RE-MAKING SELVES AND SOCIAL WORLDS: EXPERIENCES OF LIVE-IN SUBSTANCE USE TREATMENT AMONG ADOLESCENTS EXPERIENCING SOCIAL STRUCTURAL MARGINALIZATION IN VANCOUVER

Abstract

Across many settings in Canada and the US, overdose is now a leading cause of death among 10 to 18-year-olds. In the Canadian province of British Columbia (BC), there have been increased efforts to connect adolescents with substance use treatment, including live-in programs. While much previous work has focused on barriers to treatment among youth, less research has examined how adolescents, and in particular those experiencing high levels of residential instability, homelessness, and institutionalization via child protection, criminal legal and housing systems, understand and experience these programs. This qualitative study draws on semi-structured interviews with 37 adolescents and those who were very recently adolescents aged 14 to 20 who planned to access, were accessing or had recently accessed “Cypress Place” (a pseudonym), a live-in treatment program for adolescents in Vancouver, BC. Drawing on concepts of self and social world-making, our findings reveal that the changes adolescents envisioned making through live-in treatment extended far beyond abstinence from substance use, to encompass significant shifts in who they were and who they surrounded themselves with. While the weight of the social structural contexts that “followed” youth into treatment could powerfully undermine their abilities to make desired changes, this study nevertheless provides insights into how transformative projects of self and social world-making can be better supported across their treatment trajectories. Namely, providers and programs can work to bridge the kinds of self and social transformations achieved during live-in treatment with what comes next by providing opportunities for youth to stay connected and prioritizing the development of skills for living well – as individuals and as part of collectivities – that open up possibilities for recovery and healing over the longer term.

1. Introduction

Across North America, drug toxicity and related harms have been steadily increasing over the past decade, with the province of British Columbia (BC) declaring a public health emergency in 2016 (Government of British Columbia, 2016). More than 12,000 people have died of drug overdoses in BC since the public health emergency was declared, and overdose is now a leading cause of death among adolescents under 19 years of age (British Columbia Coroners Service, n.d.). Between 2019 and 2023, there were 124 suspected unregulated drug toxicity deaths among those aged 10 to 18 in the province. While this number is relatively low compared to deaths among young adults aged 19 to 29 (among this population, there have been 1486 suspected unregulated drug toxicity deaths across the same time period), this number of deaths represents a 377 % increase when compared to earlier data from 2009 to 2013 (British Columbia Coroners Service, 2024; British Columbia Coroners Service Child Death Review Panel, 2016). Heightened overdose risk is largely driven by the growing presence and potency of illicitly-manufactured fentanyl and its analogues within a street drug market that is also increasingly contaminated with non-opioids such as benzodiazepines and xylazine (Gonzalez-Nieto et al., 2025; Kennedy et al., 2024).

As an epicenter of North America’s overdose crisis, the government of BC has responded by expanding access to treatment for people who use drugs, including adolescents (British Columbia Ministry of Mental Health and Addictions, 2023). In 2023, the provincial government committed $236 million over three years to expand mental health and substance use (MHSU) care for adolescents and young adults, including doubling the number of publicly funded youth treatment beds in live-in programs (British Columbia Ministry of Mental Health and Addictions, 2023; 2024). In our setting, government-funded live-in programs typically provide time-limited (a few weeks to a few months) integrated MHSU treatment in residential facilities, supporting adolescents through a combination of one-on-one and group counselling, psychosocial education, life skills training and medications for opioid use disorder (e.g., buprenorphine/naloxone) (Government of British Columbia, n.d.; Turpel-Lafond, 2016). Despite recent expansion, access to these programs among adolescents remains uneven across the province. This is particularly the case for those experiencing high levels of residential instability, homelessness, and institutionalization via child protection, criminal legal and housing systems, often in the context of broader forms of oppression shaped by racialization, intergenerational poverty, gender, sexuality and disability (hereafter paraphrased as social structural marginalization) (Brown et al., 2024; Tyndall & Dodd, 2020). A significant body of previous work has documented specific barriers to treatment among these adolescents, as well as discrete recovery stages, processes and capacities (Acevedo et al., 2020; Alegria et al., 2011; Castro-Ramirez et al., 2021; Duff, 2015; Lu et al., 2023; Porche et al., 2022; Treloar & Holt, 2006; Turuba et al., 2022). Less work has employed qualitative methods to examine youth’s understandings and experiences of live-in treatment and how these shape possibilities for healing and recovery in the aftermath of residential programs. Our study draws on concepts of self and social world-making to explore how recovery capacities such as “social connectedness” and “positive sense of self” actually come into being (or not) in places such as live-in treatment facilities, and how we can continue to “cultivate, nurture and restore” (Duff, 2015, p. 62) these capacities once treatment programs have ended.

Adolescence is recognized as a critical period of neurological and psychological development, including as relates to the formation of a “perceived self” (Neisser, 1993) – that is, an embodied capacity for self-reflection underlying experiences of first personhood (Damon, 1984; Lakoff et al., 1999; Moshman, 2009; Pérez-Álvarez, 2018). Drawing on work from critical medical anthropology (Biehl et al., 2007; Biehl & Locke, 2017; Lester, 2017), we consider here how adolescence also constitutes a critical period of “self-making,” which we define as the manifold reflexive processes of “becoming” through which individuals enact senses of who they are and who they want to be, powerfully shaped by personal and intergenerational memories, histories and desires for the future, as well as forces of political economy and power (Biehl & Locke, 2017; Deleuze, 1997). From this perspective, the self is eminently social and understood to be “constituted through practices, including embodied, dialogical, imaginative, interpersonal, and institutional practices” (Lester, 2017, p. 24). Selves are “multiple … rather than unitary, mobile rather than stable, porous rather than enclosed, externally constituted rather than internal or ‘inner’ natural essences” (Keller, 2007, pp. 353–354). We prefer the term self-making – as well as the language of “un-making” and “re-making” adolescent selves – to the language of identity development, which arguably refers to more bounded social definitions, meanings and categories. Moreover, our analysis puts aside the more traditional psychological question of whether a “core self” exists to instead focus on how the self is lived by adolescents navigating substance use treatment, emphasizing adolescent selves as always “unfinished” and open to revision and change, even in the face of powerful social structural forces (Biehl & Locke, 2017; Lester, 2017).

