 28 interviews with 21 participants. Interviews ranged from six to 60 minutes with an average length of 31.3 minutes and were conducted either in a private location in the hospital or in a private office at the university of the lead author. The combined length of all interviews was approximately 878 minutes.

Data analysis

English audio-recordings were transcribed by the primary author or a student co-researcher. Arabic audio-recordings were translated and transcribed by the student co-researchers. English transcriptions were double-checked by the primary author for accuracy. Arabic transcriptions were checked by a second student co-researcher. Inconsistencies were discussed and resolved by consensus. All identifiers were removed during this process. A total of 248 pages of transcripts was produced.

Data analysis began with open coding, aimed at ‘fracturing’ (Holton, 2010) the data. This was done line-by-line and focused on the question of ‘what is going on in the data’ (Christiansen, 2007). Gerunds, action words ending in ‘ing’ (e.g., improving, connecting), were used for the majority of codes. This focused the analysis on processes in the data. Selective coding began after the main concern of participants became clear and several sub-core processes emerged. At this point, only data related to the main concern was coded. Finally, theoretical coding was undertaken to identify relationships between the theoretical concepts. Coding was done by the primary author using NVivo10 (QSR International Pty Ltd, 2013).

Constant comparison (Glaser, 1978) was used throughout the analytical process. Initially, incidents were compared to other incidents. This led to the development of concepts. Then, subsequent incidents were compared to concepts in order to develop, modify and saturate these concepts. Finally, concepts were compared to concepts to develop understanding of the relationships between them and to develop theoretical codes (Glaser, 1998). The coding process is illustrated in Figure 1.

Figure 1.

Illustration of coding stages.

Memoing (Glaser, 2014) was an important technique used throughout the data analysis. All analytical thoughts, musings and ideas about emerging concepts and theory were recorded. Throughout analysis, memos functioned as analytical memory and facilitated constant comparison. When theoretical saturation (Glaser, 1978) had been reached, all memos were reviewed and sorted (Glaser, 1998) into groupings representing the concepts in the grounded theory. These memos then provided the majority of content for the written theory.

Results

The majority of participants directly stated, or alluded to, their desire to make a meaningful contribution to others. They valued the support they received from others, but equally if not more important was the contribution they made to those others. What participants wanted was: 1) to feel a sense of belonging to a group of ‘others’, for example, family, co-workers, friends, etc.; and 2) for there to be reciprocity in those relationships. Thus, reciprocity membership emerged during analysis as the main concern of participants in this study.

Reciprocity is generally defined as a process of exchange for mutual benefit (Oxford Dictionaries, 2017). However, reciprocity has a more complex meaning for participants in this study due to its association with an active group association and the intrinsic value of making a meaningful contribution. In fact, participants equated having reciprocal group relationships to having a meaningful life; one of the cornerstones of Western recovery. Thus, reciprocity membership builds upon the concept of reciprocity and provides understanding of a potential pathways towards recovery in a Middle Eastern context.

Grounded theory of reciprocity membership

Four conditions need to be met in order to achieve reciprocity membership. These are contribution to, acknowledgement from, expectations of, and alignment with. Contribution to refers to what someone provides to the group. Emotional support, parenting, volunteer work, money for rent and sharing knowledge are all examples of contributions made by participants in this study. Acknowledgement from refers to what someone receives in return for their role as a member. These rewards can be tangible, such as clothing, housing and money, or intangible, such as praise, acceptance, or a sense of esteem. Expectations of refer to the demands placed upon individuals by group members. Having a reasonable amount of responsibility can encourage individuals to maintain their contribution. Having too much or too little can cause distress. Alignment with refers to the similarity between an individual's values, interests, and beliefs and those of the group.

Balance between these conditions is appraised by a sub-process called valuing, and is often reinforced by two other sub-processes called positioning and managing relationships (described below). These processes form the grounded theory that emerged during data analysis. This theory is illustrated in Figure 2.

Figure 2.

Illustrated grounded theory of reciprocity membership.

One participant provides an interesting example of the processes illustrated in Figure 2 when she describes her recent experience as an inpatient. She has had many admissions in her life in several countries and sees herself as an expert-by-experience. The group she is currently a member of is the treatment team, and as the quote below illustrates, she feels that the expectations of her psychiatrist are unreasonable.

… this guy, he just, makes me feel like I'm, I'm, stupid for, for feeling the way I do. I'm stupid for having depression, I'm stupid for having anxiety, I'm stupid for the fact that I haven't fixed it. (Margaret)

Her valuing process appraised reciprocity membership as being unbalanced because she felt she was being expected to fix her problems on her own. This prompted action through managing relationships and positioning. These processes were activated with an emotional outburst that might seem unproductive. However, through the outburst, she was able to situate herself as an expert-by-experience (positioning) and establish that she wanted to negotiate roles and responsibilities (managing relationships) in the treatment team.

