Reimagining recovery: a commentary centering youth and caregiver voices on substance use recovery and healing from across British Columbia, Canada

Abstract

Background

Internationally, substance use recovery and healing is increasingly the focus of health and public policy and practice. Yet, what constitutes recovery and healing, and how it is understood and enacted among young people who use(d) drugs (YPWUD) has been largely underexplored. This commentary argues for a re-imagining of substance use recovery and healing by centering the understandings and lived experiences of YPWUD and their caregivers.

Methods

We draw on insights from a needs assessment conducted using qualitative methods with 38 youth (14 to 24 years of age) and 18 caregivers from across the province of British Columbia, Canada, including in Vancouver, Victoria, Kelowna, and Prince George. All activities were undertaken in collaboration with our team’s Youth Health Advisory Council, a group of 9 youth with lived experience of substance use and its various interventional responses.

Findings

We discuss key insights from the needs assessment, highlighting the urgent need for more nimble approaches to supporting youth recovery and healing that adapt to shifting definitions, goals, and timelines as well as transitions across various substance use treatment, recovery, and care contexts. Our needs assessment also highlighted the often overlooked but critical role of families and caregivers. By foregrounding youth perspectives and experiences – including engagements with diverse treatment, recovery, and care programs and complex dynamics with caregivers – we identify key priorities and actionable recommendations to reorient policy, practice, and research so that they are more youth- and caregiver-centered.

Introduction

Recovery and healing in the context of illicit substance use has become a central pillar of global health and social policy [1], permeating governmental frameworks, public health interventions and guidelines, and community-based programs [2]. On the one hand, emerging paradigms embrace notions of recovery and healing as holistic processes aimed at enhancing health, wellness, and quality of life, as emphasized by bodies such as the World Health Organization [1]. On the other hand, many prevailing understandings and approaches to substance use recovery remain narrowly focused on abstinence and often overlook the intersecting social structural factors that significantly shape experiences [2]. This disregard disproportionately impacts equity-denied populations, including Indigenous, Black, and Brown communities, those experiencing entrenched and intergenerational socio-economic marginalization and unstable housing and homelessness, and adolescents and young adults [2–4].

In addition to substance use-related risks and harms, equity-denied young people who use(d) drugs (YPWUD; defined here as those between the ages of 14 and 24) often also face heightened criminalization, systemic discrimination, and, in our setting of British Columbia (BC) and elsewhere, toxic drug supply poisonings, now a leading cause of death in Canada [5]. Such realities frequently situate YPWUD within complex health, social, and legal systems, often ill-equipped to meet their needs [2, 3]. As a result, many young people rely on caregivers— including biological, adoptive, and chosen family, friends, and romantic partners—to provide emotional, financial, and material support as they navigate oftentimes fraught positions within these systems [2, 6]. Yet, many approaches to recovery and healing can overlook the experiences and perspectives of caregivers [2, 6], underscoring the need for a re-imagining of these processes that centers the experiential knowledge of both young people and caregivers and the social structural dimensions of recovery and healing such as housing, employment, and access to income.

In this commentary, we draw on insights from a qualitative needs assessment focused on youth substance use recovery and healing conducted across BC. We highlight the urgent need for more nimble approaches to supporting recovery and healing that adapt to shifting definitions, goals, and timelines, as well as young people’s moves across various substance use treatment, recovery, and care contexts, which frequently range from harm reduction-oriented care to abstinence-based live-in programming. We also underscore the complex but often critical role of families and other caregivers, who are often key sources of support but also experience significant strain. Key priorities and recommendations are provided to better align future policy, practice, and research with the diverse and shifting lived realities and care contexts of young people.

Approach

This needs assessment project unfolded in two stages: first, we conducted a scoping review, published elsewhere [6], examining qualitative studies published between 1999 and 2023 that focused on youth and caregivers’ understandings and experiences of recovery and healing in the context of past or current substance use. Next, we conducted a needs assessment using qualitative and community-based participatory approaches that directly engaged youth and caregivers with lived experience across BC. This approach was chosen to build trust with the community and identify gaps and areas for improvement in research, policy, and services. Youth and caregivers with lived experience were involved throughout both stages —from project planning and co-designing the search strategy to advising on the needs assessment and co-authoring a final report. Our team’s longstanding Youth Health Advisory Council, a group of nine young people (ages 17 to 28) with lived experience navigating substance use treatment, recovery, and healing based in Metro Vancouver (although members come from a range of urban, rural and remote settings across Canada), helped shape key areas of inquiry, refine findings, and ensure the project remained grounded in lived experience. By conducting this assessment in partnership with the community, we leveraged their knowledge and expertise to explore recovery and healing while co-developing priorities and key recommendations (Table 1). Through one-on-one conversations and group discussions conducted in four geographically distinct locations—Prince George, Kelowna, Victoria, and Vancouver—on the unceded, ancestral, and occupied territories of the Lheidli T’enneh, Syilx Okanagan, lək̓ʷəŋən (Songhees), Xwsepsum (Esquimalt), xʷməθkʷəy̓əm (Musqueam), Sḵwx̱wú7mesh (Squamish), and səlilwətaɬ Tsleil-Waututh Nations – we connected with 38 youth pursuing recovery and healing in the context of illicit substance use (aged 14 to 24; mean age of 16 years) and 18 caregivers (including family members, friends, and romantic partners of youth under the age of 24).