In addition to being a critical period of self-making, adolescence is also generally a time of seeking greater autonomy in the context of a growing multiplicity of interconnected social worlds, including the worlds of friends, family, school, work and various communities and collectivities (Betzler, 2022; Biehl & Locke, 2017). Again, here we draw on work from critical medical anthropology to consider how, as they seek both autonomy and social connectedness, adolescents begin to take a greater role in actively making, un-making, and re-making social worlds that, like selves, are also always in the process of becoming and perpetually unfinished (Biehl & Locke, 2017; Lerner et al., 2005). In what follows, we are less focused on discrete resources and outcomes such as social capital and competence than on more fluid processes of becoming (and coming undone) among adolescents navigating social structural marginalization, powerfully shaped by memories of the past and desires for the future (Biehl & Locke, 2017). Self and social world-making are, of course, deeply interconnected; adolescents enact senses of who they are and who they want to be in relation to others and to the worlds they inhabit and long to inhabit. Like perceived selves, social worlds are powerfully inflected by forces of power and political economy, which constrain certain possibilities even as they engender others.

For example, among youth experiencing entrenched poverty and unstable housing and homelessness, “street families” (defined here as friends, romantic partners and chosen family with shared lived experiences of precarity) often anchor senses of self and social world-making while also being essential sources of emotional and material support and safety (Bourgois & Schonberg, 2009; Fast, 2024). However, social worlds of the streets are often simultaneously marked by the “everyday emergencies” of entrenched poverty and addiction, including a cyclical, frenzied imperative to procure income and criminalized substances such as opioids and stimulants, regular criminal legal system involvement and frequent experiences of housing instability and street-based homelessness (Bourgois & Schonberg, 2009). These everyday emergencies are a part of what create states of unsafety and frenetic problem-solving on the streets that at once constitute and undermine particular self and world-making projects. For example, alliances and rifts within street families, friendships and romantic and income generation partnerships may be continually opened up, while possibilities for schooling and work may be increasingly foreclosed by these social structural contexts (Biehl & Locke, 2017; Fast, 2024). Our analysis seeks to consider how the everyday emergencies of youth’s lives shape the kinds of selves and social worlds that can be enacted through live-in treatment engagement, with a focus on how these places can open up desired possibilities for adolescents as they pursue healing and relief from the weight of social structural pressures.

Among youth who use drugs intensively, live-in treatment often becomes an additional social world that they must (often repeatedly) navigate (Fomiatti et al., 2017). Live-in treatment can be a potent setting or “atmosphere” of adolescent becoming, in which youth undertake new kinds of self and social world-making with a view toward healing and recovery (Duff, 2015). Indeed, previous work has highlighted the utility of the “social words” concept as a valuable heuristic device for understanding and addressing substance use practices (Bower et al., 2021; MacLean et al., 2021). A focus on live-in treatment as a social world attunes us to the constellation of actors, practices, commitments, institutions and technologies that shape understandings and enactments of health, risk and care in this setting (MacLean et al., 2021). Some previous research with adults has examined these dynamics, albeit using framings such as social connectedness and identity formation. For example, previous research among adults attending live-in treatment found that when participants fostered a sense of social connectedness in these settings, it enabled them to undertake desired changes in self-identity (Neale et al., 2018). Other research showed that some participants in a California live-in treatment facility developed a stronger sense of Indigenous identity by connecting with Indigenous peers and engaging in cultural practices during the program (De Salis et al., 2023). This, in turn, had positive implications for treatment retention and completion (De Salis et al., 2023).

Entering and undertaking live-in treatment often requires an explicit interrogation of past, present and future selves in ways that can both liberate and constrain the range of possible selves individuals can embody during and after programs (De Salis et al., 2023; Yang et al., 2020). While attending live-in treatment, one-on-one and group counselling, psychosocial education and life skills training may all encourage people to un-make and re-make themselves and their social worlds in particular ways, often in relation to substance use (Herold & Søgaard, 2019; Nash et al., 2015). For example, some Twelve Step Narcotics and Alcoholics Anonymous programs (popular in our setting and others, although less so for adolescents) ask people to identify as “powerless” over their substance use as a strategy for maintaining vigilance in the face of “people, places, and things” that can trigger a return to substance use (Gonzales et al., 2012; Labbe et al., 2014). Often, individuals are encouraged to outright avoid these “triggering” people, places and things. Alternatively, the chronic and relapsing disease model of addiction posits that people are aspiring to a state of recovery that will likely be marked by returns to substance use and treatment, including live-in programs (Bryant et al., 2022; Campbell, 2007). New understandings and experiences of selves and social worlds bound up with these and other treatment philosophies can be transformative. Alternatively, they can be limiting; for example, research has shown that the notion of addiction as a cyclical, chronic and relapsing illness requiring ongoing treatment can engender a sense of “endlessness” and disability that youth may actively reject (Fast, 2024; Garcia, 2010; Giang et al., 2020; Gonzales et al., 2012). Here, we seek to better understand the possibilities and perils of self and social world making enacted through live-in treatment engagement, and the implications for re-imagining these programs and their aftermaths to better align with adolescents’ needs, priorities and desires.

There has been some limited previous research touching on how dynamic processes of self and social world-making while attending treatment may impact treatment efficacy. For example, one study examining adolescent experiences in live-in treatment in the United States found that low program completion rates and ongoing entrenchment in daily, intensive substance use could be primarily attributed to difficulties with adjusting to the social dynamics of this residential setting (Currie, 2003). Another more recent study on adolescents’ experiences with outpatient care following live-in treatment found that while some relationships formed in treatment facilitated outpatient program attendance, others were potentially harmful to recovery because of perceived differences in maturity amongst peers that could undermine motivation and commitment to recovery (Monico et al., 2022). Still another recent study in Australia demonstrated the value of assisting young people with “learning how to live well” during live-in treatment, including supporting them in managing relationships with family and friends and fostering new forms of selfhood bound up with caring for the body, keeping busy through leisure, work and training and developing routines (Bryant et al., 2025). It was these kinds of “living skills” developed during live-in treatment that allowed study participants to meaningfully alter their substance use after the program ended (Bryant et al., 2025). These studies alert us to the importance of conceptualizing live-in treatment engagement as a trajectory that includes the period prior to program entrance, program attendance and the period following attendance. We take up this perspective here with a focus on how self and social world-making evolve and can be more meaningfully supported across this trajectory.

