Introduction
Our understanding of recovery in mental health has been significantly shaped by pioneering publications positioning recovery as a guiding vision for mental health service transformation (e.g., Anthony, Reference Anthony1993) and insightful testimonies of adult mental health consumers and advocates from the 1980s and 1990s (e.g., Deegan, Reference Deegan1988). These early works provided the scaffolding for the recovery approach to be developed and adopted by mental health policies and systems internationally. In particular, testimonies of individuals with lived experience catalyzed the notions that recovery encompasses more than a clinical outcome; recovery is also an individual process. I graduated as an occupational therapist in the 1990s and was immediately inspired by the vision for recovery as a process, as it offered a compelling framework within the evolving field of psychiatric rehabilitation for how clinicians could meaningfully support individuals in their mental health journeys. However, as my career progressed and I began to specialize in mental health services for children and young people, I started to question the applicability of recovery models, and the literature surrounding them, across different developmental stages, cultural backgrounds, and contexts.
At that time, the universal applicability of recovery had not been thoroughly considered; thus, in 2010, I conducted a critical review of the recovery concept, using a structured approach. Based on my findings, I cautioned against the application of recovery to populations traditionally underserved by the mental health care system, including children and youth, without further critical reflection (Lal, Reference Lal2010). One of my main critiques was the lack of knowledge about what recovery means from the perspectives of young people, given that most of the existing literature was based on research with adult individuals with severe and enduring mental illness. These sentiments were later echoed by other scholars (e.g., Reid et al., Reference Reid, Olsen, Farwa, Dalziel and Wyder2024; Ward, Reference Ward2014), who have aptly stated that “adolescents’ recovery is not necessarily the same as adult recovery” (Ward, Reference Ward2014, p. 88), and that some may even “experience marginalization attending a recovery oriented service” (O’Keefe et al., 2018).
Fast forward to 2025, the recovery approach has gained significant momentum in policy and service implementation internationally, particularly in the Global North including high-income countries such as Australia, Canada, Ireland, and the USA. Notwithstanding ongoing critique, this approach has been mainstreamed into the mental health care system, including child and youth mental health services (CYMHS). Concurrently, there is an emerging body of literature that examines the recovery approach and its application to CYMHS. This increased attention is highly warranted given that most mental illnesses have their onset during childhood and adolescence (Kessler et al., 2007) and that the social determinants of mental health are getting increasingly precarious for young people (e.g., climate change, political polarization, unregulated social media, impacts of AI, economic inequalities) (McGorry et al., Reference McGorry, Mei, Dalal, Alvarez-Jimenez, Blakemore and Browne2024).
In this paper, I draw on insights from this new literature to expand upon my earlier discussion (Lal, Reference Lal2010) by describing key issues pertaining to the suitability of implementing the recovery approach in CYMHS and conclude with suggestions for the future. The age group and related definitions and models of care for CYMHS vary across countries. In this discussion, I draw upon recent guidance from the World Health Organization and the United Nations Children’s Fund (2024), which advocates for global transformation of services for children and young people, defined as between the ages of 5 to 24. Such services include a combination of mental health services integrated within primary care, general hospitals, community organizations, and organizations outside of health, such as schools. When accessing these services, the severity of mental health issues that young people face can be conceptualized to be situated on a continuum from a stage of being asymptomatic with increased risk for illness, to early illness with moderate to severe symptoms, and in the last stage severe, persistent, or unremitting illness (McGorry et al., Reference McGorry, Hickie, Yung, Pantelis and Jackson2006).
Key issues in using the recovery model in CYMHS
There are several issues that problematize the application of the recovery model in CYMHS. In this section I will discuss six of which I believe to be particularly salient.
Adult-centric foundations of the recovery approach
The first core consideration is who the recovery approach was originally developed for. Originally and until today, research, practice, and policy on recovery have predominantly focused on adults living with severe mental illness. For example, the early literature was initially an advocacy response to create a vision for mental health care that involved a community approach following the deinstitutionalization movement of the 1960s and 1970s. Pioneering recovery testimonies from individuals diagnosed with illnesses such as schizophrenia (e.g., Deegan, Reference Deegan1988) shaped the field and were supported by scholars noting that longitudinal studies demonstrate that people with schizophrenia can and do recover (Harding et al., Reference Harding, Zubin and Strauss1992).
