Adm Policy Ment Health (2017) 44:92102

DOI 10.1007/s10488-015-0703-4

ORIGINAL ARTICLE

Impact of Mental Health Services on Resilience in Youth

with First Episode Psychosis: A Qualitative Study
S. Lal1,2,3 M. Ungar4 A. Malla3,5 C. Leggo6 M. Suto7

Published online: 24 November 2015

 Springer Science+Business Media New York 2015

Abstract The purpose of this qualitative study is to
understand how mental health and related services support
and hinder resilience in young people diagnosed with first-
episode psychosis. Seventeen youth between the ages of
1824 were recruited and 31 in-depth interviews were
conducted. Findings illustrated that informational and
meaning making, instrumental, and emotional supports
were experienced positively (i.e., resilience-enhancing);
whereas services with ghettoizing, engulfing, regulating,
and out of tune practices were experienced negatively (i.e.,
resilience-hindering). These results demonstrate how vari-
ous types of service-related practices influence resilience in
youth and can inform future planning of services for
psychosis.
& S. Lal
shalini.lal@umontreal.ca
1
School of Rehabilitation, University of Montreal, Montreal,
Canada
2
University of Montreal Hospital Research Centre
(CRCHUM), Montreal, Canada
3
Douglas Mental Health University Institute, Montreal,
Canada
4
School of Social Work, Dalhousie University, Halifax,
Canada
5
Department of Psychiatry, McGill University, Montreal,
Canada
6 resources considered meaningful for well-being in the
Department of Language and Literacy Education, Faculty of
Education, University of British Columbia, Vancouver,
Canada
7
Department of Occupational Science and Occupational
Therapy, University of British Columbia, Vancouver, Canada
Keywords Mental health services
Resilience
Well-
being
Service engagement
Youth mental health
Introduction
The phenomenon of resilience has attracted a surge of
attention in mental health and social services practice,
policy, and research. At the policy level, resilience has
become a focal point of initiatives within health and social
service sectors (e.g., Canadian Institutes of Health
Research 2006; Human Resources and Skills Development
Canada, Policy Research Directorate 2009). At the schol-
arly and practice levels, resilience is also increasingly
considered in several fields including developmental psy-
chology (e.g., Luthar et al. 2000), social work (e.g., Bottrell
2009), nursing (e.g., Kralik et al. 2006), and rehabilitation
sciences (e.g., White et al. 2008). Handbooks on resilience
have been published showcasing research from different
epistemological and/or social or clinical perspectives (e.g.,
Reich et al. 2010; Ungar 2012). A driving force that
underpins research in resilience is the development of
knowledge on individual 9 environment interactions that
can influence positive outcomes in the face of adversity, to
ultimately inform the planning and development of health
and social service policies and interventions (Luthar et al.
2000).
In this paper, we adopt a socio-ecological definition of
resilience that describes resilience as a process of an
individuals efforts to navigate and negotiate towards
presence of adversity, and the environments concurrent
capacity to support individual efforts (Boyden and Mann
2005; Ungar 2011). This contemporary definition shifts the
balance of attention from individually based factors

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supporting and/or hindering the process of resilience
towards the critical role of the environment (including
services) in the facilitation of resilience. Following from
this understanding of resilience in contexts where people
experience significant exposure to adversity, well-being is
the outcome individuals strive towards. Well-being can be
conceptualized in terms of its dimensions, including:
emotional well-being (e.g., experiences of happiness),
psychological well-being (meaning and self-realization),
social well-being (e.g., experiences of social worth and
positive social relations) (Keyes 2005), as well as physical,
spiritual, and moral aspects (Lal et al. 2014). Whereas
resilience is the process of health-seeking behaviors when
coping with adversity, well-being is a subjective end-state
people strive to achieve regardless of their level of risk
exposure.
A social-ecological perspective of resilience would thus
entail consideration of how the environment supports and/
or hinders resilience-related processes leading to well-be-
ing across various domains of a young persons life.
Studies of resilience, however, have largely focused on
individual processes of adaptation, with limited attention to
the social environment (Bottrell 2009; Bottrell and Arm-
strong 2012; Boyden and Mann 2005; Lal 2012; Ungar
2011). By social environment we mean social relation-
ships, physical surroundings, cultural contexts, and even
health and social services (Barnett and Casper 2001). With
regards to services, research indicates that service-related
perceptions are strongly associated with resilience in young
people (Ungar et al. 2013).
