Journal of Child and Adolescent Mental Health 2014, 26(1): 83–90Printed in South Africa — All rights reserved

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JOURNAL OF CH ILD & ADOLESCENT MENTAL HEALTH

ISSN 1728-0583 EISSN 1728-0591http://dx.doi.org/10.2989/17280583.2013.877465

Journal of Child & Adolescent Mental Health is co-published by NISC (Pty) Ltd and Routledge, Taylor & Francis Group

Clinical Perspective

‘Recovery’: Does it fit for adolescent mental health?

David Ward

School of Social Work, University of Queensland, PO Box 673, Beenleigh, Queensland Australia 4207Email: david.ward@uqconnect.edu.au

The notion of ‘recovery’ in mental health has a long and diverse history in terms of definition, treatment processes and outcomes. Particularly with regard to definition, there has been much debate in the literature. The aim of this paper is to extend the discussion by exploring how the concept is used for two developmentally divergent populations—adults and adolescents. I argued that it is indeed appropriate and valid to use ‘recovery’ in the treatment process for adolescents. However, while adults share various facets of the recovery process with their adolescent counterparts, there are also significant differences such as physiological change, the impact of peers, identity development and the role of family. These crucial differences must guide any clinical services for the adolescent population.

Introduction

Adolescence has traditionally been seen as the period between childhood and adulthood, a period characterised by significant biological, psychological and social changes. With perhaps the exception of infancy, no other developmental stage of human life seems to experience such intrap-ersonal and interpersonal structural change (Sisk and Foster 2004). Over the last 25 years or so there has been a steady increase in research investigating various spheres of adolescent life and development (Smetana, Campione-Barr and Metzger 2006). Despite such a wealth of informa-tion, gaps remain. The literature suggests that there is still significant global neglect of epidemio-logical data, research and intervention into child and adolescent mental health (Remschmidt et al. 2007, Belfer 2008,). This is particularly concerning given that up to 20% of children and adolescents worldwide may be suffering a mental illness, that in the adolescent population suicide is the third highest leading cause of death and that as many as 50% of all adult mental disorders have their onset in adolescence (Belfer 2008: 226). Australian figures are similar with an estimated 20–25% of young people aged 12–17 years experiencing a mental health disorder (Zubrick et al. 2000). An Australian survey of mental health and wellbeing incorporated data from 1 490 adolescents aged 13–17 years (Sawyer, Miller-Lewis and Clark 2007). The parent reports in this study suggested that 13% of adolescents were experiencing a mental disorder, while 19% of the adolescent reports suggest mental health problems. However, only 31% of the parent and 20% of the adolescent sample revealed they had attended any professional service to address the problems within 6 months of the survey. Equally concerning is the trend for mental health problems to develop at an increasingly earlier developmental stage (Zubrick et al. 2000). Consequently, the importance of developmental issues and how they relate to mental health is the primary theme in this article.

Given the above figures, the well-known notion of recovery is most important. It has emerged as a core theoretical principle shaping the understanding of mental illness as well as directing those services that help individuals with such difficulties. The word itself is deeply meaning-laden; one

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which is usually the starting point for any intervention. However, if such an important concept as recovery is ill-defined or applied carelessly, potentially unhelpful or negative outcomes could be the consequence. However, whether a hard and fast definition is warranted or even possible is debatable. I predict that the amorphous nature of recovery will continue, primarily because it is a reflection of the clinical jigsaw puzzle that presents itself in those with mental illnesses. Recovery from adolescent anorexia is a case in point (Couturier and Lock 2006). Is it primarily the gaining of physical weight or the gaining of sufficient emotional/developmental functioning or both? From the author’s experience, the recovery ‘criteria’ for one individual can easily be ‘reshuffled’ for another individual due to a range of personal variables and contexts. Those who have worked with individ-uals with this condition will appreciate the significant grey areas.

