MHY301 Adolescents in Recovery Oriented Systems of care: what works?

Adolescents in Recovery Oriented Systems of care: what works?

Since the turn of the 21st century, the Recovery Approach has been touted as the penultimate approach in mental health care both from a system level of care as well as for the clinician dealing with the patient. Recovery has been defined as a way of living a satisfying, hopeful and contributing life even within the limitations caused by illness(WA, 1993). The positive press surrounding this novel approach has been associated with reduced mental health service usage and lower reliance on welfare benefits(Knapp M, 2013). In this day and age where government decisions are loosely based on neoliberal policy, the fact that the Australian Bureau of Statistics is reporting 41.3% of females aged 16-24 in the 2020-21 census having an anxiety disorder highlights the need for greater application of treatment frameworks that may result in better treatment outcomes for the patient. On the world stage, the WHO attests to the fact that the incidence of mental health problems is on the rise(WHO, 2021). Without adequate measures, these illnesses could progress into serious and protracted conditions(Coughland.B, 2019).In the following essay, I will attempt to highlight the ethical and moral conflicts that ensue in real life when clinicians apply Recovery oriented clinical practice in day-to-day work.

Research in the field of recovery-oriented care has been based on adults who have contributed their personal stories about their recovery journey since the 1980s. There is admittedly a paucity of work in the adolescent and youth space(Rayner.s, 2018). Some of the key areas where adolescent recovery processes differ from those of adults include an emphasis on school, peer relationships, identity development, and the role of family(Wallstrom.R, 2021). In 2011, Dr.Mary Leamy conducted a systemic review of the literature review on the recovery stories and proceeded to develop the main operational framework in the Recovery Space; the CHIME framework(M. Leamy, 2011). Whilst this article laid the founding principles used to scientifically guide recovery in the Mental Health, there were some voices calling out for model adaptation to better promote youth specific factors that would complement the CHIME model such as focusing on peer supports, and the role of the family in recovery(J.N.L Naughton, 2018).

The biggest challenge of practicing in a Recovery Oriented manner would lie in quality of the connection and rapport that the clinician establishes with the young person as part of the thorough assessment and recovery planning process. The formation of this relationship can be quite tenuous, especially in the inpatient setting. The challenge of accepting a new condition, reactions and emotional expressions of the condition, and the presence or lack of coping mechanisms in the young people all come together to make the challenge of developing a collaborative relationship an especially arduous task. Even when an adolescent is considered unable to provide decisions regarding treatment at any given time, practitioners may still enter a collaborative relationship with the person and be responsive to their needs, concerns and preferences(State of Victoria, 2011). The advantage of this approach is the experience formed by the adolescent over time benefits both their personal subjective experiences and facilitates the formation of alliances in various care environments(N.Gray, 2021).

An example of this situation would be the recent admission of a 12-year-old girl who overdosed on 30 of her sisters 20mg fluoxetine tablets and presented to hospital for the first time. This patient was understandably reluctant to be admitted to the ward despite still having the significant tremors associated with her serotonin overdose running through her system. She had vivid memories of visiting her elder sibling in the inpatient unit and was quite difficult to placate. I took the opportunity to negotiate with the senior charge nurse to make an exception to hospital policy and permit her to be accompanied by her father who stayed the night with her on the unit. This smoothened the transition into the hospital for this patient despite having to admit her involuntarily due to her prolonged history of impulsive behaviors and new-found history of multiple attempts at self-harm.

Another key tenet of the Recovery paradigm that differs from the management in adult mental health is the theme of empowerment of the young person to be involved in their own recovery journey. The Clinical Practice Guideline for the Connecticut Department of Health and Addiction Services has encapsulated this challenging concept in stating that recovery planning should honor the dignity of risk and the adolescents right to fail. Unfortunately for the clinician, these moral principles often end up in direct conflict with the duty of care as clinicians are left to wield this delicate balance(State of Victoria, 2011) often with little assistance from our support workers. As part of the recovery approach, clinicians are encouraged to incorporate positive risk-taking behaviors to provide the young person a sense of empowerment(Department of Health, 2013).