2. METHODS

2.1. Data collection

The present analysis emerged from the Care Pathways Study, a longitudinal qualitative, ethnographic and community-based participatory research project examining how youth aged 14 to 24 (at the time of enrolment) navigate substance use and care across time and place in the context of ongoing housing and overdose crises in BC. This study began in 2018 and is led by the senior author (Danya), a white settler medical anthropologist who has been working with young people who use drugs and their families and providers since early 2008. The Care Pathways Study team is comprised of numerous students and staff (including co-authors Monique, Madison and Cameron), Youth Researchers (including co-author Drew) and Councils (see below for more details), addiction and adolescent medicine clinicians (including co-authors Eva, Martha and Sarah) and social science researchers (including co-authors Rossio and Emily). Study team members’ positionalities are characterized by diverse intersections of age, race, class, gender and sexuality. In particular, Drew would like to identify that he is a member of the Squamish First Nation, the traditional and unceded lands on which this study was conducted, and brings significant lived experience in relation to the analysis presented herein. The Care Pathways Study team meets regularly to guide all aspects of research, including the development of semi-structured interview guides and lines of ethnographic inquiry, analysis of findings and knowledge mobilization.

The present analysis draws on semi-structured, in-depth qualitative interviews conducted between October 2019 and May 2021 with 37 adolescents and those who were very recently adolescents aged 14 to 20 who planned to access, were accessing or had very recently accessed MHSU treatment at “Cypress Place” (a pseudonym). Cypress Place is an abstinence-focused live-in treatment center for adolescents aged 14 to 18 located in Vancouver, BC, although youth who attend the center may come from different parts of the province. It can accommodate up to eight adolescents of all genders and offers 10 weeks of integrated MHSU care through one-on-one and group counselling, psychosocial education, life skills training and medications for opioid use disorder. While most youth participants were interviewed during their stays at Cypress Place, a few individuals were interviewed at a youth-dedicated withdrawal management (detoxification) facility prior to attending Cypress Place, and two participants who had recently attended Cypress Place were interviewed at a local youth emergency shelter and our community research office located in downtown Vancouver, respectively.

Recruitment across these sites was facilitated by Danya’s ongoing Care Pathways Study partnerships with several programs that support youth who use substances in the context of unstable housing and homelessness across Metro Vancouver. Staff members at Cypress Place described our broader Care Pathways Study to adolescents attending the program. Youth who were interested in participating then had the opportunity to meet with Madison in a private room in Cypress Place or via Zoom, as required by COVID-19 institutional directives. At this time, Madison would describe the study in greater detail and, if the young person was interested in participating, obtain written informed consent and conduct an interview. Some individuals participated in multiple interviews during their stay at Cypress Place, and a few participated in follow-up interviews after leaving Cypress Place. Using the same recruitment protocols described above, Madison also recruited and interviewed youth at other programs, including the youth-dedicated withdrawal management facility and local youth emergency shelter mentioned above. Youth recruited through these programs were included in the present analysis if they were planning to attend or had recently attended Cypress Place.

Interviews were conducted by Madison in private rooms in the aforementioned locales or via Zoom. The interviews were facilitated by a semi-structured interview guide developed in collaboration with the Care Pathways Study team, including the Youth Health Advisory Council (YHAC), a group of approximately 10 young people with lived experience of intensive substance use, significant mental health challenges and unstable housing and homelessness, including a majority of individuals who have accessed live-in MHSU treatment in BC. The interview guide consisted of eight topic areas, including questions about youth’s past and ongoing substance use, housing and homelessness experiences and substance use treatment and care “trajectories” (see below) across time and place. We also asked youth questions about how various social relationships (e.g., with friends, romantic partners, family members, providers and staff) shaped substance use and trajectories. Through these conversations, we elicited narratives on experiences within live-in treatment as well as other systems of care and supervision, including government care and the criminal legal system, and gained insight into the evolving and overlapping individual, social and structural contexts that shaped youth’s everyday lived experiences. Interviews lasted approximately 60 min but ranged from half an hour to as long as 2 h. The interviews were audio-recorded, transcribed verbatim by contracted transcriptionists and checked for accuracy by members of the Care Pathways Study team. Data were de-identified. All participant names appearing below are pseudonyms. Ethical approval for this study was granted by the University of British Columbia’s Behavioural Research Ethics Board (H18-03529). All participants were given a $40 CAD honorarium to compensate them for their time and expertise.

2.2. Data analysis

In this paper, we present a sub-analysis of data collected as part of the broader Care Pathways Study, focused on adolescent and very recently adolescent study participants between the ages of 14 and 20 who planned to access, were accessing or had recently accessed (i.e., in the past year) Cypress Place at the time of our first conversations with them. These participants’ interview transcripts were uploaded to NVivo 12 software. Like the broader Care Pathways Study, this sub-analysis was guided by critical phenomenology, which foregrounds how participants describe and theorize their own lived experiences across time and place with close attention to social structural contexts (Guenther, 2013; Salamon, 2018). While phenomenology has historically been a highly inductive approach, critical phenomenology requires careful consideration of dynamics of power and political economy and the social structural contexts that shape everyday lived experiences (Salamon, 2018). Thus, we used both inductive and deductive strategies to extrapolate key themes.

Data were initially coded using a preliminary codebook comprised of 23 largely descriptive themes such as “treatment trajectories,” “housing and homelessness” and “social relationships.” We deductively applied the idea of “treatment trajectories” to the data during this first round of coding in order to identify moments when youth engaged, disengaged and reengaged with live-in treatment programs over time, shaped by a complex interplay of individual (e.g., mental health crises), social (e.g., family and other relationships) and structural (e.g., entrenched and intergenerational poverty) factors. This code was also used to capture the shifting experiential and experimental dimensions of youth’s MHSU treatment engagement across time and place, as they attempted to figure out what forms of care did and did not work for them (Raikhel & Garriott, 2013).

