Recovery Among People with Mental Illness (PMI) as Perceived by the Caregivers in Islamic Boarding School (IBS) in Indonesia

Background: Mental hospitals as places to rehabilitation people with mental illness(PMI) in Indonesia are limited in numbers and do not meet with the number of PMI.The society may contribute in facilitating recovery and rehabilitation place for PMI including Islamic boarding school. Some Islamic boarding schools provide rehabilitation for PMI to help with recovery process. Recovery is an important aspect to assess the success of PMI rehabilitation. Nevertheless, there has been no study on Islamic boarding school's caregivers' perception on PMI recovery.Purpose: This study aims to explore recovery perception of caregivers treating PMI in Islamic boarding school and factors affecting recovery.Methods: Data are acquired from 19 caregivers from three Islamic boarding schools providing rehabilitation for PMI with Focus Group Discussion (FGD). The data analyzed using descriptive analysis.Result: Having a good communication is a recovery criterion that is mentioned themost by caregivers. There are three biggest factors affecting recovery based on the caregivers such as prayers or religion followed by social support from family and environment and also doing activities.Conclusion: The results may depict the PMI recovery so that the health care providers can provide interventions that can support the recovery process in PMI.

People with mental illnesss have some symptoms as a form of mental disorder such as psychosis (hallucination and delusion), speech disorder, loss of motivation and cognitive disorder. Some of those symptoms may cause social and work dysfunctions, lack of interpersonal relationship, decline in personal care and mortality or morbidity (Moller, 2009;Townsend 2008). Individuals suffering from this disorder also suffer from a second disease, from social environment reaction and stigma. The society often ODEHO ³FUD]\ SHRSOH´ PDNLQJ PMI feel ashamed to the society, have low self-esteem and the absence of hope. The impact of stigmatization will result in social isolation, lack of opportunity such as in job opportunity and social discrimination of PMI (Horrison & Gill, 2010). All of these may reduce the quality of life of PMI. Some people with mental illnessV DOVR VXIIHU IURP ³SDVXQJ´ SK\VLFDO UHVWUDLQW EHFDXVH IDPLO\ RU VRFLHW\ IHHO disturbed with their presence.
Therapies for PMI can be devided into two therapies, pharmacological and nonpharmacological therapy. The pharmacological therapy such as antipsychotic agents is effective in alleviating symptoms in schizophrenia such as hallucination, delusion, speech and inappropriate affect (Moller, 2009). While the nonpharmacological therapy or psychosocial therapy in schizophrenia are psychoeducation, cognitive behavior therapy (CBT), social skills training (SST), family therapy and assertive community treatment (ACT) (Tandon, Nasrallah, & Keshavan, 2010). Psychosocial therapy has some benefits such as relieving symptoms, preventing relaps, increasing social and selfcare functions and quality of life in people with schizophrenia. Both modalities of therapy are aimed at helping the recovery of PMI.
Recovery is an important aspect to the success of the treatments of PMI. Recovery is a unique process in each individual. Recent studies stated that the definition of recovery is divided into clinical recovery and personal recovery. Clinical recovery is a low level of psychopathology or decline in symptoms of mental disorders (Bobes et al, 2009) and no rehospitalization (Grossman et al., 2008). Meanwhile, social recovery is defined as prescence of hope and meaningful purpose (Hoper, 2007;Lysaker et al., 2010), happiness (Buckland, Schepp, & Crusoe, 2013), socialization and finding place in the society and being involved in a job (Cavelti et al., 2012;Roe, Mashoach-Eizenberg, & Lysaker, 2011;Silverstein & Bellack, 2008).
Rehabilitation for PMI plays an important role in helping the recovery process. Rehabilitation is an interventional program to prevent or reduce the severity of the mental disorders in need (Perese & Wu, 2010). The government has responsibilities in Nurse Media Journal of Nursing, 5 (2), 2015, providing rehabilitation care in order to help PMI recovery based on Regulation No. 36 year 2009 about health clause 145 (Konas Jiwa, 2013). However, psychiatric hospital (PH) as a rehabilitation place for PMI is limited in number and do not meet with the number of people with mental disorders which is increasing through the years.
Islamic boarding school (IBS) is a place to learn the religion of Islam which is growing and expanding in Indonesia because of enormous supports and hopes from the society. Some IBS do not only function as a place for the students to learn but also contribute in facilitating recovery and rehabilitation place for people with mental illnesss. Some studies showed that rehabilitation in IBS is beneficial in helping recovery along with religious activities done in IBS (Sari & Wijayanti, 2014). However, during the course there are some problems affecting the PMI rehabilitation in IBS such as the lack of care giver, therapies provided, the minimum budget and the lack of society and family support (Dahliyani, 2012;Naufal, 2014).
Recovery is a crucial aspect for people with mental disorders especially to offer positive impact on the quality of life. The caregivers are the person who responsible to the development and recovery for PMI in IBS replace the role of caregiver when the PMI lived with the family. Nevertheless, study on PMI UHFRYHU\ DFFRUGLQJ WR ,%6 ¶ FDUHJLYHUV has not been done in Indonesia. Thus, the purpose of the study is to get overview of the definition of recovery and factors that may help the recovery process according to the caregivers treating PMI in IBS.