Limited knowledge exists on resilience-related pro-
cesses leading to well-being based on the perspectives of
young people (Ungar 2003, 2004) in relation to the services
they receive. Within the field of early intervention for
psychosis, for example, few studies have focused on ser-
vice-related experiences and perspectives of young people
diagnosed with first-episode psychosis and how services
support and hinder their process of achieving well-being. A
review of the literature (Boydell et al. 2010) identified only
five discrete studies focused on how young people with
first-episode psychosis experience and perceive the mental
health services they receive. In the broader youth mental
health literature, a recent review of studies capturing young
peoples perspectives of mental health services identified
issues pertaining to stigma, information, medicalization of
problems, and continuity of care as contributing negatively
to views of mental health services; whereas, quality of
mental health service providers as well as their focus on
encouraging independence was perceived positively
(Plaistow et al. 2014).
In this paper, we report on a qualitative study, the pur-
pose of which was to deepen our understanding of how
mental health and related services support and hinder the
93
processes of resilience in young people diagnosed with
first-episode psychosis. The onset of psychosis typically
occurs during adolescence and young adulthood (i.e.,
between the ages of 1525). This is a period that has been
characterized by the concept of emerging adulthood with
distinctive features of development such as identity
explorations, instability (e.g., in terms of career planning,
relationships, housing, education), and feelings of being in-
between milestones in life (Arnett 2000, 2014). Knowledge
on how services support and hinder resilience in emerging
adults has the potential to make health policies and systems
more responsive to young peoples needs, improve their
satisfaction and engagement with services and ultimately
their process of resilience during a time of transition and
stress. This study was part of a larger research project
examining how young people restore, sustain and enhance
their resilience within the context of being diagnosed with
first-episode psychosis and the role of valued activities and
the environment in supporting and hindering processes that
contribute to well-being as an outcome.
Methods
We adopted a qualitative approach, which is best suited for
providing in-depth, contextualized understanding of expe-
riences and behaviors (Denzin and Lincoln 2005). Specif-
ically, we used principles and methods of grounded theory
(Charmaz 2006) and narrative inquiry (Riessman 2008).
Grounded theory is a methodology that helps researchers
understand psychological and social processes (Lal et al.
2012, p. 5). The present study is informed by a construc-
tivist application of grounded theory methods and princi-
ples. Proponents of this perspective (e.g., Charmaz, 2006)
emphasize the importance of multiple perspectives of
participants and the researcher; the influence of social
structures and processes at micro and macro levels during
analyses; and the reflexive role of the researcher through-
out the research process (Lal et al. 2012, p. 8). Narrative
inquiry is a subtype of methodology within qualitative
research (Chase 2005) alongside other qualitative genres
such as ethnography, phenomenology, and grounded theory
(Creswell 2007). Narrative inquiry is typically used to
explore, understand, and re-present the experiences of
individuals through storied forms (Bruner 1987, 1991; Lal
et al. 2012). In this approach, the researcher strives to
locate theory within a participants narrative and keep
participant stories intact. A story is considered to be a unit
of analysis; the researcher codes data by examining various
features of communication and social action, including
language and style (Clandinin and Connelly 2000).
A comparative analysis of both grounded theory and
narrative inquiry methodologies (Lal et al. 2012)
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highlighted the theoretical commensurability between
these two approaches and their methodological comple-
mentarity. Combining the principles and methods of
grounded theory with narrative inquiry can facilitate the
elicitation of a complete and contextualized illustration of
meanings, experiences and processes of psychological and
social processes, such as resilience.
Setting and Sampling
The following criteria were used for recruitment: (1)
individuals between the ages of 1824 diagnosed with
schizophrenia spectrum and affective psychoses in the past
3 years; (2) recipients of outpatient psychiatric services;
(3) English speakers; and (4) individuals able to provide
informed consent. Participants were recruited from two
different settings located in a major urban city in western
Canada: (1) a specialized early intervention program pro-
viding multimodal treatment for young people with first-
episode psychosis; and (2) a mental health program pro-
viding psychiatric services to street youth, established
through a collaboration between a general hospital and a
non-profit organization offering food, shelter, and psy-
chosocial services to homeless youth. These two sites
created a sample with diverse social, cultural, and eco-
nomic characteristics.
Psychiatrists and case managers identified individuals
meeting the inclusion criteria and provided them with a
consent to be contacted form. This form explained the
study and invited prospective participants to either contact
the primary researcher directly, or provide written consent
to be contacted by the researcher. The University of British
Columbias Behavioural Research Ethics Board and the
ethics boards of the two recruitment sites granted ethics
approval. All participants provided written informed con-
sent and were given travel compensation of $15 each time
they attended a research-related interview.