… it was like a red flag to a bull. You can imagine the profanity he might've heard, which I don't really think he appreciated. I told him he was a disgrace to the healthcare profession and told his residents who were there to learn from him how NOT to be a doctor and asked him if he got his degree off the back of a cereal packet. (Margaret)

In effect, she is advocating for the treatment team to adjust their expectations of her and increase their acknowledgement of her efforts and experience. She was also making it clear that there is poor alignment with her and her psychiatrist's idea of adequate care. Thus, valuing the conditions for reciprocity membership as being unbalanced prompted action through two other sub-processes in order to restore those conditions. Table 2 summarizes the concepts that constitute the grounded theory of reciprocity membership.

Table 2.

Summary of concepts.

Category	Concept
Main Concern	Reciprocity membership
Conditions of main concern	a. Contribution to
	b. Expectations of
	c. Acknowledgement from
	d. Alignment with
Strategies used to maintain or achieve main concern	1. Valuing 2. Positioning a. Envisioning b. Leveraging c. Improving d. Repositioning 3. Managing relationships a. Enlisting b. Limiting c. Substitution

Valuing

As illustrated above, valuing is an appraisal of reciprocity membership. It is an invisible process whereby a person continually assesses their contribution to the community and their place within it. The valuing process entails asking questions that relate to one's reciprocity membership. Two main questions are asked:

Does this reciprocity membership equate to positive mental health and satisfaction?

Is this reciprocity membership reciprocal/balanced?

In this study, contribution to was most often the focus of the valuing process. Participants judge themselves in relation to the contribution they are able to make in the community(ies) in which they hold membership. Self-worth seems closely linked to the perceived value of these contributions. For example,

Interviewer: Do you see yourself as having any productive roles?

Ahmed: Not yet. I'm aiming for one. I think being useful to other people is what makes a person useful, ultimately. I'm trying, but I don't feel I am doing any good at the moment. I feel I am only causing harm. To my family, to my job, to this hospital … I'm just trying to get out of here, get my life back, and start new. And be productive, of course, that's part of it.

Valuing also appraises whether or not the contribution is balanced by what one receives in return. When someone is satisfied with the acknowledgement from others, it can boost self-esteem and motivate them to contribute even more.

Even if it's a small thing, when somebody appreciates, like “oh you did well, you can do all this”. You feel like, it's huge. For the people who have mental illness it's really, really, huge. “Oh wow, I can do this,” and it's pushing those people to do more productive things. (Aisyah)

Conversely, one participant recounts his disappointment when he felt the acknowledgement from his supervisor/manager was not adequate compared to the contribution he was making. The result was discontinuation of membership in the group.

I was happy doing it. Since my volunteers were happy, I was happy. But it was the last day and what [my supervisor] did, that was it for me. I'm giving everything … And in return I get disrespect … That breaks me. I stopped volunteering for one and a half years. (Abdulla)

Similarly, expectations of can be perceived as both positive and negative depending on how they are valued. Expectations that are reasonable and achievable can be helpful and motivating while unreasonable expectations can cause distress. One participant who was hospitalized after a suicide attempt discusses how his family members want him to succeed but that sometimes they push too hard.

[My family is] the source of stress for me. Well, it's a good thing, they're trying to push me to … do better and better and better. But it just doesn't stop, you know. It's good, and not good at the same time. I should be calling my own shots. (Ahmed)

Alignment with is the fourth condition of reciprocity membership, and is also subjected to valuing. Participants questioned their satisfaction with the fit between their own values, beliefs and interests and those of the group. During data analysis, an idea emerged that if mental health services could intervene to connect people with groups where they have the opportunity to make a meaningful contribution, then this may bolster the person's mental health. Shortly after the idea emerged, a participant was recruited who described himself as being “not very social”. The interviewer assumed the intervention would not work for a person like this, but was quickly corrected.

Interviewer: In your case, you probably wouldn't want to be connected with a bunch of people that you don't know, right?

Felix: Well, I don't know. Maybe … I just go with people who can benefit me as an individual … For example, help me in business. We are going to plan for business because [living here] is not permanent. So, if you introduce me to people who are interested only to be going out with the girls and drinking, I wouldn't like that. But with people whose goals are similar to mine, okay.

This excerpt provides evidence that participants would be open to having health care services help to connect them to others. This may facilitate service users' ability to develop reciprocity membership. However, these others must share similar goals.

Valuing is based on what the individual, rather than the group, deems ‘good enough’. It is based on one's own expectations, cues from the group, and perceived or actual rewards. In some cases, it is possible for health care practitioners to work with people to develop a more realistic valuing process. One participant felt he was paying too much rent to his mother, became severely distressed about what he saw as an unfair expectation of, and overdosed as a “cry for help”. He felt he got the help he needed when he was in the hospital.