Quite often as the on-call registrar in the emergency department, I am called to review a patient known to the service who is having a psychotic relapse. In this situation, I would first need to take a thorough history, perform a risk assessment of the patient. Then I would need to refer to any local Advanced Directives that the patient had negotiated with their treating team during their last admission(Campbell LA, 2009). This document would usually contain some of the patients common symptoms when they are unwell, treatment to be undertaken when the patient is unwell and name and contact details of proxy-decision maker to assist with their treatment plan. There are many times when the patient may still be symptomatic when discharged into the care of the proxy-decision maker. However this is a an example of positive risk taking where the conflict between duty of care and right to fail is exemplified.

The Mental Health Coordinating Council for New South Wales in 2014, authored a discussion paper where the adolescents interviewed echoed the sentiment that empowerment was an important aspect of the recovery journey. However, instead of the adolescents themselves making key decisions about treatment and recovery goals, they felt empowered by being consulted, feeling they are being listened to and having the support to make decisions as in conjunction with their family. The other factor to consider as a clinician carrying the delicate Recovery balance would be that Empowerment and Responsibility would be dependent on the childs own developmental stage. Many adolescents even when well, may not have the capacity or developmental competence to allow them to take control and responsibility of their own lives. This problem becomes much more complex in the setting of those experiencing mental health problems. Empowerment and self-direction would look very different for an 8 year old, a 14 year old or an 18 year old. In the setting of the younger person, treatment goals maybe more aligned with empowering the family to take control and responsibility due to differing developmental competencies and the specific needs of the child(DP.Oswald, 2006).

When the adolescent and their family are involved in defining their personal Recovery journey, the very notion of Recovery takes on a different meaning. Personal recovery goals are often non-linear, and self-defined, with a focus being on identity whilst clinical recovery can often be seen as the cure from illness with absence of symptoms. The different Recovery goalposts set up a state of tension whereby clinicians strive for an absence of symptoms whilst the family may envision a situation where the adolescent is able to function and control their presenting symptoms (Coughland.B, 2019). The level of function desired by the respective adolescent and their family would defer depending on background and premorbid socio-economic factors. Clinicians need to be acutely aware of this conflicting positions and take on a flexible approach in defining recovery goals for adolescents to practice within a Recovery oriented framework.

The concept of an ecological model of care was suggested by Kelada et. al. , when they put forward the argument that One of the strongest predictors of self-harm among adolescents was a maladaptive family environment but the role of a functional family was also what led to recovery (L.Kelada, 2018). This suggestion serves to further underscore the common knowledge that parents, and family environment were an indispensable part of the recovery journey for the young person. Acknowledging that some family environments can have high levels of expressed emotion, the clinician involved in the adolescents care should consider if there is a role for family-based therapies targeting the maladaptive regulation of emotion to assist the young person in their recovery journey (Coughland.B, 2019). As a clinician practicing in the field of adolescent mental health, one of my take away point in this matter would be that I would strive to increase opportunities and support for families and adolescents to participate in their own recovery planning. The empowerment that comes from this participation would serve the dual purpose of fueling the young persons recovery goals as well as placing a degree of responsibility back on the adolescent to work towards their version of recovery.

When promoting Recovery Oriented Care from an ecological perspective, the important role that friends play as part of the young persons recovery needs to be factored in (Coughland.B, 2019). An adolescents friendship network plays a major role in how they see and understand themselves, referencing the element of Connectedness in the CHIME framework. As such a networks reaction to ill health and expectations of recovery can both help and crush a young persons Recovery journey (E.Khoury, 2020). As a clinician working in the mental health space, the additional effort of equipping the young persons family and closest friendship networks with information about the adolescents condition helps to raise their understanding of the challenges that the adolescent is facing. It is thus advantageous to the adolescent when their friendship network can positively contribute to their Recovery journey with patience and confidence.

An adolescents recovery process is usually characterized by uncertainty and ambivalence. Ambivalence is usually characterized by various behaviors that can be construed to be self-destructive and how the adolescent perceived their illness and considered if recovery was achievable (L.Kelada, 2018). In the face of a diagnosis of a lifelong illness, the theme of Acceptance in how the young person view their new condition, the accompanying reactions and emotional expression and the knowledge about the difficulties that may persist (residual symptoms in schizophrenia, perpetual risk of recurrence of depression, or the inevitable of a recurrence of a suicidal attempt) were major challenges that the young person and their family needed to come to terms with. It is in these difficult times that clinicians and support workers hold the important role of promoting or holding Hope for the adolescent and their family(Council, 2014).