Data Collection and Analysis
Each young person was invited to participate in two
interviews approximately 2 weeks apart. The first inter-
view had the intention of establishing rapport and becom-
ing familiar with the background, daily life, illness history,
and socio-economic circumstances of the participant. The
focus of the second interview was to progressively under-
stand the experiences of participants as they related to
navigating towards resources considered meaningful for
their well-being including their experiences and perspec-
tives of the mental health and related services they received
(e.g., housing, recreation, and employment support). We
did not ask participants directly about how the environment
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Adm Policy Ment Health (2017) 44:92102
impacts on their process of resilience, as this was perceived
to be terminology that would be less consistently under-
stood across participants recruited in the study. In other
words, well-being, as an outcome of the resilience process,
was considered to be a more accessible concept. Our
analytical approach then involved examining participant
accounts of how services impacted on their well-being to
ultimately understand the role of services on supporting or
hindering resilience process (i.e., process of navigating
towards well-being).
Conducting multiple interviews facilitated prolonged
engagement with participants and reflexivity of the
researcher, both of which are recognized in qualitative
research to enhance credibility and trustworthiness of
findings. This approach also allowed the researcher to
develop rapport, explore a range of topical areas, and
observe a saturation of themes across multiple interviews
with the same participants and across participants. As a
result, in-depth and rich responses can be observed through
the lengthy nature of the interviews and resulting tran-
scripts ranging between 25 and 60 pages. In this paper, we
focus on data pertaining to young peoples experiences and
perceptions of services; specifically, their responses to
questions such as: What aspects of services have been
helpful and not so helpful for your well-being? and,
What suggestions do you have for improving services to
make them more helpful?
The first author conducted the interviews; the first author
is experienced in qualitative research, has worked as a case
manager with this youth population and their families, and
had no clinical affiliation with the patients at the recruit-
ment sites. Interviews lasted between 45 min to 2 h,
averaging approximately 90 min including breaks. Data
collection occurred between November 2010 and March
2012. All interviews were digitally recorded, transcribed
verbatim, and managed using Atlas.ti v 6.2 qualitative data
software (Atlas.ti Scientific Software GmbH, Berlin, Ger-
many). Each transcript was read by the first author and then
coded using an inductive approach. The last author coded 6
of the interviews from the total set, and interpretations by
the two authors were compared and integrated into the
coding process. Next, the codes were grouped to form
categories, and visual maps of categories and themes were
then generated. The first author also visually mapped the
categories and themes from each participants dataset to
maintain a holistic perspective of each participants
account. Then, patterns commonly observed across the
entire data set were chosen for further analysis. Constant
comparative analysis (Charmaz 2006), writing reflective
memos, and discussion among all authors occurred
throughout these three stages. In presenting the findings,
pseudonyms are used, many of which the participants
chose themselves.
Adm Policy Ment Health (2017) 44:92102
Results
Participant Characteristics
Seventeen participants, with a mean age of 22 and pre-
dominantly male (71 %), were recruited into the study,
which is consistent with the usual gender composition of
first-episode psychosis patients receiving treatment in early
intervention services (Amminger et al. 2006). Thirty-one
individual interviews were conducted; three participants
were unable to complete second interviews due to
scheduling conflicts. Participants represented a diverse
range of socio-economic and ethnic backgrounds, with a
little less than half of the sample (n = 7) representing First
Nations, Asian, and Latin American heritages. At the time
of recruitment, seven participants had less than a high
school education, five had completed high school, four had
some university level education, and one had completed a
bachelors degree. With regards to their living situation,
five participants were living with their families, another
five were living in single room occupancy buildings, two
were living independently, four were living in a group
home or shelter, and one participant was living with a
partner.
Services Experienced as Resilience-Enhancing
Participants recounted several positive experiences and
perceptions of the services they received in relation to
different types of support.
Informational and Meaning Making Support
Participants valued opportunities where they received
information on their illness and other aspects of their lives
(e.g., nutrition, stress, employment, education), particularly
when they were also given the opportunity to integrate this
information in relation to their illness and recovery expe-
riences. We refer to the latter as meaning making, a process
of integrating illness and recovery concepts into ongoing
life stories, in ways that allow individuals to put their
experiences into perspective and move forward. Participant
accounts highlighted that attending group psychoeducation
sessions were particularly helpful in facilitating the
meaning making process. For example, some described
how attending psychoeducation groups were critical to
their recovery process, particularly in relation to helping
them realize their experiences were part of an illness. As
one of the participants, Kevin, explained:
The groups were very helpful for getting me to
acknowledge that I actually had an illness. Coming
face-to-face with some of the symptoms that I was
95
having because I was still in denial when I was going
to the groups.