A second layer of more refined coding conducted by Monique included additional, more analytic codes that reflected participants’ theorizations of their own lived experiences, including “self-making” and “social world-making.” The codes “self-making” and “social world-making” emerged inductively from the data. Particularly within our large “treatment trajectories” code, we identified many instances when adolescents talked about making, un-making and re-making themselves and who they spent time with before, during and after live-in treatment. These codes were also informed deductively by previous writing on the self and the social as always unfinished and in the process of becoming, inflected by power and political economy but not completely determined by these (Biehl et al., 2007; Biehl & Locke, 2017). They were triangulated with Danya’s long term and ongoing fieldwork with this population, during the course of which she has documented numerous instances of these phenomena through fieldnotes. We brought an early analysis of data contained within these two codes to the YHAC to determine whether a sub-analysis focused on these codes was warranted, and to help identify the most poignant participant stories related to each code. This collaborative process shaped the findings we present below.

3. FINDINGS

A total of 46 interviews conducted with 37 youth were analysed. All of these youth had a history of engaging in intensive daily substance use, including the use of illicitly manufactured fentanyl (which has largely displaced heroin in our setting), crystal methamphetamine (meth) and crack cocaine. They had also all experienced some form of residential instability and periods of street-based homelessness, including sleeping outside and in shelters and “couch-surfing” at the homes of friends and family. The median age of participants was 17 years and most self-identified as white (n = 24, approximately 65 %) and as women (n = 23, approximately 62 %) (see Table 1 for an overview of participant demographics).

Table 1.

Participant demographic information

Self-identified Demographics	Number (Percentage)
Age (range, median)	14–20, 17
Ethnicity
White	24 (65 %)
Indigenous	8 (22 %)
Asian and South American	1 (3 %)
Preferred not to say	4 (11 %)
Gender
Women (inclusive of transgender women)	23 (62 %)
Men (inclusive of transgender men)	12 (32 %)
Non-binary	2 (5 %)

Interviews with youth revealed that many were engaged in transformative projects of self and social world-making before and while attending Cypress Place. Crucially, the changes that they were enacting through engagement with live-in treatment extended far beyond abstinence from substance use, to encompass significant shifts in who they were and who they surrounded themselves with. Our findings are organized around these two themes of self and social-world making, although we emphasize that these projects are often interrelated and unfold simultaneously. We use narrative excerpts from a small number of study participants in an effort to more richly illustrate these youth’s stories and important themes we identified across our coded dataset and Danya’s fieldnotes.

3.1. Self-making

A number of adolescents detailed the significant and often solitary efforts they made toward self-transformation prior to entering live-in treatment, while they were still contending with the everyday emergencies of addiction, entrenched poverty and unstable housing and homelessness. In thinking through the decision to enter a longer-term, live-in MHSU treatment program in the present, adolescents looked to both the lived realities of their immediate pasts and those realities that were likely to characterize their futures, after treatment was complete. Prior to entering live-in treatment, they described a need to take certain essential preparations “on their own,” as youth repeatedly put it to us during interviews and across Danya’s fieldwork (phrases that appear throughout the findings in quotations that are not part of longer quotes were similarly derived). Youth told us that these preparatory efforts – often undertaken outside formal systems of care and in relative isolation from those who were still using substances – felt necessary in order to build the kinds of physical, psychological, emotional and spiritual “strength” necessary to make meaningful changes while in treatment and then maintain these changes (“make them stick”) after it had ended.

For example, in February 2020, Celeste, a 14-year-old white woman, had been cycling between street-based homelessness, living with her mom and couch surfing at a friend’s place for the previous two years. During this period, Celeste was using a variety of substances intensively, including fentanyl, various stimulants (e.g., meth, crack cocaine), benzodiazepines and alcohol. She had been admitted to hospital multiple times related to overdoses and alcohol poisoning, and it was these repeated health crises that led her to begin considering entering a live-in program as a way to make big changes in her life. However, prior to entering Cypress Place, Celeste emphasized how important it was to begin the process of working on herself independently and in relative isolation from friends who were still using drugs through a “self” or “home detox” and the pain that accompanied this process. Reflecting on this while at the live-in facility, Celeste explained:

I detoxed myself. I didn’t go to detox, because if I went to detox, they’d be handing me everything I need [to begin recovering and healing]. Realizing how much pain it was [to self-detox] makes me not want to relapse again. Now if I ever think about relapsing, my brain’s like: are you kidding? Like, remember what we just did? Remember all that pain you just went through?

In addition to independence and relative isolation, for Celeste pain was a critical component of the “atmosphere of recovery” (Duff, 2015) she attempted to create prior to live-in treatment. Pain seemed to serve as a powerful catalyst for self-transformation in the present and opened up possibilities for healing and recovery over the longer term (Patton & Best, 2022). Youth reflected on the significance of the physical pain they endured as a result of self-detox, as well as the emotional pain that accompanied the ending of romantic relationships and friendships anchored in shared substance use, in preparing them for live-in treatment. Adolescents hoped that once treatment was over and they were “back out in the real world,” memories of pain might act as a deterrent from returns to substance use and relationships deemed harmful to their goals of reducing or eliminating their use, even as they re-entered home or youth shelter and safe house environments that continued to be characterized by active substance use.

Adolescents often worried about the discordance between a live-in treatment environment like Cypress Place and the realities of their everyday lives outside of this setting. However, once they began the program many found it to be a powerful space of reprieve from the everyday emergencies of their lives. For a number of adolescents, caregiving responsibilities for family members, friends and romantic partners with their own mental health and substance use challenges were lifted once they were at Cypress Place, allowing them to “just focus on themselves” and the changes that they wanted to make. There, youth described an ability to “be selfish” and “be self-centered,” in some cases for the first time in their young lives. While adolescents used this language of “selfishness,” it is important to note that desired self-transformations were often explicitly connected to desired social transformations; adolescents often worked on themselves so that they could help others. As Celeste reflected:

When I first came [to Cypress Place], I was like, ‘Oh, that’s so selfish. Like, I can only think about myself?’ [But then I thought] how are you going to help other people if you can’t focus on yourself first, you know what I mean? I can’t be, like, 75 pounds, addicted to drugs, telling people to get sober.

At Cypress Place, a different kind of atmosphere of recovery could emerge. Youth were no longer undertaking healing “on their own”; instead, they reflected on the role of providers in encouraging them to “focus on themselves,” “put themselves first” and “eat, sleep and breathe” their individual recovery goals through participation in daily activities such as one-on-one and group counselling, meals, chores, hobbies, games and sports. The rigid structure of a daily schedule and program rules was initially jarring for most of the youth we spoke with and could be a point of contention across their stays. However, youth also underscored how getting used to this structure with the constant support of caring but firm providers is what eventually allowed the “chaos” of the outside world to retreat so that they could focus on the changes they wanted to make. Some providers at Cypress Place shared with youth that they also had personal experiences with mental health and substance use challenges, which allowed a number of adolescents to feel better understood and supported through the transition from “life on the outside” to “life inside” live-in treatment.

