Understanding the Recovery Model in the Context of Emerging

Adulthood

 

Goldstein, Abby L.1

Brodkin, Sabrina2

Kofler, Danielle1

Kalb, Natalie1

 

1 Department of Applied Psychology and Human Development, Ontario Institute forStudies in Education, University of Toronto

2 Newhouse School of Public Communications, Syracruse University

 


This work is licensed under a Creative Commons Attribution 4.0 International License.

 

KEYWORDS

Adolescent, Emerging Adult, Recovery Model

 

Introduction

The purpose of this paper is to present the Recovery Model as a guiding framework for considering the developmental needs of emerging adults (ages 18-25 years old) with serious mental health issues. We first provide an overview of the unique needs of emerging adults and then consider the ways in which these needs can be met within recovery-oriented practices. We contend that the core features of the Recovery Model are well-aligned with the characteristics of emerging adulthood and that recovery-oriented services should be considered as part of larger changes in policy and practice in emerging adulthood.

Emerging Adulthood

Over the past 50 years, we have seen a significant shift in the age at which individuals reach various milestones typically associated with adulthood. Unlike previous generations, marriage, parenthood, and career stability occur past age 25 for most young individuals living in post-industrial societies in the 21st century.1-3 Although Erikson4 first discussed identity exploration as a critical developmental task, it was Jeffrey Arnett5 who noted that this task was most salient during the transition from adolescence to adulthood, a stage of development that he referred to as ‘emerging adulthood.’ Emerging adulthood is typically defined based on chronological age and spans the ages of 18 to 25 years. Arnett identified five main psychological features of emerging adulthood that distinguish it from other life stages.1,5 He noted that these features are not necessarily unique to this time of life, but they are most salient. These include identity exploration (trying out new things and figuring out who you are), instability (in education, work, relationships, and residence), self-focus (being responsible for oneself while not being responsible for others), feeling in-between (considering the self as somewhere between an adolescent and an adult), and possibility (feeling optimistic about future prospects). Although these developmental tasks often begin during adolescence and continue into young adulthood, the transitional nature of emerging adulthood sets it apart it from other life stages.5

Emerging adulthood is also accompanied by significant cognitive and psychological changes.5 Recent studies have shown that neuropsychological development continues well into the 20s, especially in the prefrontal cortex area, which is associated with greater efficiencies in emotional and cognitive processing.6-8 This continued neurobiological maturation results in further development of executive functioning abilities, enabling more complex thinking and increased capability to self-regulate emotions and cognitions during the emerging adult period.9-11 However, it is also during this age period that there is a tendency to seek out novel stimulation as a way of exploration and risk taking behaviors including substance use tend to peak during this developmental period.12-14

Despite evidence that this is a distinct period of development, emerging adults are not a homogenous group. Many emerging adults have difficulty meeting the cognitive and psychological expectations of this period. Canadian emerging adults are more likely than other age groups to be involved in risk behaviours, including problem gambling, high-risk sexual behaviours (e.g., non-use of contraceptives or protection from STIs), and alcohol use and binge drinking.15-17 Although there is a large range of ages for which there is available data on the onset of mental health issues, there is consensus among studies that this age overlaps with the emerging adult period. For example, 75% of mental health issues have their onset by age 24 and suicide is the second leading cause of death for Canadians aged 15 to 24.18,19 According to the Mental Health Commission of Canada, 21.4% of the working-age population was living with a mental health issue in 2011, with the prevalence of mental health issues peaking at 20-29 years of age.20

Several major mental health disorders have an age of onset during — or just prior to — emerging adulthood. Mood disorders, schizophrenia, and substance use all tend to have an age of onset and peak prevalence in emerging adulthood.20,21 Emerging adulthood is also an age of risk for the onset of bipolar disorder.22 Although only 1% of individuals will receive a lifetime diagnosis of bipolar disorder, the large majority of episode onset occurs before the age of 24.23 Schizophrenia, which has been referred to as ‘youth's greatest disabler’, tends to appear most often in the 16-to-30 age group and affects 1% of the population.20 It is estimated that comorbid depression occurs in 50% of patients with schizophrenia.24 Emerging adulthood is also a peak time for the onset of substance use disorders and other substance-related problems.12,25 Approximately 17% of emerging adults have substance use problem, in comparison to 7% of adults over 26 and 5% of adolescents.26 Furthermore, the rate of co-occurring mental illness and substance use disorders is staggering. People with substance use problems are up to three times more likely to have a mental illness and people with a mental illness are twice as likely to have a substance use problem compared to the general population.27 Given the increased onset and prevalence of serious mental health disorders during emerging adulthood, models of treatment need to consider the unique needs of this population. The Recovery Model of treatment is one such treatment model that has particular relevance for individuals with major mental health disorders.