Another participant, Jake, elaborates on how being
exposed to others stories helped to identify his experiences
as symptoms of an illness:
And then you talk to people, who said theyve heard
or seen the same things or thought the same things,
and youre like, okay, well, Im definitely suffering
from symptoms here.
Participants also highlighted the benefits of having peer
support workers present during group psychoeducation
sessions, that is, individuals who were further along in the
recovery process. For example, Jake described the critical
impact a peer support worker had on him, instilling hope
for a normal life after being diagnosed with schizophrenia:
[She] explained that with the right combination of
medications or professional help, which we were
getting, you could actually treat the symptoms and
live a normal lifea good role model to see that you
could recover from it
Instrumental Support
Instrumental support refers to direct and tangible ways that
service providers assisted young people. This occurred, for
example, through accompanying a young person to an
appointment, providing help to complete employment assis-
tance forms, or facilitating the process of returning to school.
As Ken noted, theyre getting me set up with bursaries to go
to [Name of School] getting me aware through that and
shes, um, helping me with references and stuff like that. So,
thats good. Conversely, participants highlighted the nega-
tive impact on their well-being when this form of support was
absent in their interactions with service providers.
Emotional Support
Emotional support from service providers was experienced
as helpful when it contained expressions of empathy,
acceptance, encouragement, kindness, respect, belief in
capacity for personal growth and success, a non-judg-
mental attitude, and hope. Participants identified these
types of interactions as contributing positively to their
well-being. Goddess, for example, described how her
psychiatrist had the most effect on her life because she
believes in Goddess and is committed to helping her.
Likewise, Ross described the profound impact that his case
manager had on his life:
This guy is so kind Hes very comfortable, very
secure. And youre like, wow, this guy really makes
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me feel comfortable and at home. Hes always
encouraging, and he always has a smile on his face.
When you walk through that door, he shakes your
hand every single time. And every time you leave, he
shakes your hand. He shows that he has respect for
you, of the challenges that youre going through
Hes always positive about things Amazing role
models like that, who can show you and help you and
believe in you. They make all the difference because
they show you what is possible.
Emotional support, received through participation in
group interventions, such as recovery-oriented groups, was
also experienced as helpful for well-being. For example,
Maslow described the personal impact of hearing the sto-
ries of others:
It was really comforting not only getting informed,
but feeling the comfort of other people who experi-
enced what you experienced is amazing.
Lily further explained, the group shares and it helps
cause you hear other people have the same problem as
you, and you dont feel alone.
Services Experienced as Resilience-hindering
Four types of service-related practices were identified as
negatively influencing participants well-being, particularly
in relation to social well-being:
Engulfing
Some participants described feeling over-involved with
mental health services. For example, Jake, who attended a
specialized early psychosis program 3 times a week for
various meetings, said:
I find that because Im so involved with [name of
program], and Im so involved with stuff that deals
with the illness, that it takes control of my social life
and its all that I have on my mind, and its pretty bad.
Similarly, Nelsons account also illustrates the theme of
engulfment within the context of excessive involvement
with mental health services. Nelson was a 24 year-old man
living independently in a one-bedroom apartment and had
been receiving specialized services for approximately 2
years. He was attending two different community organi-
zations for individuals with mental illness 4 times per week
for recreational services, education, and work-related sup-
ports. He saw his case manager and/or psychiatrist at a
specialized early psychosis program bi-weekly and a job
counselor on a monthly basis at an organization special-
izing in providing vocational and educational services to
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Adm Policy Ment Health (2017) 44:92102
individuals with a mental health disability. Given Nel-
sons interest in an acting career, his job counselor con-
nected him to a theatre company dedicated to people
affected by mental illness. Nelson was disappointed that
this acting opportunity would be with other individuals
with mental illness and that the plays would be focused on
mental illness. After 2 years of receiving mental health
services, Nelson expressed a desire to normalize his life by
distancing himself from settings focused on individuals
with mental illness and frustration with over involvement
with mental health-related services:
The most annoying thing is that everything is for
mental health reasons and I just dont want this. If its
a film thing, I dont want it to be just for mentally ill,
and just to address stuff like that. I want it to be, just
normal.