Table 1.

Recommendations for providers and health systems to support youth navigating substance use recovery and healing

	Recommendation	Explanation
A	Define recovery in collaboration with youth.	Do not assume what recovery means to youth, and be alert to shifts in definitions across time. For example, recovery may initially include reduced use and later be defined as total abstinence, with definitions often shaped by the type and context of care (e.g., community-based harm reduction-oriented programs versus abstinence-based live-in programs).
B	Use supportive language that makes room for missteps and learning.	Use language that motivates youth to keep moving forward with self-defined recovery and healing goals and avoid language that may lead to feelings of pressure and looming or actual failure.
C	Encourage youth to continually (re-)define their treatment, recovery, and healing goals and timelines.	Focus on strengths and supporting youth in learning what it means and how to live a fulfilling, pleasurable, and “fun” life over attempting to “fix” them. Be alert to changes in goals and timelines across time, place, and treatment, recovery, and care contexts.
D	Provide opportunities to practice recovery during programs.	Help youth move toward more independent recovery and healing by first supporting them in navigating challenges and missteps. Live-in programs should aim to provide opportunities to practice recovery in real-world contexts, such as through the use of short-term day, evening, or weekend passes.
E	Treatment and recovery programs should approach returns to use (e.g., while on day and weekend passes) as learning opportunities.	Prioritize policies that approach returns to use as opportunities for learning and growth rather than as grounds for discharge. Avoid framing returns to substance use as a lack of readiness for recovery and instead use debriefs to identify challenges and collaboratively develop strategies.
F	Reduce barriers to treatment and recovery programs and recognize that repeated engagements are often viewed positively by youth.	Implement measures to reduce barriers to care and ensure youth have access to treatment at the moment they want or need it. Recognize and support youth who are engaged in multiple treatment and care programs simultaneously or in rapid succession (e.g., OAT and harm reduction programs) as their needs, goals, and desires quickly evolve.
G	Provide quality housing and income support.	Ensure access to a continuum of safe and desirable housing, adequate income, and access to vocational opportunities and social connectedness to support evolving recovery and healing.
H	Promote caregiver involvement that fosters a balance between support and autonomy for youth.	Design programs that promote caregiver involvement while recognizing and supporting youth who prefer to pursue recovery and healing independently. Be alert to changes in youth’s needs and goals regarding caregiver involvement across time and place.
I	Provide programs for caregivers to learn about youth substance use, treatment, recovery, and healing independently from youth.	This is particularly important when caregiver and youth needs, priorities, and desires are not aligned, and when youth are engaged in multiple treatment and care programs simultaneously or in rapid succession (e.g., OAT and harm reduction programs) that may require different caregiver support strategies.
J	Create new and scale up existing caregiver and family support programs.	Develop comprehensive support programs characterized by flexible hours and outreach approaches to address the emotional, social, and material challenges and common emergencies faced by caregivers and families.
K	Expand family liaison services and caregiver peer supports.	Increase the availability of family liaison workers and caregiver peer support to strengthen relationships with and between youth, caregivers, and providers.

Participants were diverse in age, race/ethnicity, gender identity, sexual orientation, and ability. Youth described engaging with a wide range of treatment, recovery, and care programs, including live-in (i.e., residential) programs, stays in hospital and other institutional (e.g., medical detoxification) settings, and accessing community-based counseling, mutual support groups (e.g., Narcotics Anonymous), harm reduction services, and opioid agonist therapy (OAT). Participants were primarily recruited through youth services (e.g., integrated youth services centers, live-in treatment and recovery programs) located in Prince George, Kelowna, Victoria, and Vancouver. In Vancouver, participants were also recruited via our team’s frontline research office located in the downtown core, where we are able to regularly connect with youth who are not currently accessing the range of youth services listed above. Across all sites, some youth were actively engaged in treatment and recovery programs at the time of the needs assessment (including 14 youth who were currently attending abstinence-based live-in programs), others had recently completed programs, and some were navigating multiple treatment, recovery, and care engagements simultaneously or in close succession, such as community-based counseling, harm reduction services, and OAT. In what follows, we highlight the key takeaways from this needs assessment, presented as a series of priorities and actionable recommendations (Table 1).