Testimonies illustrated the importance of narratives in recovery and paved the way for a growing body of qualitative research that sought to conceptualize recovery from narrative accounts. This research was subsequently synthesized to develop definitions, frameworks, and models for conceptualizing recovery, with common themes such as the importance of hope, healing, empowerment, social connection, identity, meaning and purpose, meaningful activities, self-care/self-management, and the environment/context (e.g., Jacobson & Greenley, Reference Jacobson and Greenley2001; Lloyd et al., Reference Lloyd, Waghorn and Williams2008; Lal, Reference Lal2010; Leamy et al., Reference Leamy, Bird, Le Boutillier, Williams and Slade2011).
Yet, despite the extensive conceptual development on recovery, it has historically and primarily been shaped by adult lived experience; in other words, the literature that exists on recovery in mental health is for the most part, inherently adult-centric. For example, CHIME, one of the early and popular recovery frameworks, was informed by studies that included adult participants diagnosed with severe mental illness (Leamy et al., Reference Leamy, Bird, Le Boutillier, Williams and Slade2011). This scenario has remained largely the same, as illustrated by Dell et al.’s (Reference Dell, Long and Mancini2021) summary of 25 systematic reviews reporting on the perspectives of personal recovery, which found that most participants in studies on recovery were middle-aged adults. This calls into question the extent to which an approach originally and primarily informed by adult lived experience can be applied to the difficulties experienced by children, adolescents, and transition-age youth and their needs. Moreover, the same gaps apply to the evidence base regarding treatment interventions (pharmacological and non-pharmacological) for children and young adults, which is significantly limited compared to adults across health fields (Berkley et al., Reference Berkley, Walson, Gray, Russell, Bhutta, Ashorn, Norris, Adejuyigbe, Grais, Ogutu and Zhang2025), including mental health.
Limited multi-stakeholder participatory research
There is also a lack of multi-stakeholder involvement in recovery research as partners and advocates rather than as research subjects. By multiple stakeholders I am referring first and foremost to young people and their families/carers, and others such as service providers and decision makers. This gap means that multiple perspectives, including those of young people are underrepresented in setting recovery research priorities, designing recovery research (e.g., methods), its implementation, and knowledge translation. The paradigm shift in youth mental health service transformation over the past decade in Global North countries such as Canada, Ireland, Australia, and the UK have demonstrated the importance of centering youth voice in the design of services and in research (Iyer et al., Reference Iyer, Boksa, Lal, Shah, Marandola, Jordan, Doyle, Joober and Malla2015). It is important that this trend permeate the recovery literature more meaningfully to enhance the relevance and effectiveness of recovery-oriented research, policy, and practices in CYMHS.
Privileging individualistic ideologies
One of the most common concerns expressed about the recovery approach is the “individualistic worldview” that culturally and philosophically forms the core foundation to its conceptual understanding (Price-Robertson et al., Reference Price-Robertson, Obradovic and Morgan2017, p. 109). The assumption is that recovery is an internal, psychological, and emotional process. Moreover, key elements of recovery in popular frameworks are predominantly focused on an intra-personal process (Price-Robertson et al., Reference Price-Robertson, Obradovic and Morgan2017). This critique is particularly relevant when considering the context of children and youth. For example, the recovery approach emphasizes individual agency and self-determination, yet children are typically dependent on their families (Ward, Reference Ward2014) for their well-being.
Moreover, power dynamics between young people and adult therapists are different than the power dynamics experienced by adults with their therapists. Younger children may not have the words or confidence to fully express themselves (Reid & Alford, Reference Reid and Alford2023) to an adult stranger. Also, what a child knows about their experiences can get dismissed due to societal biases about the capacities of children (Reid & Alford, Reference Reid and Alford2023).
In addition, an overemphasis on individual processes such as self-management places a high amount of responsibility on the individual at the risk of ignoring structural and social realities, such as poverty, discrimination, and lack of access to resources (Reid & Alford, Reference Reid and Alford2023). Further overshadowing these factors is the limited research attention given to how recovery unfolds within structural, systemic, and social realities, including race, gender, and education. This is the case for both the CYMH recovery literature and the adult mental health recovery literature. For example, an overview of 25 systematic reviews conducted by Dell et al. (Reference Dell, Long and Mancini2021) found that recovery researchers have generally placed less emphasis on reporting these factors, echoed also in the review by Reid et al. (Reference Reid, Olsen, Farwa, Dalziel and Wyder2024). Even when a broader range of sociodemographic characteristics is reported upon, the samples tend to illustrate limited diversity (this also applies to studies that recruited from locations with diverse populations).