OBJECTIVE
The objective of this study is to explore recovery perception of caregivers treating PMI and factors affecting recovery perceived by the caregivers in Islamic boarding school in Indonesia.

Study design
This study is a qualitative research with fenomenology method meaning that a study has the purpose of depicting and analyzing. With this method, the authors may understand about PMI recovery perception according to the caregivers and factors affecting recovery.

Sample and setting
This study conducted at three boarding schools in Demak, Magelang and Yogyakarta which provided rehabilitation among PMI. Participants in this study are caregivers treating PMI in IBS. Inclusion criteria for the participants are (1) caregivers who are responsible for treating PMI, (2) living in Islamic boarding school and (3) are willing to participate in this study.

Ethical Considerations
This study had been approved by the ethic committee from Faculty of Medicine Diponegoro University. The informed consent was obtained from all patients. Informed consent is provided for the participants to gather information in the study, the right to participate and the confidentiality guaranteed by the researchers including anonymity.

Data collection and analysis
Data collection is used by the questionnaire about personal identity, and Focus Group Discussion (FGD). The authors then use descriptive analyses to thoroughly review the significant results.

Characteristics of the participants
There are 19 caregivers from three Islamic boarding schools. The description of SDUWLFLSDQWV ¶ FKDUDFWHULVWLFV FDQ EH VHHQ LQ WDEOH  There are some factors affecting the recovery according to caregivers such as therapy/ prayers, family and environmental support, doing activities, faith to recover and taking medications. These things are stated by an informant as follows: «UHOLJLRXV DFWLYLW\ GRLQJ 4XUDQ UHFLWDO SUD\HU PD\ DFFHOHUDWH UHFRYHU\ (AK) «WR UHFRYHU IDFWRUV FRQWULEXWLQJ WR LW DUH ZLOOLQJQHVV IURP PHGLFDWLRQV WR KHOS prayers given: communal prayers may make us closer and have more faith in Allah. (RR)