Priority 1: acknowledge the range of youth and caregiver perspectives on substance use recovery and healing, including diverse definitions, goals, and timelines

We asked youth and caregivers to reflect on what recovery and healing meant to them, and how services and health systems could better support the various definitions and goals they set for themselves. Many connected with the term “recovery” and the range of goals it can encompass. However, for others, the term felt “too big” and “too scary,” evoking a sense of pressure to “get it all right,” extending indefinitely into the future, when instead they needed to focus on more immediate priorities such as “staying alive” or “getting better each day.” Many noted that using the term recovery could imply the potential for “total failure” and stressed the importance of checking in with youth and respecting the language they most connect with (See Recommendation A). Our conversations revealed the importance of learning how to view “slips” and “relapses” as missteps and learning opportunities rather than as “the end” of recovery and healing. Youth and caregivers agreed that while there are diverse recovery definitions and multiple lived realities of healing, meaningful pursuits frequently center around learning to “fill the time,” manage boredom [7], and build new relationships and a sense of social connectedness in the absence of substance use. For youth engaged in live-in treatment and recovery programs, support in learning how to build and maintain daily routines once highly-structured programming ended was viewed as critical. Youth shared that recovery could be about looking toward the future or the past (or both), processes of reflection that could be usefully supported by culture-based healing that helped individuals (re-)connect with their identities, families, communities, ceremony, and land – practices that, according to a number of Indigenous youth, are currently insufficiently integrated across many treatment, recovery, and care programs (See Recommendation B).

Priority 2: avoid reducing recovery to narrowly-defined understandings of treatment and design programs to include opportunities to “practice recovery” and flourish more broadly

Our needs assessment revealed that treatment and recovery are often, but not always, interconnected. Treatment – broadly defined here to encompass a range of approaches such as one-on-one counseling, mutual support groups, medication-assisted therapy, and live-in programs delivered across institutional and community-based settings – can be a crucial part of recovery. However, recovery should not be reduced solely to ongoing treatment engagement, medication adherence, and attempts to “fix” youth substance use. The latter can feel particularly damage and deficit-centered. Many youth emphasized the importance of thinking beyond narrowly-defined treatment goals – such as managing withdrawal and reducing or eliminating substance use – and instead focusing on supporting them in learning what it means to “live well” [8] – that is, learning to foster senses of meaning, fulfilment, pleasure, “fun,” and social connectedness [9] that are less linked to, or completely independent of, substance use.

Youth shared examples of current practices that fell short of this. For instance, in longer-term live-in treatment programs, strict rules around curfews and phone access were often experienced as punitive rather than supportive, making it harder for youth to feel connected to the very family members, friends, and romantic partners who most strongly motivated them to “keep going” with recovery and healing [10]. Others noted that a range of in- and out-patient treatment programs sometimes focused too narrowly on substance use-related goals, without acknowledging other priorities, such as managing mental health, (re-)connecting with school, family, and friends, securing safe housing, and managing boredom [7]. Youth shared stories about programs that focused too much on what they did wrong, instead of what they could do right in the short, medium, and longer-term. Relatedly, they emphasized the need for treatment programs to build upon strengths, with appropriate attention paid to both smaller, more immediate wins (e.g., “I was sober on my birthday”) and more long-term successes (e.g., resuming school, becoming a peer worker) (See Recommendation C).

Over time, many described needing to learn how to independently navigate challenges to recovery and healing, while recognizing that, especially initially, they require support. Ideally, youth are given opportunities to “practice recovery” while they can still return to structured treatment environments (e.g., live-in programs, day programs) to debrief with staff and providers with whom they have established trusting and warm relationships ([9] see Recommendation D). While remaining mindful of how active substance use in abstinence-based programs can affect the experiences of others and occasionally constitute a safety risk, returns to use while engaged in treatment programs should ideally be viewed as opportunities to learn, not as “total setbacks” and not as a reflection of a lack of interest in pursuing recovery or healing. This allows individuals to develop new skills and expand their capacity over time – a process that youth viewed as crucial to their success (See Recommendation E).