Developmental differences
Given that the recovery approach is largely drawn from adult lived experience, it lacks attention to the developmental changes and milestones that are particularly relevant in the CYMHS context (Naughton et al., Reference Naughton, Maybery, Sutton, Basu and Carroll2020). Children, adolescents, and transitional aged youth are at critical junctures in their lives that entail major developmental changes – biological, psychological, and social. As such, developmental processes that young people experience are significantly different from those of adults. Young people are still in the early stages of developing their identities, whereas adults have typically had more time and life experience for identity development (Ward, Reference Ward2014). The processes of attachment and individuation are also particularly important for young people. Furthermore, they transition from childhood through adolescence to young adulthood within a shorter time frame than the changes that occur beyond young adulthood. As such, they are in a constant state of growth and transformation. Although identity and transformation continue to evolve in adults with serious mental illness, the biological, developmental, and contextual factors present early in life and differ from those encountered later. This makes the application of adult-centric recovery models to CYMHS particularly challenging, as traditionally recovery approaches have not attended to the developmental stages of younger populations.
Differences in illness trajectory stages, illness experiences, and interactions with service providers
Young people’s mental health experiences and how they present in service settings are different than adults seen in mental health care. For example, young people will often initially present with general distress or subthreshold symptoms and behaviors that do not necessarily meet the criteria for a mental disorder (Malla et al., Reference Malla, Shah, Iyer, Boksa, Joober, Andersson, Lal and Fuhrer2018). Some will develop diagnosable conditions, but many others will not. As such, the concept of recovery and its related terms, such as mental illness, may have less meaning and accessibility for this population (Lal, Reference Lal2010). This claim is supported by a recent review, which found that young people exhibited fluctuations in their views of recovery and ambivalence about its meaning (Moberg et al., Reference Moberg, Skogens and Schön2023). Previous research has also found that stakeholders in CYMHS find the term recovery to be confusing and implying a “cure” rather than a process (Friesen, Reference Friesen2007). Others have found that some people “struggled to benefit from a recovery orientation,” possibly due to a lack of consensus on its meaning (O’Keefe et al., Reference O’Keeffe, Sheridan, Kelly, Doyle, Madigan, Lawlor and Clarke2018, p. 644), which especially rings true for the CYMHS context.
Moreover, qualitative research on adult perspectives of recovery demonstrates that individuals define recovery in varied ways – some in relation to illness and the possibility of a cure, and others as a wellness-oriented process of evolving toward a new sense of self. Notably, many individuals incorporate elements of both perspectives in their lived experiences (Piat et al., Reference Piat, Sabetti, Couture, Sylvestre, Provencher, Botschner and Stayner2009). However, there are risks associated with an overreliance on a medical model of recovery, particularly when the emphasis is on symptom remission as the primary outcome. Such a focus can overshadow other important outcomes such as functional recovery and more nuanced dimensions of recovery such as overcoming trauma, meaning-making, and coherent identity development. In addition, there can be further detrimental impacts such as marginalizing and disempowering young people who continue to experience symptoms. Ultimately, such a narrow focus can limit the activities of service provision and broader policy making, taking away attention from the psychological, social, and contextual factors that are important for supporting recovery in children and young people.
Even if young people do meet the criteria for a mental disorder, in many cases it can evolve into a different disorder over time (Malla et al., Reference Malla, Shah, Iyer, Boksa, Joober, Andersson, Lal and Fuhrer2018), indicating diagnostic fluidity. This contrasts with most of the recovery literature that stems from the experiences of adults that typically will have more established diagnoses and more time to consider its meaning within the broader spectrum of their lives. Moreover, the research that does focus on recovery in young people, typically involves individuals diagnosed with a serious mental disorder. These differences highlight the need for caution when applying recovery frameworks to younger populations in the early phases of illness.
In addition, children, adolescents, and transition-aged youth are often at the beginning stages of their interactions with the mental health care system, often receiving services for the first time (Lal, Reference Lal2010). Their contact with mental health services may be in community settings (e.g., schools), primary, secondary, or tertiary levels of care. Whereas the recovery approach has primarily been informed by research on individuals accessing services higher up in the hierarchy of care.
Children and adolescents also present as a unit with their caregivers, and in some cases may even be too young to access services on their own, which provides a different experience of care. The issue is further complicated by the wide international variation in the age at which a minor can access mental health services without parental consent, due to differing legislation and health care practices. For example, research indicates that few countries have a defined minimum age for consent to mental health treatment (Noroozi et al., Reference Noroozi, Singh and Fazel2018). In contrast, for adults, age is not a restriction to access services independently.