Clinicians can promote hope for adolescents and their families who suffer from mental health by being realistic and truthful about their mental health issues and explaining that whilst there may still be residual symptoms of illness, living meaningful and contributing lives is a real possibility. Here the role of linking the patients with peers who have lived experience will be invaluable for the adolescent and their family to come to terms with the situation (K.Lindstedt, 2018). Whilst having peer support workers (especially those with lived experience) are an invaluable resource, organizations must be cautious about merely paying lip-service to the Recovery theme by absorbing these peer workers into generic clinical roles. Allowing the peer support worker to perform their primary function, ie to promote hope in the young person who is receiving treatment, build a sense of identity and focus on facilitating self-determination should be the primary focus of the support worker.

I would like to use the examples of clinician led recovery approaches to highlight some of the challenges applying these principles in my day-to-day clinical practice where I work in the Northern Territory. I have worked in the Don Dale Youth Detention Centre admittedly in the capacity of a general practitioner. Don Dale became infamous in 2016 when it was featured in a 4 Corners expose which later became the subject of a Royal Commission in 2017 due to mismanagement of the children within the center. One of the biggest challenges of working in the detention center was the lack of awareness amongst the corrections officers present about dealing with adolescents who have neurodivergent conditions. It was around this period that Banksia Hill Detention Centre Project Results from the Telethon Institute in Western Australia were published. This study found that 1 in 3 young people in youth detention in Western Australia are formally diagnosed with Fetal Alcohol Spectrum Disorder and 9 out of 10 young people reviewed in detention are living with at least one severe impairment in a neurodevelopmental domain(C.Bower, 2017). In Don Dale, whilst we were armed with this knowledge, there was very limited resources available to assist us in the process of diagnosis, coming up with management plans and even spreading awareness amongst the corrections officers about dealing with children with these conditions. Fortunately, the Telethon Institute from Western Australia was contracted to come into Don Dale and provide education sessions to the corrections officers on how to interact and de-escalate the adolescence offenders within the center.

The use of Compulsory Treatment Orders ( CTO) have often been seen as an extension of the involuntary treatment provided in hospital. Especially for patients who are seen as too unwell to manage themselves. Quoting locally available data, in 2019 the rates of CTOs were the highest in South Australia at a rate of 112.5 per 100,00 people(Light, 2019). The Northern Territory where I work led the nation with the highest number of acute inpatient involuntary admissions (89.3% of all hospital admissions)(Welfare & Government, 2022). The use of involuntary admissions and CTOs are seen to undermine the patients agency and not in keeping with Recovery Oriented Care approaches. However there has been some contrary evidence which would suggest that it would take 85 outpatient CTOs to prevent one readmission, 27 to prevent one episode of homelessness and 238 to prevent one arrest(Kisley SR, 2011).

In day-to-day clinical practice, there are evidence-based Recovery Oriented Approaches that can be practiced by the clinician. One of the easiest approaches to take would be referring to the patients Wellness and Recovery Action Plan (WRAP). The WRAP used to create recovery plans by guiding adolescents to reflect on those things that have assisted them to stay well in the past. Planning tools in the WRAP focuses on self-motivation, identifying strategies to enhance well-being, recognizing and dealing with distress through to crisis planning(Doughty C, 2008). RCT evaluated outcomes in a particular study that showed benefits involving patient symptoms, hope and quality of life.

In my discussion above, I have attempted to demonstrate how clinicians can practically use Recovery Oriented Approach, outlined examples of ethical conflict that arise when applying Recovery Oriented Care Principles in day to day clinical practice and highlighted some of the local challenges trying to incorporate the aforementioned principles in may day to day work in the Northern Territory. Whilst the implementation of Recovery Oriented Care would facilitate better patient outcomes, I still feel that the biggest challenge that needs to be surmounted would be the challenge to effect societal change such that the recovering patient has a receptive social network to go back to, develop a sense of identity and find a personal sense of meaning that imbues them with of hope and happiness.