Importantly, many of the youth in this study wanted to re-make themselves in ways that would allow them to transcend ascribed and adopted labels such as “addict” and “homeless.” Working on this at Cypress Place, they looked to both their pasts and the future. Some emphasized the desire for a “fresh start” and the opportunity to become someone new. Others described a desire to return to who they “used to be” before intensive substance use. Mickey, an 18-year-old Indigenous young man, first arrived at Cypress Place in December 2019. Before this, he had spent four months in a court-ordered live-in treatment program in northern BC as an alternative to entering youth custody, and then lived independently via government support for a brief period before returning to substance use and being evicted from his housing to enter street-based homelessness. Across this trajectory, Mickey described experiencing a high level of social disconnection and isolation. When we spoke with him during his first month at Cypress Place, he was feeling optimistic about how a period of relative stability and consistent provider support at the facility might allow him to work on himself and get back to who he used to be, before substance use:

I have to think of who I was in the past, to create myself again as a whole person, not just a drug addict. [At Cypress Place] I’ve started thinking about what I can become if I stop using.

In live-in treatment, with the everyday emergencies of “real life” temporarily lifted and the constant support of providers, youth were sometimes better able to muster the physical, psychological, emotional and spiritual strength they felt they needed to make big changes in their lives. They were able to actively “work on themselves,” namely in the areas of addressing trauma and other mental health challenges and diagnoses, regulating emotions, and reconnecting with interests, hobbies and leisure activities. However, even within Cypress Place, desired forms of self-transformation could remain intimidating and ultimately impossible undertakings. For example, Ella, a 17-year-old white woman, had spent over a year cycling through various live-in treatment facilities at the time of our first conversation with her. The initial decision to try treatment was not her own; rather, it was made for her by her foster parents and social worker. However, she framed her most recent entry into Cypress Place as “her choice,” made with the support of a provider at another service. She entered Cypress Place with a desire to “learn more about herself” and connect with other adolescents with shared lived experiences. Once there, however, she found the work of treatment more difficult than anticipated. As Ella explained in August 2020:

It’s really hard to work on emotions [in live-in treatment] because it’s something that you have to keep on working on [inside and outside of the facility], and I haven’t been doing that [even in Cypress Place], if I’m honest with you. Because it just takes a lot of energy, and a lot of motivation and I don’t have energy or motivation to do any of those things. That’s one of the main reasons why I left [live-in treatment previously] and I started using. Because I was like, I don’t have the time for that. Like, I don’t have the time to, like, focus on everything.

Ella saw treatment as a place where she needed to work hard on managing, processing and regulating her emotions as a means of self-transformation. For Ella, the prospect of doing this substantial work on herself was overwhelming and produced a sense of exhaustion that seemed to be highly familiar in the context of a long institutional trajectory that periodically “landed her” in live-in treatment. In addition to experiencing an accumulation of exhaustion, adolescents who regularly cycled in and out of live-in programs also seemed to be particularly aware of what they were returning to after their time at Cypress Place was complete. In the face of all of this, it could simply seem too difficult to make the big changes they were reaching for (“I don’t have the energy or motivation to do any of those things”).

3.2. Social world-making

Like the weight of the social structural contexts they were contending with, social worlds encompassing existing relationships with friends, romantic partners and family also followed adolescents into live-in treatment. Just as they expressed desires to un-make and re-make themselves in particular ways, prior to and during treatment adolescents also described desires to un-make and re-make their social worlds. As noted above, often these projects were interconnected. In order to work on themselves, adolescents described reconfiguring their social worlds, bolstering certain relationships and ending others, including those that had previously anchored their emotional and material worlds. The extent to which adolescents were able to un-make and re-make their social worlds to align with desired futures varied; for example, they might express a significant amount of power in relation to ending and pursuing friendships, respectively, while cutting off contact with or working on relationships with family could feel much more uncertain and fraught, particularly when adolescents knew that they would be continuing to rely on these individuals for places to live and sleep and other kinds of material support once treatment was over. For many, processes of un-making and re-making social worlds and selves were closely tied to broader aspirations, including finding stable housing, finishing school and pursuing meaningful employment.

For example, once at Cypress Place, Mickey (introduced above) began reflecting on his friendships prior to entering treatment, and how he had to terminate some of these in order for him to make desired changes in his life. Deleting some friends off Facebook became an important component of a plan he developed with a provider at Cypress Place:

I had five people on my Facebook – they were kind of, like, fall back people if I wanted to relapse. I took Facebook off my phone before I came [to Cypress Place], and then I finally went on my Facebook yesterday, and I saw, like, five people that I could go see if I wanted to use again, and I took them off my Facebook without a hesitation. Before I came [to Cypress Place], I didn’t want to take them off Facebook, but now I have the mind state of: they can’t be on my friends list.

Mickey’s focus was on ending certain relationships; for Celeste (also introduced above), the desire was to bolster her existing relationship with her mom as a crucial component of re-making herself and her social world:

My mom’s the only one there – all of [my friends] have left now because I got sober. [My mom] was the only one trying to keep me safe [before I came to Cypress Place]. Everyone else who were my friends were the ones that were actually helping me mess my life up.

For Yasmin, a 17-year-old white woman who we met in February 2020, it was her best friend who was well-positioned to anchor her to a more “normalish” social world and sense of self. At the time of our first conversation with her, Yasmin was staying at a short-term withdrawal management facility and preparing to start treatment at Cypress Place the following week. She described feeling unsupported by her family for much of her life but had maintained a close friendship that was a source of support and inspiration, even as she grappled with self-doubt:

My best friend, she thinks I’m really strong. She says I’m the strongest person she’s ever met. So when I hear stuff like that, I know that I have to keep trying [with attending treatment], because if I don’t, and I just, like, give up, then, like, things would be so different. Like, my best friend, she’s way better than me. She doesn’t use drugs, she goes to school every day, like a regular school, and has a normalish life. And she tells me that I’m her role model, and thinks so high of me, when I see myself as so low.