The Recovery Model

In tandem with the demographic shifts that have resulted in a prolonged period from adolescence to adulthood, we have also seen a major shift in the mental health treatment landscape over the past 50 years. In particular, there has been increasing recognition that a diagnosis of major mental illness does not inevitably lead to an individual's decline and, instead, many individuals, under the right circumstances, can recover from major mental health disorders.28 Since the 1980s, and with the support of grassroots consumer and advocacy groups, the Recovery Model has developed as a rival for the biomedical model based on the principle that recovery is possible. In recent years, the Recovery Model has received greater attention in the mainstream mental health literature and has influenced practice and policy worldwide, with a focus on greater social inclusion for those with mental illness.29

 

The Recovery Model is an approach to mental health care that shifts the focus from diagnosis and symptom resolution and emphasizes empowerment and control over one's life, with a focus on creating a meaningful life that includes self-discovery and growth.30, 31 Recovery is conceptualized as a process or journey, which contrasts with acute care models where symptom exacerbation is treated as an episode or crisis and the goal is symptom reduction. Through the recovery process, those struggling with mental illness are able to discover, or rediscover, a sense of identity beyond struggle and survival and drawn on expertise of those who have experienced mental illness, which includes peer and family support.28-29, 32

 

Over the past decade, the Recovery Model has served as a framework for mental health service delivery in Canada and the United States. With the development of the Mental Health Commission of Canada in 2007 and publication of the mental health strategy in 2009, recovery-oriented care became the foundation for mental health services in Canada and this was reaffirmed with the publication of Changing Directions, Changing Lives: A Mental Health Strategy for Canada.33 The US took a similar position in outlining guidelines for mental health and substance use services that draw from the Recovery Model. In 2012, the Substance Abuse and Mental Health Services Administration (SAMHSA) in the US released a statement on recovery from mental health and substance use disorders that captured the spirit of the Recovery Model and emphasized ten guiding principles of recovery, which are intended to provide a guideline for the development of mental health and substance abuse programming that supports individuals on the pathway to recovery throughout the lifespan.34

 

Recovery in Emerging Adulthood: Applying a Developmental Framework

 

Despite clear guidelines and a national policy promoting recovery-oriented care, the implementation of a recovery-oriented mental health system in Canada has faced many challenges and has not yet been fully realized.35, 36 In addition, although there is significant enthusiasm for the Recovery Model in the adult mental health literature there has been far less attention to implementing this model with emerging adults. The relevance of the recovery model for working with adolescents with mental health issues has been discussed elsewhere,37, 38 but, with a few exceptions, little attention has been paid to the ways in which this model fits within the developmental framework of emerging adulthood, as outlined by Arnett.1 Other authors have identified the lack of developmentally appropriate resources as an area in need of further attention and have highlighted the ways in which treatment services can better meet the developmental needs of emerging adults.39, 40 In 2015, the Mental Health Commission of Canada released a report outlining the need for developmentally-appropriate mental health services for emerging adults and urging a national agenda that considers the policy and practice needs of this population.41 We argue here that the principles of recovery have particular utility in considering the developmental context of emerging adulthood and should be considered a guiding model for considering services for this age group. It is with this in mind that we consider a conceptual description of the Recovery Model from the perspective of emerging adulthood, as characterized by Arnett.1

 

Several qualitative studies on the mental healthcare needs of young people have engaged youth and mental health clients to better understand the ways in which current service systems can best meet the needs of emerging adults and common themes have emerged from this work.42-44 First, participants identified the need for age-appropriate services that reflect youth culture and the social roles that youth occupy. Second, participants felt that models of treatment should foster the development of identity and autonomy should encourage self-determination and should support identity development focused on the person and not the diagnosis. Third, participants felt that clinicians should be empathic and authentic and create a safe and supportive environment while encouraging participants to take personal responsibility for their mental health care. Finally, participants noted that treatment models should be collaborative and avoid isolating clients and should encourage collaboration with peers and mentors. These themes are well-aligned with models of recovery outlined in the literature, which emphasizes personal control, empowerment, identity development away from the ‘patient role’, and use of social support through engagement with peer support networks and sharing of recovery narratives through connecting with others with lived experience. In addition, these themes converge with Walker and Gowen's45 positive development model, which highlights four developmental assets as critical for a healthy transition into adulthood: 1) developing a positive identity, which includes self-efficacy and empowerment; 2) capacity and motivation to make choices and follow through on tasks that are consistent with personally meaningful goals and values; 3) developing skills that build mastery and facilitate the capacity for adult roles; and 4) establishing healthy, prosocial supportive relationships. Below, we further elaborate on the convergence between recovery-oriented practices and the core features of emerging adulthood, as outlined in Table 1.

Table 1. Overlapping features of emerging adult theorya, developmental assets and the guiding principles of recovery.

Features of Emerging Adulthood

Features of Recovery

Optimism/Possibilities

Hope

Identity Exploration

Redefining identity

Finding meaning in life

Self-Focus

Taking responsibility for recovery

Deepening Relationhipsa

Supportive relationships and prosocial connectedness

Note. The features of emerging adulthood are drawn from Arnett (2004), Features of Recovery are drawn from Andresen, Oades, and Caputi. 40 aTwo of the characteristics of emerging adulthood — instability and feeling in-between — are not included in the Table, but are important contributing factors to the difficulties faced by emerging adults with mental health issues. bDeepening a relationship is not one of the core features of emerging adulthood, but is an important task of this developmental stage.