I [got a] lesson … that I should discuss. Listen more than talking. And [discuss] with the family. Even when I [don't] get everything. Not everything I can expect to take [from] my mom. (Abdul Rahman)

Valuing is an ongoing, invisible, and highly subjective appraisal of reciprocity membership. It entails two main questions relating to whether a person is satisfied with their contribution and whether reciprocity is balanced. When a person judges reciprocity membership as being unsatisfactory or unbalanced, valuing activates other strategies. These strategies, positioning and managing relationships, are discussed in the following sections.

Positioning

Positioning can occur in response to an unsatisfactory or unbalanced appraisal of reciprocity membership and is used to improve one or more of the conditions for reciprocity membership. It does this by enabling people to bring new skills, knowledge, education, experience, ideas, or credentials to the group. Positioning is achieved through several sub-processes: envisioning, leveraging, improving and repositioning.

Envisioning enables participants to imagine a stronger contributory role for themselves. Imagining a different future is a precondition for taking action to achieve that future. One participant describes what she is envisioning for herself:

I have aspirations you know, [my family] canceled education for me, for the time being, so I will do [start a business] in the meantime. When I have kids, at least I can tell my children I have done something. (Fatemah)

This person is envisioning multiple paths for growth and contribution. She primarily desires postsecondary education, but her family will not permit this. Instead she plans to run a small business with her friend, so that once she has children, she can be a role model to them.

Although participants' mental illness was not usually a primary concern, it was sometimes leveraged to achieve a goal. In this study, leveraging refers to using one's mental illness to help maintain or achieve reciprocity membership. For example, one participant became a spokesperson. He felt his illness gave him something special to share with others. In fact, his illness increases his ability to contribute to certain groups; for example, by giving lectures to university students and providing a service user perspective on healthcare workers' continuing professional development. Unfortunately, though, very few others leverage their illness in this way due to the stigma associated with their condition.

Improving is another form of positioning. Education is the most common way that participants enacted this process. Improving allows people to gain new knowledge, skills, and credentials, which in turn, improves their potential contribution to. It also potentially facilitates entry into new communities through employment opportunities. Improving seems to be a bigger concern for the younger participants in the study.

Repositioning also occurs. This happens when community members react to changes in membership structure or roles by adapting to new circumstances. For example, one participant began a new job. This job allowed her to contribute to her family in a different way, financially. This contribution was highly valued by the participant and allowed her to renegotiate certain undesirable expectations of. This repositioning led to a higher sense of self-esteem and eliminated thoughts of suicide, which had been frequent over the preceding several years.

Managing relationships

Managing relationships is the second sub-process that some participants used to develop or balance reciprocity membership. This process allowed participants to initiate, maintain, improve and terminate connections to groups. It is enacted through a number of sub-processes.

One of these sub-processes, enlisting, refers to joining a group. This usually happens by making new connections with people who facilitate access to a group, or by reconnecting with previous acquaintances. These new memberships can be temporary, such as a peer support group on an inpatient unit, or longer lasting, such as a new job. One person provided an example of how enlisting can occur through social media.

Online, I feel more free [sic] and I can talk to people. I met a lot of cool people and there are a couple of communities that I'm part of. (Salma)

Limiting is another sub-process of managing relationships. This process was enacted in two ways by participants in this study. One was by limiting engagement and the other by limiting disclosure. In regards to engagement, participants may have to distance themselves from some groups in order to maintain reciprocity membership in others. One participant describes how she was not able to fully engage in a group due to her more important responsibilities to her family. This trade-off was a personal sacrifice undertaken for the benefit of maintaining reciprocity membership in her family.

I tried to contribute [to the other group] as much as I could because I want give the most I could, without disturbing my family's time. But there are times that I was really disappointed, when I wasn't able to participate in a certain activity that was a dream of mine. But because of my family, I couldn't do it, and I stepped back again. (Aisyah)

Limiting disclosure occurs in response to the perception that sharing information related to one's mental illness might prevent reciprocity membership. One form of limiting disclosure involved people distancing themselves from group members when they were unable to hide their mental illness; for example, during periods of relapse. People who used this strategy usually associated it with stigma. For example, one participant chose to tell his wife he was in jail rather than in the psychiatric hospital in order to protect his marriage.

One final sub-process involved in managing relationships is substitution. If reciprocity membership fails in one group, the group can be replaced. Substitution can be temporary or permanent. One interesting example of temporary substitution is provided by Abdul Rahman, who became unsatisfied with his family's expectations of him. He took an overdose of medication, not with the intention of committing suicide (“I did not mean to kill myself. I don't want to die”) but with the intention to substitute his family with his treatment team. The steps he took seem extreme and illogical, but because of the limited services and difficulty accessing these, this was probably the only way he could guarantee re-entry into the treatment team. This type of behaviour is commonly referred to as ‘secondary gain’, which carries a negative connotation. However, the example above demonstrates how it can be an adaptive response to worsening mental health.