While the concept of recovery is a somewhat elusive term, it has been used continually for many years. It would seem that Anthony’s (1993) oft-quoted definition seems as applicable today as it was 20 years ago:

Recovery is described as a deeply personal, unique process of changing one’s attitudes, values, feelings, goals, skills, and/or roles. It is a way of living a satisfying, hopeful, and contributing life even with limitations caused by illness. Recovery involves the development of new meaning and purpose in one’s life as one grows beyond the catastrophic effects of mental illness (Anthony 1993: 15).

Some authors argue that use of the term invites risk, discouraging individuals from seeking professional help or generating unrealistic expectations about an objective state (Meehan et al. 2008). Others seek to operationalise the concept. For example, Noordsy et al. (2002) suggest a definition that includes components of hope, personal responsibility and moving beyond illness with a range of scales to measure these concepts. Others such as Davidson et al. (2005) have reviewed the literature and condensed a range of concepts into primary themes such as ‘redefining hope’, ‘overcoming stigma’ and ‘managing symptoms’. Still another framework based on a review of the literature is the Leamy et al. (2011) five element model that includes connectedness, hope, identity, meaning and empowerment.

Recovery and adolescent mental health

While recovery itself remains a longstanding and core component in the mental health literature, it remains one that is rarely found in the context of adolescent mental health. When the literature does link these two areas, it tends to focus on recovery from specific disorders such as depres-sion (Woodgate 2006) or more commonly, physical illnesses such as cancer (Grinyer 2007). Unfortunately, it appears that even within the literature on adolescence, mental health issues lag behind medical phenomena. Adolescents experiencing physical or mental illnesses have the same developmental issues as their healthy counterparts, but risk developmental rupture due to poor health, physical changes or scholastic difficulties (Taylor, Gibson and Franck 2008). However, much of the data still investigates recovery from within a medical framework. For example, there has been helpful qualitative research into the lived experience of adolescents with serious cardiac conditions (Zeigler and Nelms 2009) and the experience of adolescents coming to grips with asthma (Kintner 1997). Conversely, there appears to be less qualitative research exploring the notion of recovery within child and adolescent mental health.

Typical of this gap in the literature are a range of texts that fail to link recovery with younger populations. While acknowledging the usefulness of texts such as Recovery in mental illness (Ralph and Corrigan 2005) for general recovery principles and particularly the value of qualitative research in recovery, it is disappointing that the volume omits any information on how this well-used concept in the mental health literature can inform work with the adolescent population. This gap in the literature is not uncommon. Even when the literature explores recovery from a lived experi-ence framework, it does so with adult populations, and with a significant proportion exploring only schizophrenia or psychosis (e.g. Noordsy et al. 2002, Davidson et al. 2005, Borg and Davidson 2008, Bradshaw, Armour and Roseborough 2008). Reviews of the literature often link recovery with schizophrenia or psychosis (Bonny and Stickley 2008). I argue that this gap in the literature is most

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significant, as it increases the propensity for adolescent difficulties to be addressed via conceptuali-sations that are primarily generated from adult data (Weisz and Hawley 2002).

Youth mental health incorporates a broader population base, and there remains much in the recovery literature that does not developmentally fit a younger generation (Frieson 2007). While the concepts of mental illness and recovery are regularly utilised, it becomes increasingly difficult to use the terms as the age bracket decreases for younger service users and their families. Such a heterogeneous group therefore requires the concept of recovery be stretched accordingly. Finally, some concepts of recovery (e.g. empowerment and self-determination) may also be applied to the families or caregivers. There needs to be further discussion about how adolescent recovery is a deeply social process (Topor et al. 2011).

Commonalities between adult and adolescent

Of course, many parallels exist between adult and adolescent recovery principles. Both wish an amelioration of symptoms and a better quality of life, guided by various mental health professionals and services. The subjective experiences of treatment and recovery can also be similar in many respects. To help demonstrate this, material has been borrowed from the author’s current research project (Ward 2014). It investigates the lived experience of inpatient life as expressed by adoles-cent patients, their parents, and staff of the unit. A qualitative piece, it explores various domains of adolescent life in a long-term residential psychiatric unit during an important developmental phase. The quotes below start to give a sense of the parallels and contrasts between adolescent and adult experience. Pseudonyms are used throughout the participant extracts.