Priority 3: make recovery and healing “feel possible” by “giving multiple chances” and addressing the social and structural dimensions of well-being, such as social connectedness, housing, and income support

Recovery and healing can start to “feel impossible” for youth who continually encounter barriers to engaging with treatment, recovery, and care programs, such as lengthy wait times, punitive rules that result in being asked to leave programs, discrimination, and a lack of warmth, safety, and inclusivity (See Recommendation F). For example, during engagements with live-in programs, youth described experiences of being “kicked out” for minor violations, such as missing a curfew; these abrupt “endings” could be highly destabilizing and make continuing to prioritize recovery and healing very difficult. Youth emphasized the importance of spaces that “feel like home” and where staff engage warmly and collaboratively with youth, “giving them multiple chances” to practice change in the face of missteps and demonstrating that they “see the whole person in front of them” and “really care about the person and their whole life, not just their substance use.” Youth and caregivers did not generally view going to programs repeatedly as a failure but as important opportunities for incremental learning, developing greater self-efficacy, building on existing strengths, and “getting better” over time.

Following live-in programs in particular, a lack of safe and desirable housing that “actually feels like a home” and inadequate income support left many youth feeling that maintaining recovery and healing was impossible. A crushing sense of “going nowhere” [7] with their goals, despite treatment and recovery program engagement, was intensified for youth who had few or no supportive relationships with family, friends, and service providers – or who needed support fostering these relationships ([9, 10]see Recommendation G).

Priority 4: carefully promote caregiver involvement in youth recovery and healing, and enhance support for caregivers

Active caregiver involvement in youths’ recovery and healing was often valued by youth and caregivers alike. However, many described the importance of striking a delicate balance between providing support without being “too pushy” or stifling. Youth emphasized the need for caregivers to avoid “overbearing” behaviors, such as repeated questioning and constant surveillance. Instead, youth and caregivers stressed the importance of building a relationship characterized by compassion, patience, curiosity, learning, and open communication (See Recommendations H & I).

As described above, some youth engaged in live-in programs described how rigid program policies could limit family contact to brief phone calls, making it difficult to maintain the connections that supported their recovery and healing. Others in community-based settings said they wished staff could help caregivers understand how to support them without “watching their every move.” Across various treatment, recovery, and care programs, some youth emphasized the need for more consistent provider support in navigating challenging relationships with family members and caregivers [9, 10] who were themselves experiencing mental health and substance use challenges, or completely lacked understanding of these issues and available interventions (e.g., OAT). Youth underscored the need for their caregivers to acknowledge that working on recovery and healing is tremendously hard, recognize their strengths, avoid “empty” motivational phrases (e.g., “you’ve got this”), and actively listen with curiosity and without judgment.

Our needs assessment also highlighted the enormous challenges caregivers face while supporting youth through treatment and recovery—from diminished capacity to care for others to strained family relationships to reduced capacity to work. Caregivers expressed the urgent need for more robust services and programming focused on them to address the emotional, psychological, and financial toll and stress of their roles and impacts on siblings (See Recommendation J). Additional services such as round-the-clock family liaison and outreach services (to provide support during after-hours crises when caregivers often have no one to turn to), extended crisis-support hours, and more caregiver peer support groups were consistently mentioned (See Recommendation K).

Conclusions

Our qualitative needs assessment identified some of the different understandings, experiences, and priorities that must be addressed to better support youths’ recovery and healing in the context of illicit substance use. To better position youth for success, treatment, recovery, and care programs and services must be nimble enough to align with youth’s varied and shifting definitions, goals, and timelines and actively engage youth and their caregivers throughout all stages of care and planning. Our recommendations are intended to be adaptable across different care contexts to better meet the needs and priorities of youth and their caregivers.

Abbreviations

BC

British Columbia

OAT

Opioid agonist therapy

YPWUD

Young people who use(d) drugs

Author contributions

CRE: Led project administration, project conceptualization, writing – original draft. KH: Writing – reviewing & editing. DF: Writing – reviewing & editing. KM: Writing – reviewing & editing. SB: Writing – reviewing & editing. RT: Writing – reviewing & editing. EM: Writing – reviewing & editing. MJI: Writing – reviewing & editing. MC: Writing – reviewing & editing. DF: Contributed to project administration, project conceptualization, writing - reviewing & editing.

Funding

This work was supported by funding provided by the University of British Columbia/British Columbia Ministry of Health Seed Grant (AWD-024519).

Data availability

No datasets were generated or analysed during the current study.

Declarations

Ethics approval and consent to participate

Not applicable.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.