Reciprocity membership, mental health and mental illness

This study began as an exploration of how people manage the challenges of having a mental illness in their day-to-day lives. However, during initial analysis, most of the concerns that arose related to participants' location within social structures and seemed to have very little to do with mental illness. Participants wanted to see themselves as productive, and while their mental illness sometimes made this easier or more difficult, it was often set aside for the more concerning work of achieving or maintaining reciprocity membership.

Eventually though, mental health and mental illness found their way back into the analysis. For example, mental illness can be seen as a threat to reciprocity membership. One female had been hospitalized in the past with postpartum depression, and expressed a concern during the interview that she would relapse. Her fear was not directly related to becoming ill again or being hospitalized, but to her not being able to work (i.e., contribute to).

I will be admitted again in the hospital, and, it will change my life, you know? Because I have children, and I have to take care of the children. I have my future to work, you know? It will affect my work, how can I go to work … that's why I'm taking my medication and going to my appointments because I don't want to relapse. (Iman)

Another connection that emerged is that when reciprocity membership is absent or breaks down, it seems to be associated with distress. This distress is a burden on one's mental health and can lead to deterioration and relapse. For example, Omar spoke of not able to support his family financially due to a temporary setback. He says, “How am I supposed to support my family [under these circumstances]? … even if I am happy with my new wife, I feel depressed.” His circumstances and resultant inability to contribute to his family in the way he feels he should cause his mental health to deteriorate. He begins hearing voices and sleeping in his car at night to avoid his family.

Some participants had tenuous connections with others, but no real sense of membership or belonging. These people seem to have poor mental health, low resilience, and frequent relapse. One such participant described her disconnection with her family,

Why my ex-husband doesn't ask about me [sic] or take care of me [stated with distress]? Why doesn't he put me in a house with the children? Why didn't he take me back? He should do that. He is supposed to ask about me in this long absence. (Jamila; translated from Arabic)

Finally, throughout the study it seemed that individuals with balanced and stable reciprocity membership were more hopeful and optimistic about the future, had multiple strong and resilient connections, and were empowered to make choices and undertake challenges. In other words, these people seemed to have a more positive recovery experience.

Discussion

The aim of this study was to explore people's experience of mental illness and recovery in a Middle Eastern context. This was done through a grounded theory study of the main concern(s) of mental health service users and the strategies used to resolve this concern(s). The grounded theory that emerged from our data suggests that participants were most concerned with seeking reciprocity through relationships with others. When reciprocity membership was balanced, it seemed to be associated with recovery. Thus, reciprocity membership may be one potential pathway towards recovery in a Middle Eastern context.

Recovery in the mainstream (i.e., Western) literature refers to a process where people strive to lead a meaningful life in spite of the limitations caused by their illness (Anthony, 1993), within a social context (Topor, Borg, Di Girolamo, & Davidson, 2011). Reciprocity membership can be viewed as an analogous process through which people find meaning, where meaning is synonymous with the concepts of value and satisfaction, within Qatar's sociocultural context. Finding meaning occurs primarily through the contributions that participants make to others. These contributions help people feel “useful” and “productive” within a complex network of social relationships.

Service user accounts from Western countries demonstrate that recovery happens through a series of small steps and achievements with frequent ups and downs (Deegan, 1988; Spaniol, Wewiorski, Gagne, & Anthony, 2002). Similarly, participants in this study worked towards reciprocity membership by taking steps to become better positioned and to strengthen or maintain relationships. This happens through a series of adjustments and readjustments. Additionally, reciprocity membership is unstable. External and internal pressures can cause it to become unbalanced (‘downs’). When it does, people take action to restore balance (‘ups’). Thus, the process of balancing reciprocity membership is similar to Western service users’ recovery experiences, but is also subtly different. In particular, the focus on contribution and reciprocity, rather than personal (i.e., individual) recovery, may contrast with mainstream conceptualizations of recovery.

Individualism or self-determination is one of the main areas where Western conceptualizations of recovery may fall short in other contexts (Bayetti et al., 2017; Slade, Williams, Bird, Leamy, & Le Boutillier, 2012). This is mainly because many non-Western cultures are viewed as less individualistic, placing greater importance on the family and community. Thus, efforts to promote recovery by encouraging personal autonomy may seem out of place in collectivist cultures.

However, self-determination seemed important to participants in this study. But unlike Western conceptualizations (Drake & Whitley, 2014), the desire for self-determination was aimed at developing an individual's contribution to a group. In other words, efforts towards self-determination in this context were undertaken primarily for the benefit of the group, which simultaneously had personal benefit as well.

Social connectedness is one Western recovery concept that seems closely aligned with reciprocity membership. However, it is often vaguely or inconsistently defined in the literature. Some use the term to refer to ongoing or long-term interpersonal ‘closeness’ with accompanying social support (Fraser & Pakenham, 2009). Others describe connectedness as trusting relationships that promote feelings of belongingness and identity (Galloway & Henry, 2014). In these definitions, connectedness is often seen as one-sided, with the service user occupying the role of ‘consumer’ or recipient of support.