Upon entry into Cypress Place, adolescents were also immersed in and began to actively create new social worlds characterized by novel possibilities and complexities. They expressed excitement as well as trepidation about living together with other youth who had similar lived experiences, as well as the opportunity to connect consistently with providers. Peers and staff at Cypress Place became sources of inspiration and frustration for adolescents as they envisioned alternative futures. For Winona, a 16-year-old Indigenous woman, her first experience with group living was at Cypress Place. Prior to entering the program, she had been cycling in and out of government foster care placements and periods of time staying at a family home where numerous individuals were struggling with their own mental health and substance use issues. Winona was excited by the possibilities for social connection, regular help and stability that live-in treatment offered. She had been at Cypress Place for about eight weeks when we interviewed her in August 2020, recalling:

[Living at Cypress Place] is pretty exciting, and also scary. I was nervous [when I first arrived]. I had never lived with teenagers. I was hearing about group therapy, and I was like, ooooooh, there’s a whole bunch of other teenagers and we’re going to hang out. I thought, we’re going to be sober, and there’s going to be people to help me here.

Some adolescents described positive experiences with the new social worlds of live-in treatment; they connected with other youth and providers in ways that supported desired self and social transformations. Adolescents generally spoke highly of their interactions with providers at Cypress Place, highlighting that staff seemed to genuinely want to help them, including by welcoming them back if they left treatment prematurely and working to resolve conflicts – whether with peers or staff – fairly (see below). More important than focusing on the problems that arose, however, was providers’ focus on helping youth to (re)connect with sources of enjoyment, pleasure and fun, such as various hobbies, games and sports. It was these kinds of activities that could most powerfully support the kinds of self and social transformations that adolescents desired (e.g., “I have to think of who I was in the past”).

Youth expressed hopes that relationships with both peers and staff and the kinds of self and social transformations they enacted at Cypress Place would transcend their time there to positively shape recovery and healing over the longer term. Particularly as they entered the second half of their stays at Cypress Place, however, many worried about what would happen when the program ended. Jessi, a 17-year-old white woman, noted that while residents received lots of different kinds of valuable education and life skills training at Cypress Place, including numerous modules focused on “aftercare planning,” there was not enough focus on navigating program “endings,” nor did she feel fully equipped to use the different tools she had gained in treatment (e.g., dealing with difficult emotions) back out in the “real world”:

Aftercare plan is – there’s 14 modules, but there’s none about endings. None. That is something that needs to be a thing, like, everywhere. There needs to be things in programs, and treatment, about endings. Because there’s nothing here, nothing at all. It’s literally just like module, module, module, ACP [aftercare plan], commencement, you’re gone. You can call, and they can call you, but that’s it. It’s like, I don’t learn about using the tools outside. I learn about using them here.

As Jessi noted, former residents of Cypress Place are able to connect with providers for phone support; they are also offered a limited number of aftercare therapy sessions. However, Avery, a 20-year-old white transgender man, particularly emphasized the value of alumni nights held at the facility, which allowed former residents like himself to return to the facility to connect with adolescents currently in treatment. This ability to re-enter the social world of Cypress Place and maintain a thread of connection between “inside” and “outside” perhaps helped to mediate the sense of ending that Jessi talked about and was “good for recovery,” as Avery explained during an interview at our community research office:

[Cypress Place] is awesome. I still actually go there and do the alumni nights. You get to talk about your experience to the youth [who are still in treatment there]. And, um, I think it’s good for my recovery, actually. To just be up there and, um, you know, talking about my experience, and they’re asking me all these questions, and, I don’t know – it kind of puts my life back into perspective, and it’s really helpful for me and for them.

Madison: What kind of questions do people ask you?

Um, like, if they’re leaving in a couple days, they’ll ask for, like, some strategies around that. Or if they’re wanting to use [substances] right now, like, what’s something I would say to them to, like, help get them through that. Or, um, you know, just what my experience was like at Cypress Place or what I didn’t like at Cypress Place and how I dealt with that.

As Avery alluded to (i.e., “What I didn’t like at Cypress Place”), a number of adolescents emphasized frustrations with other youth at Cypress Place as needs and desires clashed. Despite rules that prohibited cliques and romantic relationships meant to encourage youth to “just focus on themselves,” the social worlds of treatment were often inflected by past and present interpersonal dramas. These dramas were themselves often powerfully shaped by the everyday emergencies of adolescents’ former lives – for example, conflicts relating to burgeoning romantic relationships that constitute for these adolescents crucial sources of emotional, material and moral support when they are out on the streets. Even more mundane ongoing dramas (e.g., “It’s like being in school”) could undermine one’s ability to work on oneself. Ella (introduced above) explained:

Other youth being, like, friends, crushes, stuff like that – it’s just so distracting. And, like, how people think of you, it’s almost, like, being in school. Sometimes it’s hard being here because of all the drama that goes around. I’m trying not to get involved in all that and trying to still focus on myself and keep on remembering why I’m here. But when one person’s having a bad day, I get the bad energy too, and I start feeling like crap, so then I start acting like crap. I don’t really like acting like a crappy person, but when that energy’s around me it’s like – it just comes out.

Marcella, a 17-year-old white woman who first entered Cypress Place at the age of 15, also discussed the challenging social world of live-in treatment. At the time of our conversation with her at a local youth shelter in December 2020, Marcella detailed the numerous government foster care placements, emergency department admissions and stays in other live-in treatment and recovery facilities located across BC that she had endured across her life. She was preparing to try treatment at Cypress Place again, hoping that this time her outcome would be different. She had left the program prematurely the first time she tried it:

A lot of the people that were in [Cypress Place] were a lot older than me, and I was really easily influenced. I was naive, because I was 15 years old. I ran away with a girl that was older than me in the centre, and we ran away to [a neighborhood with an active open drug scene], and that’s when I did down [opioids] for the first time. So, unfortunately, going to treatment kind of opened up that door for me.