Possibility and Optimism

Arnett identified emerging adulthood as a time of optimism and possibility.1 Emerging adults overwhelmingly view the future as full of possibilities and even those who currently feel dissatisfied with their lives perceive that things will improve for them.46 Hope is also central to the recovery process and clients who reflect on their recovery process often identify their hope for a better future as a turning point in their journey.44 Recovery-oriented models also encourage a sense of agency, a belief that clients are capable of bringing about change in their own lives, which can propel them forward through difficult times.41 Unfortunately, for emerging adults, experiencing a serious mental illness can interfere with this sense of hope, lead to increased pessimism about the future, and contribute to difficulty accessing mental health services.47 Because emerging adulthood represents a time of life during which most major mental health issues are early in their trajectories, there is an important window of opportunity to instill hope for a better future. Within recovery-oriented models, emerging adults with mental health issues should be encouraged to address hopelessness and explore future goals and values with the same sense of possibility that is typical of this time of life. This optimism for a healthy and productive future should also be communicated and supported by others within the individual's peer, professional and community networks.33

 

Identity Exploration

Identity exploration and the formation of a stable identity is a critical task for healthy transitions into adulthood48, but become increasingly difficult in the context of psychological disorders that are inherently destabilizing. The onset of psychological disorders during emerging adulthood coincides with a developmental stage that is characterized by instability and feeling ‘in-between’.1 Furthermore, the process of diagnosis and treatment often involves multiple hospitalizations that disrupt involvement in the institutions that mark this developmental period, including college and university attendance.49 The recovery process, with its focus on identity and meaning-making, has the potential to mitigate these challenges through emphasizing identity development that considers the individual, rather than the disorder, and highlights the individuals personal resources and strengths, including cultural identity and values.34, 43

 

Self-Focus

One of the core features of emerging adulthood is a focus on the self.1 This is not to be confused with selfishness, but reflects the fact that emerging adults have not yet reached an age where they are responsible for others. Emerging adults are not yet in committed relationships, stable employment or parent roles. They are able to make decisions independently, without requiring the permission or consent of others. This reflects a shift from adolescence - where parents still play a primary role - to autonomous decision-making, where the emerging adult takes responsibility for his or her own decisions. However, this process of shifting from dependence to independence is more complex when considering the needs of emerging adults with mental health concerns. Parents of emerging adults with mental health difficulties struggle to find a balance between supporting their child's autonomy while also monitoring their child's mental health and advocating for their child's access to appropriate services.50 This same struggle plays out in the mental health service system and requires the attention of service providers. Although there is no longer a legal obligation to involve families in treatment, emerging adults are often financially dependent on parents and are often still living in the family home.51 Recovery-oriented care considers this balance in its emphasis on establishing collaborative relationships and recognizing that the client is autonomous and the expert of his/her experiences, while also encouraging family involvement and other social relationships that foster healthy social roles.34

 

Deepening of Relationships

Although the theory of emerging adulthood does not explicitly address relationships with others, emerging adulthood is considered a time of transition for relationships. The self-focus of emerging adulthood does not imply selfishness and relationships often deepen and become more intimate during emerging adulthood.52 Emerging adults with mental illness may have difficulty with this transition to greater intimacy in relationships due to social impairments, social isolation, or withdrawal from social institutions due to fears of stigma. The Recovery Model emphasizes social inclusion and personal connection, with peers and professionals acting as support networks and allies. This is particularly important for emerging adults from marginalized groups, including immigrant and homeless emerging adults, those living in poverty, and LGBTQ and racialized emerging adults. Although in-person peer support networks offer an opportunity for relationship building within one's community, for those living in rural areas or with limited access to in-person networks, online social networks may offer a viable alternative. Online peer networks have several advantages over in-person networks for those with serious mental illness, particularly for those with social impairments associated with serious mental illness and difficulties accessing in-person support networks.53

 

Conclusions

 

Emerging adulthood represents a time of significant risk for the onset and exacerbation of mental health difficulties. In addition, mental health issues might interfere with the critical developmental tasks of emerging adulthood, further highlighting the need for developmentally appropriate services. With its emphasis on hope, the Recovery Model holds promise as a foundational framework for providing services for emerging adults that meet their unique developmental needs. As outlined in Table 1, the Recovery Model can be considered alongside the theory of Emerging Adulthood to facilitate positive transitions into adulthood among those with serious mental illness.1 As Canada prepares to create a policy agenda that considers the mental health and addiction needs of emerging adults,41 models of recovery offer an opportunity to align mental health treatment with the unique developmental needs of this population.

 

Acknowledgements

 

The authors do not have any conflicts of interest to declare regarding the publication of this article or its content.

 

Dr. Goldstein is supported by the Canada Research Chairs (CRC) Program.

 

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Copyright (c) 2017 Abby Goldstein

Journal of Recovery in Mental Health ISSN 2371-2376