Reciprocity membership theory suggests that social connectedness in a Middle Eastern context is dependent on reciprocity. Taking this view, we suggest that recovery in this context is supported by social connectedness primarily when the conditions for reciprocity membership are present in the connection. In other words, simply being with, or receiving support from, others is inadequate. There has to be opportunities to contribute, expectations need to be reasonable, acknowledgement must be sufficient, and interests or values have to align. Additionally, participants seemed to desire connections with groups (i.e., memberships) rather than connections with individuals.

Viewing social connectedness through a lens of reciprocity membership provides a potential explanation for the contrasting influences of family and religion on recovery that were highlighted in the introduction. Some participants in this study felt that they did not have the opportunity or ability to make a meaningful contribution to their family, or that their family's expectations were too high. These situations caused significant distress. Thus, if a person feels that their family is having a negative impact on their mental health, it may be possible that one or more of the four conditions for reciprocity membership is out of balance.

Reciprocity membership can similarly be applied to hypothesize an explanation for the influence of Islam on recovery. Islamic culture emphasizes individuals' place within the much broader community of all Muslims, or the Umma (translation: nation) (Abudabbeh, 2005). A person's contribution can be viewed as the prayers and religious ceremonies they undertake, or the charity they are involved with. Acknowledgement may be positive life experiences, such as a new baby in the family or a promotion at work, which are often seen as blessings and attributed to God. Expectations may relate to the religious observances and modest lifestyle that are expected of many Arabic people in the Middle East. The theory developed allows us to hypothesize that when reciprocity is balanced, religion is a source of mental strength. Unbalanced reciprocity (e.g., not being able to complete daily prayers or undertaking forbidden activities) causes guilt and anxiety. This is an oversimplification of the complex role of religion in Qatar and nearby countries. However, it provides a frame of reference that could be used to incorporate religion into recovery efforts or to guide future research.

We previously conducted a scoping review of research on mental illness from the Gulf Cooperation Council (Bahrain, Kuwait, Oman, Qatar, Saudi Arabia, United Arab Emirates; a socio-political alliance of countries with similar culture and history) that reported subjective data from people with mental illness (Hickey, et al., 2016). We were not able to identify any study that focused specifically on recovery, but it was possible to extrapolate three recovery-related concepts. These included the widespread use of traditional (i.e., religious) healers to treat symptoms of mental illness, the pivotal role of extended family support, and the importance of religion. Results from the current study suggest that traditional healers are more important during the initial presentation of illness, rather than as an ongoing part of the recovery process. As discussed above, family support and religion were clearly linked to recovery in the current study, and reciprocity membership may mediate whether these factors are beneficial or detrimental to mental health.

Looking at recovery studies from other non-Western countries, other similarities arise. Lam et al. (2010) investigated recovery from first-episode psychosis in Hong Kong. Participants highlighted the importance of regaining cognitive and social functioning. The importance of maintaining a productive role was clear, “… having opportunities to participate in valued activities that contributed to and introduced them to the world of others would enable them to be less occupied with their inner worlds” (Lam et al., 2010, p. 583). This conclusion by the authors similarly applies to participants in the current study who were able to better cope with their mental illness when they had valued contributory roles in their community.

In a phenomenological study on recovery from mental illness conducted in Israel, Bril-Barniv, Moran, Naaman, Roe, & Karnieli-Miller (2017) focused on aspects of disclosure and concealment as it related to recovery. Community reintegration was a key practice that enabled participants to attain tangible supports. Interestingly, participants also identified providing support for others as an important step towards recovery. This reinforces our current finding that support alone is inadequate to promote recovery. Reciprocity, or the opportunity to give as well as to receive, must also occur.

The results of this study suggest that reciprocity membership is one potential pathway towards recovery from mental illness in the Qatari context. Promoting balance between contribution, acknowledgement, expectations and alignment in people's relationships with communities has the potential to increase key components of mental health, such as optimism, resilience, and empowerment. This process functions similarly to mainstream understandings of recovery. However, concepts such as social connectedness and self-determination are enacted with a stronger emphasis on developing or maintaining a productive community role. This finding aligns with conceptualizations of recovery from some other non-Western countries. Reciprocity membership also provides an understanding of how unique sociocultural factors, such as extended family and religion, influence mental health and recovery from mental illness. These differences, compared to mainstream conceptualizations, suggest that reciprocity membership provides a framework for recovery in Qatar and other countries in the region that is more reflective of service users' experiences in that context, compared to existing models.

Study strengths and limitations

Using grounded theory to explore people's experiences of mental illness in Qatar was a strength of this study. It enabled us to speak directly with mental health service users about their experiences with mental illness and the social processes involved in managing their illness. This methodology also led to the development of a substantive theory that is grounded in the concerns of service users in Qatar. This theory has implications for the ongoing development of health and social services in the country. The theory has also led to several hypotheses that provide grounds for future research in the area. Before now, anecdotal evidence was the main source of service user data available for planning services and research. This study is the first to provide in-depth, systematically collected evidence on people's experiences of mental illness in Qatar.