Regulating Practices of Services
Several participants were provided access to housing
resources and support through the mental health services
they received. In such cases, participants lived in settings
such as group homes, youth shelters, and single room
occupancy buildings. Some of the participants, particularly
those living in youth shelters and single room occupancy
buildings described the regulating practices of these envi-
ronments as inhibiting their well-being. By regulating
practices, we mean efforts to control behaviour through
rules. For example, Darren, a 20 year-old who was living
in a downtown youth shelter where he also received mental
health related services (e.g., visits with a psychiatrist,
social worker, outreach worker) described the rules at the
youth shelter as infantilizing. He said that he could not
access his Facebook account at the shelter, although it was
the principal way he kept in touch with his friends. He also
could not receive calls directly at the shelter and did not
have a cell phone. Moreover, Darren explained,
You cant watch TV until after 4:00 pm on the
weekdays. You have to be out of the house between
1:00 and 4:00. You cant go on the computers until
after 4:00 pm. You, uhwhats the other one? Oh
yeah, you cant go on the computer, or go on TV after
a night meeting. You cant swear, but thats an
understandable rule. You cant talk about drugs.
What else cant you do? You cant watch any movies
with drugs or anything. You cant watch movies over
18A. Its a little ridiculousOh yeah, you cant have
any music with violence cause it might be a trigger.
In other parts of the interview, Darren emphasized that
he was trying really hard to turn his life around, behave
more responsibly, and act like an adult. One can contrast
Adm Policy Ment Health (2017) 44:92102
these efforts with how the regulating practices imposed by
his environment worked against him: Oh my God! Ten
oclock? Im 20 and I have a ten oclock curfew. In this
case, a structured environment organized with the overall
intention of protection through rule regulation was hin-
dering Darrens subjective experience and process of
moving towards greater autonomy and independence.
Similarly, Smiley, who lived in a single room occupancy
building downtown, described her housing environment as
follows: I dont like it. Its their rules. Like the guest
rules, its really annoying. Like I feel like Im in an insti-
tution It makes me feel like a retard a group home.
She explained that she wanted to spend time with friends in
her room; however, the building rules allowed only one
visitor at a time and prevented her friends from staying late
or sleeping over. She said that she had no other choice but
to hang out with her friends outside where they were more
inclined to get into mischief and where their safety was
at risk. Smiley emphasized: it sucks, because Im not a
crackhead or a junkie they shouldnt put me in places
like that
Ghettoizing Patients
All participants who had access to housing in single-room
occupancy buildings through their involvement with men-
tal health services described these settings as ghettos, in
others words, predominantly occupied by a minority or
marginalized group. For example, Philip, a young man
struggling with substance abuse, described his residence
and its surrounding neighbourhood as follows:
Every time you walk down the street you see some-
one on a crack pipe, a crystal meth pipe, a pot pipe or
drinking alcohol every block you walk here. And its
nothing but trigger after trigger here, so its not the
right environment for people trying to stay sober
Just being around these kinds of people, its not the
right place for me.
Participants also expressed feeling in danger in these
environments. For example, Michael, another young man
living in a similar building as Philip, recounted a housing
experience that was replete with stories of humiliation,
harassment, and trauma:
Some of the people that live in that building should
not be in a building like that. Like its honestly a
danger to them Theres one that keeps harassing
me, he actually torments me like, its a harsh hate
crime what he does, its disgusting people like that,
they turn a building into something where you dont
even want to be there I stay on the street more than
I live there.
97
Being Out of Tune with Needs
Several participants in the study described service provi-
ders interactions as being out of tune or disconnected
from their instrumental, informational, or emotional sup-
port needs. For example, Goddess made reference to health
care providers occasionally throwing question after
question, without an inkling of caring which made her
feel worse instead of better. She explained:
If they were a little more in tune with, like, how
youre feelinginstead of asking a million ques-
tions like, lets talk about thingsthat mean
something, you know, especially when Im not feel-
ing well You have to kind of use your knowledge
about whats appropriate for that person.
Another participant, Ken, described being subjected to a
vocational counseling assessment that he perceived little
rationale for, as he had already chosen his career path:
I forget what theyre called where you do all those
stupid questions and they come out with a form. And
I already told them, no, I dont want to do this. I
already know what I want to do And its just kind
of running through a wheel Like, they treat
everyone as the same client. And they give them the
same psychology test and the same thing. And they
should just talk, like, honestly talk to them It was
just the tedious, sort of, monotonous questions that
theyre asking me. And its, like, I can just tell you
straightforward what I want.