Interviewer: ‘Is that hope still there, Sam?’Sam: ‘Hope’s always there, even if it’s tiny. For me, it’s always there.’Interviewer: ‘Where does that come from?’Sam: ‘I’m not sure exactly. I guess inside myself there’s always going to be a part of me that wants to go on, which sometimes I don’t like to accept. I think, “No, I’m just depressed and I don’t want to go on!” But I think there’s always going to be a part of me that says “Sam, you want to go on and you don’t want to die!” So there is a bit of hope in me. Even if it’s small’ (Male, 15 years old).

While the above quote is from a 15-year-old adolescent, the themes of hope and ambivalence could have been easily expressed by an adult. Indeed, the notion of hope is a ubiquitous theme running through almost every definition of adult recovery (Onken et al. 2007). It is also a theme that cuts across the developmental life cycle.

Another common theme within adult recovery is that of respectful therapeutic relationships, particularly in hospital contexts:

A psychiatric patient, however, might well find a ward that is rundown and peopled by staff who do not seem to have the same expectations of respect for patients and of a generally good professional working relationship between staff and patients. A psychiatric patient might instead, as I did in one of my hospitalizations, find staff who avoided talking to the patients as far as possible and whose only interaction with patients was to give commands (Anonymous 2007: 846).

The above experience is mirrored in the adolescent population, again found in Ward (2013):Meg: ‘I find — I feel like they have no right to judge me because I haven’t talked to them at all, and they know none of my things. They’ve only read what’s written down in my file, which doesn’t really explain me well. My file is full of gaps and…’ Interviewer: ‘There’s a lot more to know than what’s written about you.’Meg: ‘Yeah. And I find the nurses they’re just – well the casuals – are just like “Oh I’ll just go and read your file and I’ll understand then”. And you’re just like, “No, there’s a lot more behind me than just what’s in my file!”’ (Female, 14 years old).

The desire to be seen as human, to be known, and subsequently deserving of respect, is again an existential theme regardless of where one is on the developmental continuum. Needless to say, it is an unfortunate truth that adolescents and adults also share other aspects of mental illness,

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particularly the issues of stigma and clinging diagnostic categories. Both groups are aware that while a physical health condition is something that happens to us, when it comes to mental health we are mentally ill. Corollary to this, is the lay misconception that much of mental illness (particu-larly so for adolescents) stems from, and is perpetuated by, behavioural dysfunction. Consequently, the individual concerned needs to stop attention seeking, take responsibility, ad infinitum. The author has heard in many a case conference where it was debated as to whether an adoles-cent with an eating disorder can’t eat, or won’t eat. This of course has profound and far reaching repercussions for when there has been sufficient ‘recovery’ to be discharged. The dimensions of recovery then, are truly broad; clinical recovery, psychological well-being, social and occupational domains are all dimensions of recovery that every adult and adolescent share (Lal 2010). However, they do not share some domains: dimensions that inform mental health conceptualisation and subsequent treatment. These are discussed in the following section.

The adolescent as a work in progress

While there is common ground in recovery for the adult and adolescent populations, there are also significant differences. The adolescent is in the midst of a critical life cycle stage concurrently incorporating the physical, psychological and social domains. I have outlined four sample areas of the adolescent’s life that stand in contrast to their adult counterparts: family, peers, identity and physiological change.

First, the family environment of the adolescent has generally been accepted as the most influen-tial facet during adolescence and consequently the most researched (Steinberg 2000, Collins and Laursen 2004). This stands in contrast to their adult counterparts. While it is acknowledged that families exert an important influence for adults in the mental health system, the immediate family of the adolescent remains more so given that adolescents are usually far more dependent on the family of origin and attachment/individuation development is still ongoing. Past clinical experience has revealed that familial issues are often foremost in the mind of emotionally troubled teens:

‘I guess my little sister is sort of sad because I’m not there like I always am. Guess my mum...happy partially, because she believes I can get the help she thinks I need and get better...she says she’s sad when I’m not around but I don’t really believe her. My brother says he’s happy. I don’t know, I wouldn’t ask my stepdad’ (Female, 16 years old).