Another factor that was both a strength and a weakness was our position as cultural outsiders. Having a limited knowledge of a culture can help the researcher to identify differences and social patterns that would not normally be apparent to someone who is native to the culture (Hammersley & Atkinson, 2007 ). Simultaneously, service users may not have felt comfortable sharing personal information with a foreigner, and the principal author may have misunderstood or misinterpreted culturally-nuanced information. However, we attempted to address these potential weaknesses by working with a group of local student co-researchers.

Finally, the study sample has several potential weaknesses. Some might view the sample size as a weakness. However, one article that reviewed grounded theory studies found that sample size ranged from four to 87, with an average of 32 (Mason, 2010 ), making the current sample typical. The relatively young age of participants may affect transferability to older populations. The oldest participant was 47 and the average age was 30. It is possible that being productive and negotiating roles in a community may be higher priorities for this age group. Several participants were enrolled in, or had recently completed university. Participants in this group in particular were focused on finding employment, working and being able to contribute financially to their families. In contrast, older adults in the region may have different concerns and priorities as well as more established and stable roles in their communities. These potential differences may mean that current results have limited relevance to the older adult population.

Directions for future research

This study has multiple implications for research in the areas of mental health and recovery in a Middle Eastern context. The supportive/detrimental role of the extended family, the influence of Islam on mental health, and stigma are all areas where additional knowledge would be helpful. Additionally, gaining broader and more in-depth perspective from service users in the region would strengthen mental health service and policy development. However, it is important to note that the diversity in culture, language, economics, religion, etc., across the region makes it impossible to predict whether current results reflect the experiences on mental health service users in other countries. While this study adds a new perspective to people's experience of recovery in a Middle Eastern country, results should not be generalized to other countries in the region without further study. Future studies on reciprocity membership theory and its utility in promoting recovery are a logical next step for the current research. Any application of the theory to practice would require careful evaluation and further research.

Conclusion

Personal recovery has become an increasingly popular focus for mental health services around the world. Recent evidence suggests that research among more diverse populations is important to provide a more inclusive view of recovery. We investigated the main concerns of mental health service users in a Middle Eastern context as well as the strategies they use to address this concern. Participants desired reciprocity membership – opportunities to make a valuable contribution to some form of group where expectations of them were reasonable, acknowledgement was adequate, and where interests and values align. Balanced reciprocity membership seems to foster recovery. Our research offers the first exploration of mental health service users' recovery-related concerns in a Middle Eastern context and offers potential directions for service development and future research.

Footnotes

Acknowledgements

We are grateful for all the participants who shared their stories as part of this research. This work would not have been possible without their contributions, as well as invaluable support and guidance from Prof. Annie Topping, Dr. Suhaila Ghuloum, Dr. Chris Todd, Mr. Mohamoud Adam, Icra Elwadia, Mona Saleem, Amna Ahmed, Eiman Ahmed, Shamsa Jama and Suad Nur.

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: The authors would like to thank the University of Calgary in Qatar for providing seed funding to support the project.

Jason Hickey, PhD, RN, is an Associate Professor of Nursing at the University of New Brunswick. Prior to his current position, Dr. Hickey worked in the Faculty of Nursing for the University of Calgary in Qatar. During that time his research spanned the areas of nursing education in a cross-cultural context, interprofessional education and practice, and mental health and illness. This current work was completed as part of Dr. Hickey's PhD studies at the University of Manchester. His current program of research focuses on working with vulnerable Indigenous communities in Atlantic Canada to promote mental health and well-being.

Steven Pryjmachuk, PhD, PGDipEd, RN (Mental Health), CPsychol, SFHEA, is Professor of Mental Health Nursing Education in the School of Health Sciences at the University of Manchester, UK. His professional background is in nurse education, psychology and mental health, particularly the mental health of children and young people. He has more than 70 publications relating to his professional background. He is a mixed methods researcher and has been involved in a variety of small and large internally and externally funded projects including several as Principal Investigator. He is currently President of the advanced practice organisation, the International Society of Psychiatric-Mental Health Nurses.

Heather Waterman, Professor of Nursing and Ophthalmology, former Dean and Head of School of Healthcare Sciences, Cardiff University, is a health services researcher with 25 years of experience, over 60 publications, and PGR supervision experience (18 PhD/MPhil completions). Coming with a clinical background of ophthalmic nursing, she has research interests in promoting self-care of patients with long-term conditions, especially those concerning loss of sight. Her methodological expertise lies in action research with a current focus on translating research into practice. She has been lead or collaborator on several externally funded grants from medical charities, HTA, and NIHR. She has sat on funding committees including the MRC Health Services and Public Health Research Board and carries out peer reviews for, for example, the SDO, HTA.