DISCUSSION
Recovery is a unique process in each individual. The definition of recovery in people with mental disorder (PMI) that is found in most studies is being able to communicate followed by behaving like normal person and cooperative. This definition is in line with previous studies referring that recovery is an outcome with low level of psychopathology and severity of the existing symptoms such as speaking and behaving well (Bobes et al., 2009;Silverstein & Bellack, 2008). Some expressed by caregivers DOVR GRQ ¶W PHHW RWKHU FULWHULD L H WKH UHWXUQ RI VRFLDO IXQFWLRQ OLNH ZRUNLQJ DQG DEVHQFH of rehospitalization (Grossman et al., 2008). This shows that the definition of PMI recovery chosen mostly by the Islamic boarding school caregivers still focuses on the clinical recovery or the low level of psychopathology or lack of symptoms of mental disorder.
Only few caregivers mention that PMI recovery chose the presence of socialization and purpose in life that is a part of a personal recovery (Cavelti et al., 2012;Roe, Mashoach-Eizenberg, & Lysaker, 2011).This study was supported by other studies about the concept of recovery as a process to achieve a meaningful life (Hopper, 2007), happiness (Buckland, Schepp, & Crusoe, 2013) or quality of social relationship, selfesteem, and hopes (Lysaker et al., 2010). The study is also supported by Ciudad, Bobes and Alvarez (2011) in his study that recovery in PMI at least meet three different criteria i.e. reduced symptoms, increased function and subjective response in each individual. The lack of symptoms can be obviously seen such as good communication, absence of hallucination or good orientation. Increased function can be seen by socialization and activities while subjective response can be seen by knowing the purpose of life.
Factors affecting recovery according to participants of the study are therapies done by the Islamic boarding school such as prayers, family and environmental support, doing activities, faith to recover and taking the medications. Some caregivers in Islamic boarding school believe that therapies and supplications given to PMI while living in Islamic boarding school contribute hugely to recovery process of PMI. This agrees with other studies done in Islamic boarding school that is Dahliyani (2012) exploring methods and religious activities done in Islamic boarding school to PMI. The result showed that religious activity done in Islamic boarding school for PMI such as congregational prayers, Quran recital, review about wisdom stories, communal supplications, remember RI *RG ¶V PHVVDQJHU VWXG\LQJ DQG LQGLYLGXDO PHQWRULQJ. The main therapy applied is, among others, supplications and proven effective on PMI recovery.
Besides, supplication is a part of spirituality which is beneficial for PMI recovery. This is in line with previous studies done by Sari and Wijayanti (2014) which attempted to explore spiritual experience of PMI and benefits while living in Islamic boarding school. The results were: 1) spiritual definition of being close to Allah and religious activities which become increasingly consistent, and 2) benefits of spirituality i.e. recovery from mental illness, symptoms management, behavioural change, emotional change and attention for the future. Spirituality plays an important role for patients including helping recovery of PMI.
Nurse Media Journal of Nursing, 5 (2), 2015, Some caregivers also choose family and environment support as an important influence to affect the PMI recovery while living in Islamic boarding school. Some caregivers complain about the lack of family support of PMI. The results are in line with other studies that the low rate of seclusion and the abundant social support may increase recovery and quality of life of PMI (Roe, Mashoach-Eizenberg, & Lysaker, 2011).
The results of this study show that therapy, supplications etc play more important role compared to medications. This contradicts the previous studies in other countries stating that medication compliance and types of medications given are predictors for recovery (Novick et al, 2009). Some Islamic boarding schools in Indonesia providing rehabilitation for PMI do not utilize medications in the treatment of PMI similar to previous studies done in IBS but only using therapies and prayers which are considered beneficial for the PMI recovery process (Dahliyani, 2012;Nusrotuddiniyah, 2013).

CONCLUSION
The study reflects recovery perception people with mental illness (PMI) according to caregivers treating PMI in Islamic boarding school. Most caregivers consider PMI recovery has some characteristics, with top three characteristics as follow: being able to communicate well followed by behaving like normal people and is cooperative. 0HDQZKLOH IDFWRUV DIIHFWLQJ UHFRYHU\ DFFRUGLQJ WR ,%6 ¶ FDUHJLYHUV DUH SUD\HUV IDPLO\ and environmental support, doing activities, faith to recover and taking medications. There are three themes acquired from this study that is spiritual definition, spiritual experience and its effect.
The result of the study recommends that mental health care providers may discuss regarding education about mental illness WR ,%6 ¶ FDUHJLYHUV FRQVLGHULQJ WKHUH DUH ,%6 LQ Indonesia that provide rehabilitations for PMI. Besides, health care providers and/ or psychiatric hospital are expected to provide spiritual therapy and facilities for PMI ¶V spiritual improvement because supplications and spiritual condition may help with PMI recovery process.
PMI recovery in this study is a perspective of PMI caregivers living in IBS. Therefore, future studies may explore PMI recovery from the perspective of PMI, family or mental health care provider such as psychiatrists and mental nurses. As a result, all elements have the same perception on PMI recovery and proper measures to help with PMI recovery process.

ACKNOWLEDGMENTS
This paper is part of research funded by the Faculty of Medicine, Diponegoro University Indonesia under its Programme Grants for Developments and Applied Research.