Ella and Marcella’s experiences point to how the atmospheres of live-in treatment are always multiple and shifting. Compared to “life outside,” Cypress Place could be a space of relative calm and consistency where youth could finally work on themselves and their relationships with provider and peer support. It could also be a space dominated by interpersonal “dramas” and encounters that could foreclose possibilities for healing and recovery. In some cases, messy dynamics between peers seemed to completely eclipse those with providers. In other cases, these messy dynamics involved providers, who stepped in to enforce rules around socializing (e.g., prohibiting physical affection between youth who become romantically involved while at Cypress Place). Particularly when the enforcement of rules was seen to be “unfair” or “unrealistic” for adolescents given their current interpersonal capacities, skills and lived realities, these interactions could contribute to feelings of being misunderstood, surveilled and punished, and could lead adolescents to leave treatment early.

However, challenging interpersonal dynamics while in treatment could also serve as a catalyst for desired self-reflection and transformation. Kalia, a 17-year old white woman who we spoke to in February 2020, entered Cypress Place after a period of significant housing instability and disconnection from family and friends. She was hopeful that live-in treatment would give her the space to learn about herself and how to better relate to others. She reflected:

The main thing in a treatment program is literally not even the work [i.e., participating in programming]. It’s putting yourself in a house with a bunch of other people who have the same problems as you and then just connecting with everybody, and learning stuff about yourself. Seeing some people react with anger, and storm away, or scream and yell and punch things. You’re like, whoa. Did I really do that? Did I look like that? It’s like a mirror, almost.

4. DISCUSSION

The overdose crisis is having devastating impacts on the lives of youth in BC and, in particular, those navigating contexts of social structural marginalization. While the provincial government has committed to expanding bed-based, live-in treatment services for adolescents (British Columbia Ministry of Mental Health and Addictions, 2024), there is a paucity of qualitative research on how adolescents understand and experience these programs, including how healing and recovery actually unfold in these settings (or not). A better understanding of these dynamics is urgently needed to design programs that are acceptable to and effective for equity-deserving adolescents. Importantly, the youth who participated in this study did not only view live-in treatment as a means of reducing or eliminating their substance use. Rather, it was a setting in which the everyday emergencies of their lives could be temporarily suspended, allowing them to make significant changes to who they were and who they surrounded themselves with, within and beyond the program (see also Bryant et al., 2025). How do we support adolescents in undertaking these highly-valued self and social world-making projects, within live-in treatment settings and beyond? How do we re-imagine treatment, healing and recovery programming and philosophies so that they better align with youth’s needs, priorities and desires (Treloar & Holt, 2006)? Answering these questions is more urgent than ever in the context of an ongoing North American overdose crisis, climbing deaths and continued efforts to scale up treatment beds in our setting and beyond.

Our findings simultaneously reveal youth’s ambitions regarding the big changes they wanted to make before and during live-in treatment, and how the weight of the social structural pressures that followed them into treatment could cause these oftentimes fragile ambitions to collapse (e.g., “I don’t have the energy or motivation to do any of those things,” “Sometimes it’s hard being here because of all the drama that goes around”). In doing so, we build on previous work highlighting the limitations of treatment approaches that focus too heavily on ameliorating a diseased state of “addiction” rather than on meaningfully addressing the social structural contexts that shape substance use, and promoting broader physical, psychological, emotional and spiritual wellness or “strength,” as some youth put it (Bryant et al., 2022; Fast, 2024; Hansen & Metzl, 2019; Treloar & Holt, 2006). As others have argued (Bryant et al., 2025), treatment programing is often premised on the assumption that increasing knowledge and skills directly related to substance use and recovery (e.g., being better able to navigate triggering people, places and things) will allow youth to reduce or eliminate their substance use. Yet, particularly for adolescents who are returning to circumstances of social structural marginalization once live-in treatment is over, substance use often serves a number of vital functions and relationships with the potential for significant harm nevertheless often continue to be at the center of their emotional, material and moral worlds (Bryant et al., 2022; Canêdo et al., 2022; Fast, 2024; Fast et al., 2023; Lee et al., 2025). For these individuals in particular, this kind of education may be significantly misaligned with their lived realities of both substance use and healing once they are back outside in the “real world.”

Instead, and consistent with an emerging body of work, our study emphasizes the value of treatment, recovery and healing pedagogies focused on broader “living skills,” and in particular those related to self and social world-(un/re)making (Bryant et al., 2022, Bryant et al., 2025; Hallam et al., 2018; Laudet & White, 2010). Live-in treatment settings like Cypress Place can engender new possibilities for adolescent becoming beyond framings that center the amelioration of illness and disability. At live-in treatment, the adolescents in this study longed to work on themselves as individuals, friends, children and romantic partners, to list only a few possibilities. To do this, they need knowledge and skills for daily life defined beyond substance use, such learning how to build, nurture or sever relationships with family, friends and romantic partners; how to care daily for the body, mind and spirit; how to keep busy through leisure, work, school or other training; and how to create everyday routines. From this perspective, recovery and healing can be understood as an accumulation or “assemblage” of seemingly mundane everyday self and social world-making practices, habits, commitments, relations and technologies (Duff, 2015), rather than as an acquisition of greater substance use-related knowledge and skills leading to abstinence. At Cypress Place, healing and recovery capacities like “social connectedness” and “positive sense of self” came into being when adolescents added and deleted friends on social media, reconnected with a hobby that used to bring them joy and practiced daily routines around meals and chores. More aligned with Indigenous knowledges and a desire-based lens, a focus on what it means to live well – both as an individual and as part of a collectivity – moves us away from a focus solely on the damage caused by mental health and substance use challenges and how to “fix” these, and instead emphasizes relationality, self-determination and healing from substance use as vital, interconnected processes (Bryant et al., 2022, 2025; Treloar & Holt, 2006; Tuck, 2009).

While our study clearly demonstrates how self and social world-making are interconnected, it also points to the importance of supporting adolescents with each of these as distinct enterprises, and potentially prioritizing one over the other depending on youth’s needs and desires (Bryant et al., 2025). For a number of those in this study, self-making – whether undertaken before or during live-in treatment – was understood and experienced as a highly independent and oftentimes isolated endeavour. Youth described working on re-making themselves before entering live-in treatment by undertaking painful detoxification from substances or break-ups with friends and romantic partners “on their own.” Once at Cypress Place, they framed working on themselves as “selfish,” even as they did so in order to help others. While these adolescents framed their experiences in highly individualized terms – they were “on their own” and “selfish” – it is critical to note that their independence and isolation were powerfully shaped by social structural marginalization. Our previous research underscores that, in the context of entrenched and intergenerational poverty, social exclusion and systems of care and supervision that do not “take them anywhere” desirable, youth in our setting often conclude that they are better off managing their mental health and substance use on their own (Fast, 2024). Moreover, adolescents are able to “be selfish” at Cypress Place only because some of the everyday emergencies of their lives, including demands to care for others with their own mental health and substance use issues, have been temporarily lifted.