References

Abudabbeh

(2005) Arab families. An overview. In: McGoldrick

Giordano

Garcia-Preto

(eds) Ethnicity and family therapy, (3rd ed) p. 423437. NY: Guilford Press.

Al-Nahedh

(1999) Relapse among substance-abuse patients in Riyadh, Saudi Arabia. Eastern Mediterranean Health Journal 5(2), 241–246.

Alsharekh, A. (2012). The Gulf family: Kinship policies and modernity. London: Saqi Books.

Al-Solaim

Loewenthal

(2011) Religion and obsessive-compulsive disorder (OCD) among young Muslim women in Saudi Arabia. Mental Health, Religion & Culture 14(2), 169–182.

Andresen

Oades

Caputi

(2003) The experience of recovery from schizophrenia: Towards an empirically validated stage model. Australian and New Zealand Journal of Psychiatry 37(5), 586–594.

Anthony

W. A.

(1993) Recovery from mental illness: The guiding vision of the mental health service system in the 1990s. Psychosocial Rehabilitation Journal 16(4), 11.

Bayetti, C., Jadhav, S., & Jain, S. (2017). The re-covering self: A critique of the recovery-based approach in India's mental health care. Retrieved from http://repositoriocdpd.net:8080/handle/123456789/1653.

Bennet, J. (2009). Early childhood education and care in Dubai. Retrieved from: https://www.khda.gov.ae/CMS/WebParts/TextEditor/Documents/Early%20Childhood%20Education%20&%20Care%20-%20Executive%20Report%20-%20Eng.pdf.

Bilal

A. M.

Kristof

Shaltout

El-Islam

M. F.

(1987) Treatment of alcoholism in Kuwait: A prospective follow-up study. Drug and Alcohol Dependence 19(2), 131–144.

10.

Bril-Barniv

Moran

G. S.

Naaman

Roe

Karnieli-Miller

(2017) A qualitative study examining experiences and dilemmas in concealment and disclosure of people living with serious mental illness. Qualitative Health Research 27(4), 573–583.

11.

Christiansen

(2007) A simpler understanding of classic GT: How it is a fundamentally different methodology. Grounded Theory Review 6(3), 39–61.

12.

Deegan

P. E.

(1988) Recovery: The lived experience of rehabilitation. Psychosocial Rehabilitation Journal 11(4), 11–19.

13.

Drake

R. E.

Whitley

(2014) Recovery and severe mental illness: Description and analysis. Canadian Journal Of Psychiatry. Revue Canadienne De Psychiatrie 59(5), 236–242.

14.

El Haddad, Y. (2003). Major trends affecting families in the Gulf countries. Retrieved from: http://www.un.org/esa/socdev/family/Publications/mtelhaddad.pdf.

15.

El-Islam

M. F.

(1982) Rehabilitation of schizophrenics by the extended family. Acta Psychiatrica Scandinavica 65(2), 112–119.

16.

Fellow, J. (2013). Qatar's delicate balancing act. 16 January 2013, BBC News. Retrieved from: http://www.bbc.co.uk/news/world-middle-east-21029018.

17.

Fraser Pakenham (2009) Resilience in children of parents with mental illness: Relations between mental health literacy, social connectedness and coping, and both adjustment and caregiving. Psychology, Health & Medicine 14(5), 573–584.

18.

Frese

F. J.

Davis

W. W.

(1997) The consumer–survivor movement, recovery, and consumer professionals. Professional Psychology: Research and Practice 28(3), 243–245.

19.

Galloway

A. P.

Henry

(2014) Relationships between social connectedness and spirituality and depression and perceived health status of rural residents. Online Journal of Rural Nursing and Health Care 14(2), 43–79.

20.

Glaser

B. G.

(1978) Theoretical sensitivity: Advances in the methodology of grounded theory, (1st ed). Mill Valley, CA.: The Sociology Press.

21.

Glaser

B. G.

(1998) Doing grounded theory: Issues and discussions, Mill Valley, CA: Sociology Press.

22.

Glaser

B. G.

(2014) Memoing: A vital grounded theory procedure, Mill Valley, CA: Sociology Press.

23.

Glaser, B. G., & Strauss, A. L. (1967). The discovery of grounded theory: Strategies for qualitative research. Chicago: Aldine Publishing.

24.

Hammersley, M., & Atkinson, P. (2007). Ethnography: Principles in Practice. Routledge.

25.

Hickey

J. E.

Pryjmachuk

Waterman

(2016) Mental illness research in the Gulf Cooperation Council: A scoping review. Health Research Policy and Systems 14(59), 1–14.

26.

Hickey

J. E.

Pryjmachuk

Waterman

(2017) Exploring personal recovery in mental illness through an Arabic sociocultural lens. Journal of Psychiatric and Mental Health Nursing 24(2–3), 163–170.

27.

Hofstede

(2001) Culture's consequences: Comparing values, behaviors, institutions and organizations across nations, (2nd ed). Thousand Oaks, CA: SAGE Publications, Inc.