For this adolescent female, there are a range of conflicting attachments in the one family system, a family system that continues to exert tremendous influence on the recovery process as well as her developmental growth generally. In other words, during this life-cycle stage, attachment and individuation processes will continue to occur simultaneously with recovery. I suggest this points to another distinctive of the period.

Second, the impact of peers during adolescent development is crucial. Peer relationships during adolescence incorporate individuals, groups, same-sex and opposite-sex relationships and can be constructive or destructive for the developmental journey (Smetana et al. 2006). The same could be said for adults. However, particularly given the ongoing development of identity during such a critical period, I suggest that peers will exert a more powerful influence on the recovery process for adolescents. Unhelpful peer socialisation may lead the adolescent into problem behaviours such as substance use (Curran, Stice and Chassin 1997) or sexual promiscuity (Dishion 2000). This is especially noteworthy for adolescent psychiatric inpatients. For example, a high concentra-tion of one particular condition may well have possible contagion effects (Taiminen et al. 1998). Conversely, other studies suggest that the presence of one’s peers assists the adolescents in their recovery (Hutton 2008).

While deserving a paper in its own right, much of the adolescent peer interaction occurs within an educational context; again, unique to adolescents:

Interviewer: ‘Okay. I’m wondering then how does the [inpatient] school compare to your other school experiences?’Meg: ‘Um, other school experiences were quite bad because I used to self-harm myself at school all the time because I just thought that I didn’t belong and I shouldn’t be at school

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because I had no reason to be at school because I didn’t know anything and everyone would tease me. So I just used to self-harm or something like that just to try and get myself suspended or to not go to school. But here I don’t do anything. I just sit there and read or do maths or something. I don’t try and get myself suspended or anything like that. So it’s quite good that I’ve changed my way from my old self to my new self’ (Female, 15 years old).

Themes of belonging, bullying, self-harm and a transition from ‘old self’ to ‘new self’ are obvious. This complex interplay between peers, the educational system and identity formation all coalesce to form a developmental foundation from which adulthood later emerges.

Third, the notion of identity development during adolescence is one that has been researched over many years (Kroger 2003). The identity substrate of an adult is largely set, while the adoles-cent ego is a work in progress. For the most part it has its genesis now, “Because it is the first time that all of the necessary ingredients exist for its construction” (Marcia 2002: 202). Consequently, adolescents who experience mental illness have a greater chance of a compromised self-esteem and shattered sense of normality (Hinshaw 2005).

Finally, the adolescent is experiencing tremendous and unprecedented physiological change (Sisk and Foster 2004). Some research suggests that these physiological changes create develop-mentally thin ice where the adolescent-in-transition is far more vulnerable to seek out potentially damaging experiences due to the structural and chemical reorganisation of the brain (Spear 2000). Not only does puberty itself have considerable variation in its timing, other areas of psycho-social development are often on a very different schedule to that of any physical development. The timing of puberty as well as stress levels during this stage are often linked to psychosocial problems during adolescence and beyond (Walvoord 2010). Once again, this points to uniqueness in development via the converging of multiple physical, cognitive and social domains. It is therefore a time of opportunities and pitfalls for the teen.

These four areas represent a small sample of the developmental domains that converge to create a period of bio-psychosocial flux for the adolescent. Many other theories of adolescence exist, with other complex and debated facets such as educational issues and wider socio-economic variables (Santrock 2003). Below is an outline of the four sample areas of recovery. As well as the four areas reviewed above, the five element model by Leamy et al. (2011) has also been incorporated as a good example of the common elements between adult and adolescent recovery principles.