The findings of this study further alert us to the relative isolation that youth experiencing social structural marginalization often face as they attempt to work on healing and recovery with very limited resources and social connections outside of networks of friends, family and romantic partners who are themselves struggling with mental health and substance use challenges. Taking into account these lived realities, providers at live-in treatment programs can work with adolescents on self-making skills that can be undertaken more independently, such as learning how to keep busy through leisure activities, hobbies and basic routines. For some adolescents, this focus on self-making as a highly independent and somewhat isolated endeavour may remain the focus for the entirety of their stay in treatment. Alternatively, the focus of a stay may be on simply alleviating some of the everyday emergencies of poverty, residential instability, institutionalization and caregiving responsibilities. By prioritizing these material aspects of healing, we create an atmosphere wherein “safety [can settle] into the body,” (Duff, 2015, p. 69) perhaps eventually opening up the possibility of other kinds of work on selves and social worlds.

For the majority of youth in our study, however, live-in treatment was a place from which to work on relational aspects of healing, often inextricably linked with transformations of selfhood. Our study builds on previous work to underscore the impacts of adolescents’ existing social worlds on live-in treatment engagement, experiences and outcomes (Green et al., 2012; Lee et al., 2025; Wagner et al., 2017; Williams & Chang, 2000; Yao et al., 2012). The social worlds that they bring with them into programs can both support and impede pursuits of healing and recovery. Across their treatment trajectories, youth need more help with navigating the highly complicated relationships in their lives, and yet this need is not often adequately addressed in our setting and others (Green et al., 2012; Lee et al., 2025). Live-in treatment is a space where youth can receive more consistent support with this (e.g., aided by a provider, Mickey contemplated deleting and then deleted several friends off of Facebook with relative ease). However, the abrupt “ending” of this support is deeply problematic, as Jessi pointed out. Youth need more support with practicing the relationship and other skills they learn while at live-in treatment once they are “back out in the real world.” Day treatment and recovery programs may be particularly helpful in this regard (Duffy & Baldwin, 2013; Russell et al., 2021).

New senses of self and social worlds formed at live-in treatment can engender atmospheres of safety, belonging and becoming well, opening up possibilities for recovery and healing beyond these places, particularly if friendships with peers and relationships with staff can be maintained (Duff, 2015). This study builds on previous work to demonstrate that friendly yet firm relationships with providers are often experienced as highly supportive and even “lifesaving” among adolescents while attending live-in programs (Fast, 2024; Green et al., 2012). Adolescents in our study and elsewhere have emphasized that it is the authenticity and reciprocity (i.e., being able to get to know each other) of these relationships that often matters most, even more than the specific help being offered (Green et al., 2012). When relationships with peers and providers are abruptly terminated upon exiting live-in programs, adolescents can feel as though a newly formed, highly valued social world has been shattered, sometimes with devastating consequences. Alternatively, finding ways to build greater continuity into these relationships (e.g., Cypress Place’s regular Alumni nights) may powerfully support youth as they continue to re-make themselves and their social worlds after live-in programs have ended. Peer navigators who form meaningful relationships with adolescents while at live-in treatment and then continue these relationships afterwards could be helpful (Stanojlović & Davidson, 2021; Tracy & Wallace, 2016). Providers and workers, including peer workers, can constitute an important bridge between adolescents, the social worlds of live-in treatment, and the social worlds they are attempting to cultivate after treatment, such as networks of peers with similar recovery and healing goals attached to particular drop-in and community centers. This kind of post live-in treatment bridging focused on social world-making is essential.

Alternatively, and consistent with previous work (Currie, 2003; Neale et al., 2018; Riehman et al., 2003), some of the participants in our study described not always enjoying interacting with their peers and feeling distracted by familiar interpersonal drama while attending live-in treatment, underscoring that the atmospheres of live-in treatment are always multiple and can shift quickly. While in some cases these scenarios lead adolescents to leave treatment prematurely, Kalia also alluded to how such negative experiences can actually open up opportunities for youth to work on re-making themselves in desired ways. This diversity of youth’s experiences underscores the significance of individualized and nimble approaches to treatment pre-planning (i.e., conversations with and support provided before entering live-in programs), in-program planning and after-program planning with youth. During treatment, providers can explicitly discuss with adolescents how they want to work on themselves (or not), including in relation to others who may alternately be sources of inspiration and frustration (or not). Our findings emphasize that pre-planning and after-program planning are often of equal or even greater importance to adolescents; many of those in our study were engaged in this kind of work independently, undertaking particular – and sometimes purposively painful – actions prior to entering live-in treatment with a view toward the kinds of self and social transformations that were necessary for continued success after programs were over. By co-creating individualized and evolving pre-program, in-program, and after-program plans, care providers can better ensure that plans align with adolescents’ lived realities (e.g., returning to settings of entrenched poverty and active substance use) and needs (e.g., the need to work on a relationship with a parent who is navigating their own mental health and substance use issues).

Finally, while this study was focused on live-in treatment engagement, it also underscores the importance of providing adolescents with a continuum of substance use care, including harm reduction services. Having access to the full spectrum of harm reduction services ensures that adolescents have access to what they need to keep themselves safer and alive as they make decisions about whether to pursue live-in treatment and other forms of healing and recovery (Canêdo et al., 2022). Indeed, it has been argued that harm reduction philosophies are often the most inclusive because they are not premised on an expectation of abstinence but can also make room for the goal of abstinence when individuals’ needs, desires and priorities shift (Treloar & Holt, 2006). Adolescents such as those involved in this study continue to lack access to harm reduction, and in particular, youth-dedicated overdose prevention sites and spaces (Canêdo et al., 2022; Marchand et al., 2023).

In conclusion, this study provides important insights into how transformative projects of self and social world-making can be better supported across youth’s treatment trajectories. Namely, providers and programs can work to bridge the kinds of self and social transformations achieved during live-in treatment with what comes next by providing opportunities for youth to stay connected and prioritizing the development of skills for living well – as individuals and as part of collectivities – that open up possibilities for recovery and healing over the longer term.