Kevins account illustrates the importance of matching
instrumental support with needs and preferences. He had
been referred to a physical activity group specifically for
people with mental illness, but did not go because he was
scared of embarrassing himself: it would help to have
someone there every step like a personal trainer. Kevin
suggested that service providers should go above and
beyond to reach out to people and bring them into a healthy
lifestyle rather than simply referring to other groups and
services. The theme of being out of tune was also evident
in young peoples accounts of receiving mental health-re-
lated information and lacking the opportunity to interact
with service providers on the meaning of this information
in a more personalized way. As Ken explained:
But I havent had [name of mental health service
provider] sit me down as, like, a friend-to-friend thing
and tell me what [diagnosis] really is. Hes just given
me random sheets that say, oh, its a disorder, blah,
blah, blah Like, it would be better if [name] could
actually go over it with you, make sure that the client
is actually understanding what youre saying not just
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them saying yeah, yeah, yeah. You know, try to get
some feedback and interaction with them when
youre talking to them about it.
Ken further explained that when young people are
subjected to these types of encounters, which reflect
information transfer rather than interactive conversation,
they passively withdraw from the conversation while being
physically present (e.g., with the nod of a head and utter-
ances of agreement).
Lily also described a disconnected, lack of in-depth
approach that she experienced in her interactions with
service providers and suggested this could be an area for
improvement: Not being as distant, instead of its always
Are you taking medicine? or How much youre taking?
Its not really involved with personal issues Thats what
I think could be changed. Kevin brought up the feeling of
being timed when interacting with service providers. Such
interactions, he said, inhibited his ability to feel comfort-
able enough to express personal aspects of his life:
It was always kind of detached, and I always felt like
we were on the clock and not really supposed to talk
about things like that [relationships] It just wasnt
an environment where I felt comfortable with it. The
people werent really so emotional. They just felt
detached in general. Like they were just doing their
jobs and werent really curious or interested. So, I
didnt really feel like expressing myself.
Discussion
We sought to better understand how services support and
hinder resilience, based on the perceptions and narrative
accounts of young people diagnosed with first-episode
psychosis. This research is well-aligned with, and supports
recent literature that has focused on the social, cultural, and
institutional practices and processes that shape young
peoples well-being and resilience (Bottrell and Armstrong
2012; Ungar 2012; Ungar et al. 2013). Our findings show
how the availability, accessibility, and meaningfulness of
services and supports in the environment play a key role in
promoting and/or hindering young peoples process of
resilience. Specifically the analysis identified three types of
service-related supports as resilience-enhancing, namely:
informational and meaning making, instrumental, and
emotional. The analysis also revealed four types of service-
related practices as resilience hindering: engulfing, regu-
lating, ghettoizing, and being out of tune with patient
needs. These latter findings are consistent with previous
research on young peoples experiences of services, which
identified themes such as drive-by assessment[s] (p. 556) engagement and contextual attunement to a young persons
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Adm Policy Ment Health (2017) 44:92102
and a lack of personal control (Darbyshire et al. 2006,
p. 557). Moreover, the findings show the importance of
matching supports with need (e.g., emotional support when
feeling down; instrumental support when needing help with
accessing community resources; and meaning making
support when receiving illness-related information).
The opportunity to hear the stories of others, and share
experiences with others in terms of psychosis and the
process of recovery, was considered highly valuable by
participants and contributed to their building a narrative of
resilience. The value of such opportunities is also echoed
within the broader mental health peer support literature
(e.g., Davidson et al. 2006) and is consistent with first-
episode psychosis research. All participants in Fisher and
Savin-Badens (2001) service evaluation study, for exam-
ple, expressed the value of sharing their experiences with
others. More recently, Windell and Normans (2013) study
identified that relationships with peers within the psychi-
atric community contributed positively to young peoples
process of recovery and were sources for: hope, reducing
alienation, strategies for coping, and social connection. In
the present study, hearing stories of psychosis and recovery
from peers reduced experiences of isolation and difference.
It facilitated rebuilding a normal sense of self, an aspect
considered by young people diagnosed with psychosis as
important for their well-being (Lal et al. 2014).
These findings can inform future planning of specialized
services for psychosis. It is important that young people
receiving services for first-episode psychosis are provided
with ample opportunities to interact with peers that have
gone through similar experiences and to share experiential
knowledge. Specialized services do typically involve the
provision of information on psychosis and treatment
through presentations, videos, and pamphlets; however, the
opportunity for young people to exchange stories and
moments of support among themselves is still inconsis-
tently available to many youth.
While it has been argued that people with mental illness
should be empowered to develop their own stories of
themselves (Lysaker and Buck 2006, p. 30), it is also
important to recognize the complexity inherent in the
process of facilitating meaning making processes with
patients (Roe and Davidson 2005). This rings particularly
true in settings where biomedical discourse is hegemonic in
its expression within psychiatric care and research.