28.

Holton

J. A.

(2010) The coding process and its challenges. Grounded Theory Review 9(1), 265–269.

29.

Jacobson

Greenley

(2001) What is recovery? A conceptual model and explication. Psychiatric Services 52(4), 482–485.

30.

Kronfol

Ghuloum

Weber

(2013) Country in focus: Qatar. Asian Journal of Psychiatry 6(3), 275–277.

31.

Lam

M. M. L.

Pearson

R. M. K.

Chiu

C. P. Y.

Law

C. W.

Chen

E. Y. H.

(2010) What does recovery from psychosis mean? Perceptions of young first-episode patients. International Journal of Social Psychiatry 57(6), 580–587.

32.

Lapsley, H., Nikora, L. W., & Black, R. M. (2002). “Kia Mauri Tau!” Narratives of recovery from disabling mental health problems. Retrieved from http://researchcommons.waikato.ac.nz/handle/10289/1666.

33.

Leamy

Bird

Boutillier

C. L.

Williams

Slade

(2011) Conceptual framework for personal recovery in mental health: Systematic review and narrative synthesis. The British Journal of Psychiatry 199(6), 445–452.

34.

Lustig, R. (2011). Tiny Qatar's growing global clout. 1 May 2011, BBC News. Retrieved from http://www.bbc.co.uk/news/world-middle-east-13229852.

35.

Mason, M. (2010). Sample Size and Saturation in PhD Studies Using Qualitative Interviews. Forum Qualitative Sozialforschung/Forum: Qualitative Social Research, 11(3). Retrieved from http://www.qualitative-research.net/index.php/fqs/article/view/1428.

36.

Oxford Dictionaries. (2017). Reciprocity – Definition of reciprocity in English. Retrieved from: https://en.oxforddictionaries.com/definition/reciprocity.

37.

Oyserman

Coon

H. M.

Kemmelmeier

(2002) Rethinking individualism and collectivism: Evaluation of theoretical assumptions and meta-analyses. Psychological Bulletin 128(1), 3–72.

38.

Pincus

H. A.

Spaeth-Rublee

Sara

Goldner

E. M.

Prince

P. N.

Ramanuj

Patton

(2016) A review of mental health recovery programs in selected industrialized countries. International Journal of Mental Health Systems 10: 73.

39.

QSR International Pty Ltd. (2013). NVivo (Version 10).

40.

Repper, J., & Perkins, R. (2003). Social inclusion and recovery: A model for mental health practice (2nd edition). Edinburgh; New York: Bailliere Tindall.

41.

Slade, M. (2009). Personal recovery and mental illness: A guide for mental health professionals (1st edition). Cambridge; New York: Cambridge University Press.

42.

Slade

Leamy

Bacon

Janosik

Le Boutillier

Williams

Bird

(2012) International differences in understanding recovery: Systematic review. Epidemiology and Psychiatric Sciences 21(4), 353–364.

43.

Slade

Williams

Bird

Leamy

Le Boutillier

(2012) Recovery grows up. Journal of Mental Health 21(2), 99–103.

44.

Song

L.-Y.

Shih

C.-Y.

(2009) Factors, process and outcomes of recovery from psychiatric disability: The unity model. International Journal of Social Psychiatry 55(4), 348–360.

45.

Spaniol

Wewiorski

N. J.

Gagne

Anthony

W. A.

(2002) The process of recovery from schizophrenia. International Review of Psychiatry 14(4), 327–336.

46.

Suleiman

M. A.

Nashef

A. A.

Moussa

M. A. A.

El-Islam

M. F.

(1986) Psychosocial profile of the parasuicidal patient in Kuwait. International Journal of Social Psychiatry 32(3), 16–22.

47.

Supreme Council of Health. (2013). Qatar National Mental Health Strategy. Changing minds, changing lives: 2013-2018. Retrieved from: https://www.moph.gov.qa/health-strategies/Pages/national-mental-health-strategy.aspx.

48.

Teller, M. (2014). Has wealth made Qatar happy? 29 April 2014, BBC News. Retrieved from: http://www.bbc.com/news/magazine-27142647.

49.

Topor

Borg

Di Girolamo

Davidson

(2011) Not just an individual journey: Social aspects of recovery. International Journal of Social Psychiatry 57(1), 90–99.

50.

Whitley

Drake

R. E.

(2010) Recovery: A dimensional approach. Psychiatric Services 61(12), 1248–1250.

51.

Willen, B., Perniceni, A., Lohmeyer, R., & Neiva, I. (2016). Power women in Arabia: Shaping the path for regional gender equality. Retrieved from: https://www.pressreader.com/kuwait/arab-times/20160311/281633894339919.

52.

World Health Organization. (2005). Mental Health Atlas 2005. Retrieved from World Health Organization website: http://www.who.int/mental_health/evidence/mhatlas05/en/.