Implications for practice

I suggest that given the parallels between adult and adolescent recovery, it is indeed a concept that, despite the ongoing debate as to its defining features, will remain a useful notion. It remains a hopeful perspective, one that focuses on life and one that tends to be strength-based rather than deficit-based. It is wide enough to incorporate both the individual and the systemic. It can incorpo-rate the clinical remediation of symptoms as well as personal elements such as self-determination and hope. Conversely, recovery still can equate for some as ‘cure’, be potentially stigmatising with children or adolescents and remains rooted in an illness-based, medical model.

It remains then, an elastic notion; one that lies somewhere between the clinical and the spiritual, straddling the worlds of empiricism and existentialism. However, I want to highlight the central thesis of this discussion; that developmental issues remain the core feature that separate adult and adolescent mental health. Given the previously mentioned areas of adolescent development that distinguishes the adolescent population, a core feature of adolescent recovery is a developmental reconstruction, one which as the name suggests, is a reinitiating and rebuilding of developmental tasks. This of course raises the question of how to provide such a developmentally informed mental health service for adolescents: • The once-a-week talking therapy session that is often based on adult therapeutic models needs

to be reconsidered. Therapeutic intervention must be mindful of the developmental tasks of adolescence and incorporate them accordingly.

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• Diagnostic labelling, however useful, must be utilised carefully during such a transitional, temporary stage. Particularly for personality classifications that can lead to far reaching consequences for the developing identity of an adolescent.

• The inclusion of adolescent-connected systems such as school/education, peers, health, family and other groups. Not merely to collect further collateral, but as active “external conditions” (Jacobson and Greenley 2001: 484) that may well be key structures in the adolescent’s recovery.

• The concepts of recovery and resilience are closely intertwined (Friesen 2007, Fletcher and Sarkar 2013). Notions such as positive adaption to adversity and good outcomes despite threats to development are concepts that could prove most fruitful in constructing a develop-mentally informed recovery process.

• The valuing of adolescent lived experience via qualitative research that offers an “adolescent-centred view” (Rich and Ginsburg 1999: 377).

As one individual with mental illness stated, “mental illness is not like having diabetes” (Anonymous 2007: 846). I suggest too, that adolescents’ recovery is not necessarily the same as adult recovery. While all those in recovery seek out new meaning and purpose for their lives, there is also, for the teenage population, a developmental reconstruction that allows the adolescent to continue to progress toward a satisfying and productive adult life.

Acknowledgements — The author thanks Professor Robert Bland and Associate Professor Peter Newcombe at the University of Queensland for their helpful comments on an earlier draft of this manuscript.

Table 1: Common and contrasting recovery themes

Adult Primary common recovery themes(Leamy et al. 2011) Adolescent

Role of familyThe adult’s family can play an important role in encouraging their loved ones to overcome the impact of mental illness and stigma (Rose, Mallinson and Walton-Moss 2002).

Peers The recovery process for adults can be enhanced by supportive peers (Topor et al. 2011).

Identity developmentAdults redefine their identity and start viewing their mental illness as only one aspect of themselves. They also recover from societal stigma associated with this (Davidson et al. 2005, Leamy et al. 2011).

Physiological changeApart from typical ageing processes, physical development has been completed.

Connection with others

Hope for the future

Developing and maintaining identity

Discovering and maintaining meaning in life

Empowerment and control over one’s life

Role of familyA crucial influence for the recovery journey, with attachment and individuation processes ongoing (Collins and Laursen 2004).

PeersPeers exert tremendous pressure on the developmental trajectory with peer contagion a strong factor in adolescent difficulties (Dishion and Tipsord 2011).

Identity developmentIdentity development is a core work in progress, influenced by peers and various systems such as education (Kroger 2003). Building on earlier years, this period will be foundational for adult identity.

Physiological changeProfound physiological change that could have significant implications for later life (Sisk and Foster 2004, Spear 2000).

Journal of Child and Adolescent Mental Health 2014, 26(1): 83–90 89

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