Different systems of care and social environments
The daily lives of children and youth take place in different systems of care and environments, when compared to adults. Services for children and adolescents, for example, are often separate from adult mental health services (e.g., in terms of government funding, service providers, physical settings, therapeutic approaches, etc.). Labeling of issues is approached differently across age groups; for example, for children, issues may be referred to as emotional or behavioral versus mental illness (Friesen, Reference Friesen2007; Lal, Reference Lal2010). The treatment goals for young people, may focus on development, the family environment, academics, and peers, which may not be the same as for adults who will often need a different set of skills (Friesen, Reference Friesen2007; Lal, Reference Lal2010). Moreover, youth transitioning toward adulthood have historically been at risk of falling through the cracks in between these two systems. Applying recovery research based on individuals who have experienced the mental health care system as adults can be problematic, as it overlooks the structural differences in health care experiences.
In addition, the social environments of children, adolescents, and transition-age youth, which include family, school, peers, service providers (Lal, Reference Lal2010), and increasingly the online environment, are different from adults. Regarding the latter, adults may also be enacting their daily activities online, but the social aspects of where and how young people engage online is different from adults.
Re-thinking recovery
Overall, research continues to generate evidence for the cautionary use of recovery in CYMHS. There is a lack of consensus among service providers, family members, and other key stakeholder groups on whether the term “recovery” should be applied to CYMHS (Friesen, Reference Friesen2007; Naughton et al., Reference Naughton, Maybery, Sutton, Basu and Carroll2020). At the same time, there appears to be consensus that some concepts of recovery, such as hope, connections, and identity, are relevant for CYMHS (Naughton et al., Reference Naughton, Maybery, Sutton, Basu and Carroll2020). Nonetheless, if the recovery approach is to be applied to CYMHS, there is a need for adaptation.
Adaptations to the recovery approach include: addressing the diverse realities of young people’s lives, such as their relational dependence on their social support network, including families/carers (siblings and extended members) and peers; their developmental stages and changes; their illness phases; their early stages of help-seeking and initial contact with the mental health care system; the unique contexts of the CYMHS systems of care; and the social, structural, and systemic realities that shape their lives and multiple roles. It is also important to consider the online environment as a core element of the environment that influences young people’s development and daily experiences. Historically, recovery models and the research underpinning them have given limited attention to these elements.
In addition, it behooves the field to further consider the development of youth-focused models of recovery, or adaptation of existing ones. Advances toward these aims have started to emerge, including, for example, the development of theory on youth mental health recovery from a parental perspective (Kelly & Coughlan, Reference Kelly and Coughlan2019) and the development of an ecological youth recovery model based on the experiences of young adults with a severe mental health condition (Rayner et al., Reference Rayner, Thielking and Lough2018). It is also important to consider other concepts that are relevant for CYMHS, such as relational models of recovery (e.g., Price-Robertson et al., Reference Price-Robertson, Obradovic and Morgan2017) and ecological frameworks for their insights for research, policy, and practice in CYMHS.
Existing research efforts on understanding recovery in young people is typically based on small sample sizes and restricted to specific country contexts. Additionally, beyond age and sex, there is limited reporting on the social circumstances of the participants (e.g., race, ethnicity, education, income). This raises the important question of who’s narratives are not being represented in recovery research, an issue that also challenges the broader literature on mental health recovery. Possibly even, recovery research in the Global North has privileged certain races, economic status, education, and other determinants of mental health, a sentiment similarly expressed by O’Keefe et al. (2018). Thus, a closer and systematic examination of these factors across studies warrants attention.
Conclusions
While the recovery approach has been transformative in adult mental health care, its direct application to younger populations requires careful consideration and adaptation. Despite several decades since the recovery model appeared in the mental health literature, few primary studies explore recovery from the direct experiences of young people and its implementation in CYMHS. The existing studies often overlook phases in help-seeking, points in care, and the implications of structural, systemic, and social realities. Nonetheless, evidence suggests a nascent field at the intersections of recovery and CYMHS has emerged. To advance understanding of when, if, and how recovery can be applied to CYMHS, more partnered research is needed across diverse young populations (considering a range of factors, for example, gender, age, ethnicity, sexual minorities, physical disability, economic circumstances, and geographical location – including rurality), their help-seeking trajectories, and grounded in their lived experiences and those who support them. This can help to ensure that services are meaningful for them. Any approach applied to CYMHS needs to be youth centered. Wide-sweeping adoptions of recovery models and frameworks by mental health policies, health systems, and services without critical reflection and systematic investigation, do a disservice to young people and the good intentions behind the origins of the recovery pardigm.
Funding statement
This work received no specific grant from any funding agency, commercial, or not-for-profit sectors.
Competing interests
SL was the Canada Research Chair in Innovations for Youth Mental Health between 2017 and 2025. This role is disclosed for transparency. The author declares no competing interests.
Ethical standards
The author asserts that all procedures contributing to this work comply with the ethical standards of the relevant national and institutional committee on human experimentation with the Helsinki Declaration of 1975, as revised in 2008.