Biomedical discourse can be perceived and experienced as
very helpful for some young people (e.g., see Larsen 2007);
however, for others, it can come into tension with, and run
the risk of overshadowing, disengaging, disrupting, and
even capsizing potentially helpful processes of meaning
making. Thus, the delicate nature of how this can be
addressed beyond information provision, with dialectic
Adm Policy Ment Health (2017) 44:92102
narrative process, within the context of his or her social
circumstances, requires ongoing consideration by practi-
tioners as well as researchers.
Lysaker and Buck (2006) suggest the following princi-
ples to keep in mind for supporting narrative processes:
engaging in a non-hierarchical dialogue in which
explanatory models are not imposed, and engaging in a
conversation that elicits individuals understandings of
past, present, and desired futures, and how to get there.
This has implications to consider in relation to how psy-
choeducation is currently delivered in early psychosis
programs, wherein there may still be a tendency to focus on
a biomedical system of explanation (e.g., chemical imbal-
ance). Moreover, Or et al. (2013) highlight the importance
of insight being accompanied by a non-stigmatized inter-
pretation of illness.
A recent review by Yanos et al. (2015) identified six
interventions targeting self-stigma in persons with mental
illness, many of which provide opportunities for narrative and
meaning making opportunities. One of these interventions
was developed specifically within the first-episode psychosis
field and addresses identity work in relation to stigma and
illness and shows promising results (e.g., McCay et al. 2006).
Other interventions, such as Narrative and Cognitive
Enhancement Therapy also show promise based on large
(N [ 100) quasi-experimental research (Roe et al. 2014),
albeit, evaluation of such interventions are in their early stage
(Yanos et al. 2015). In general, studies on how to improve
resilience-enhancing narrative processes through patient-
provider interactions, group interventions, and patients nat-
ural support networks require further development.
From a system and service delivery perspective, providing
psychoeducational interventions that match young peoples
varied needs and having the therapeutic skills to support these
needs, poses a human resource and system capacity challenge
for service providers and system planners. Empowering
young people with the freedom to enact their narrative process
may be constrained at times by other commitments and
responsibilities of service providers, as well as lack of human
resources and skills training in this area. There is potentially a
taken for granted tension that exists herein between support
for the idea of helping young people construct an adaptive
narrative of their experiences, and the actual actions engaged
in, or the capacity to do so effectively.
There is also the challenge of making peer-based
opportunities accessible to young people; for example,
some may not be willing or able to attend groups due to
stigma or competing priorities respectively. Thus, other
ways through which peer support can be offered could be
considered, for example through online, secure platforms.
System-level mental health strategies and program policies
should stipulate the importance of providing narrative-
based peer interventions, but also enhance the capacity of
99
service providers in delivering such interventions in person
as well as through new technologies.
In terms of how services hinder the process of resilience,
the findings suggest that service-related practices such as
regulation, over-involvement with appointments, and
ghettoization can negatively influence resilience through
impacting on self-stigma, sense of self, and identity more
broadly. Stigma contributes negatively to self-esteem,
which has been observed in first-episode psychosis popu-
lations (e.g., Windell and Norman 2013) and in individuals
with schizophrenia spectrum disorders more broadly
(Yanos et al. 2008). Negative experiences of service-re-
lated practices can also contribute to disengagement, which
is of particular concern given that adolescent and young
adult populations are at high risk for service disengage-
ment, which is often associated with poorer clinical and
functional outcomes (OBrien et al. 2009). This is well-
illustrated in the present study, for example through
Kevins account in which he described how he emotionally
withdraws from his interactions with service providers
when their approach to assessments does not match his
expressed needs. Thus, it is important to understand young
peoples experiences and perceptions of services as these
can contribute positively or negatively to their engagement
(Lal and Malla 2015).
There are also policy implications of this study at the
intersections of mental health services and housing, par-
ticularly as it applies to young people living in substandard
and ghettoized housing conditions. While many of the
youth in this study accessed housing resources through
their participation in mental health services, one could
argue that these youth were nonetheless homeless given the
substandard, congregated, and ghettoized conditions of the
buildings (and neighbouring communities) that they were
placed in (using Smileys word). This is not only sub-
stantiated by participant perspectives on their housing sit-
uations, but also based on the continuum notion of
homelessness as a socio-structural phenomenon that
includes living in youth shelters, substandard housing, and
spending a large proportion of ones monthly income on
housing (Frankish et al. 2005). All three of these factors
correspond well to the situations of 41 % of the young
people in this study and presented as barriers to their
resilience process, for example through their social and
psychological well-being.
