Addressing the complexity of recovery beyond reductionist, diagnosis‑driven care: a realist evaluation of a family-centered, narrative-based child and adolescent psychiatry practice

Abstract

Background: Conventional approaches following the biomedical model focused narrowly on symptom reduction often overlook critical social and familial factors influencing youth mental health, perpetuating stigma and long‑term dependence on care. As an example of a unique and innovative family-centered, narrative based approach in child and adolescent psychiatry in the Netherlands, this study examines “Het Huis”, to understand what aspects of its systemic, recovery‑oriented approach support meaningful recovery, for whom, and under what conditions. Methods: We conducted a theory‑driven realist evaluation. An initial program theory was developed from a document review and stakeholder interviews. It was then iteratively tested through observations of 27 therapy sessions, 24 practitioner reflection reports, and 41 semi‑structured interviews with children and their parents collected between September 2023 and August 2024. Data were coded thematically using Context-Mechanism-Outcome configurations and refined via peer deliberation and member checks. Results: The findings confirmed and extended the initial program theory, revealing a dynamic “recovery loop” sustained by five core mechanisms, including enhanced tolerance for therapeutic friction, collective understanding of distress, integration of behaviors into a shared family narrative, structured peer engagement, and reduction of anxiety and negative cognitions. These mechanisms fostered (1) an effectively collaborating therapeutic and family system, (2) a co‑constructed multidimensional narrative of distress, and (3) strengthened individual and familial recovery capital, which in turn reinforced the therapeutic alliance and sustained the loop. Conclusions: This study provides empirical support for a systemic, narrative‑based model of child and adolescent psychiatry that moves beyond reductionist, diagnosis‑driven care. By illustrating potential key mechanisms and contextual enablers, the refined program theory offers a blueprint for designing and implementing family‑focused, recovery‑oriented services in diverse settings. Clinical trial number: Not applicable.