Unstable housing conditions can contribute to the
exacerbation of psychosis, or slow down time to symptom
remission (thereby prolong the duration of untreated psy-
chosis), and also have an effect on other co-morbidities
such as substance abuse, all of which were observed in this
study. As Smiley explained, she resorts to alcohol abuse as
a way to cope with the stress of her housing situation, and
as Philip emphasized, it is difficult to stay sober when one
123
100
is literally surrounded by trigger after trigger. As a recruitment from two different types of service settings
group, participants recruited from the mental health pro-
gram providing psychiatric services for street youth rep-
resented complex, multiple morbidities compared to those
recruited from the specialized early intervention program
for psychosis. Where a population seems most in need of
services, they seem in this case to be the least served in
terms of access to appropriate housing, specialized services
for psychosis, and psychosocial social supports.
These findings highlight, at the minimum, an area that
warrants further attention from the policy, research, and
practice arenas: the interface between homelessness (and
associated structural factors, such as poverty, lower levels
of education), access to specialized early psychosis ser-
vices, and recovery in early psychosis. There may be jus-
tification for exploration of a three-pronged intervention
approach. First, a housing first model could be considered
in which young people are provided with reasonable and
permanent access to housing. Research on such an
approach suggests that individuals with co-morbid psy-
chiatric and substance abuse concerns can make improve-
ments in both areas within 2 years of being provided with
stable housing (e.g., Tsemberis et al. 2012). Moreover, this
is achieved without placing contingency demands for
abstinence or treatment compliance before providing
access to appropriate housing. Second, a re-consideration
of how early psychosis services in collaboration with
housing and support services are organized and delivered
for this subgroup of young people with particularly com-
plex needs is warranted. This may include interagency and
intersectoral collaborations to facilitate simultaneous
access to appropriate housing conditions, evidence-based
substance abuse harm reduction, community-based clinical
case management, and meaningful activity engagement.
Third, it is important to increase the capacity of clinicians
in being able to adequately address youth experiencing
first-episode psychosis who are also entrenched within the
context of drug abuse and poverty.
The limitations of this study include a small sample which
means that there may be experiences and perspectives not
represented here. The sampling strategy did not account for
individuals who dropped out of treatment, which could also
provide perspectives of services that we have not accounted
for. Nonetheless, the fact that participants were able to share
both positive and negative perceptions of services suggests
that the sample was not biased towards a particular view-
point. This may partially be attributed to the fact that the
interviewer was not associated with the treatments partici-
pants were receiving and also the framing of questions in
relation to not so helpful as opposed to using phrasing such
as not helpful or other more negative terms.
Strengths of the study include the sociodemographic
diversity of the sample, multiple interviews, and
123
Adm Policy Ment Health (2017) 44:92102
with common themes identified in participants accounts
arising from across the two settings. In addition, the use of
methods and principles from both grounded theory and
narrative inquiry helped us dually privilege individual
accounts as well as identify common elements across
participants narratives. The explicit, systematic and rig-
orous analytical procedures of grounded theory facilitated
the development of a cross-case analysis and understanding
of the environments role in young peoples process of
resilience. The narrative approach, meanwhile, helped us to
understand how elements in the environment influence
experiences and processes of resilience.
Conclusion
Understanding young peoples experiences of mental
health services can be a complex endeavor given that they
often receive several types of interventions at the same
time (e.g., medication, education, family support) and
sometimes from services coordinating with each other
(e.g., housing services with mental health services). Elic-
iting their service-related perspectives and narrative
accounts is valuable as it can provide insights on how
services influence their process of resilience, which is
important for the planning and coordination of services that
are engaging, meaningful, and effective for youth. A
qualitative, narrative approach, wherein youth are provided
with opportunities to share their perspectives on well-be-
ing, the adversities and difficulties they face, and how the
environment supports and/or hinders their resilience, across
various domains of their lives can help to advance theo-
retical understanding of resilience process and ultimately
improve services. Future research could focus on the
relationship between resilience and service-related prac-
tices (including patient-provider interactions, peer-based
interventions, and socio-structural elements of service
provision) on a larger sample of youth with first-episode
psychosis.
Acknowledgments The first author was partially supported by a
Doctoral Scholarship Award from the Canadian Institutes of Health
Research while conducting this research. The third author is sup-
ported by the Canada Research Chair Program. This research received
no specific grant from any funding agency in the public, commercial,
or not-for-profit sectors.
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