Self-Change in Facilitating Empowerment: Applying a Narrative Perspective to Adolescents with a Mental Health Diagnosis

Youth empowerment is a critical research area because it has implications for reducing adolescent mental health stigma while improving their life trajectory, engagement in treatment and meaningful opportunities, and increasing self-esteem. The present inquiry is derived from a larger study and strives to enhance knowledge of youth empowerment by using Frank’s rhetoric of self-change—a form of narrative analysis—to understand events and reactive experiences of illness as occasions for changing the self. This narrative approach facilitated the development of a youth empowerment process because of its ability to identify similar characteristics across the three cases of youths included in this analysis. Actively participating in age/developmentally appropriate activities put the adolescents on a trajectory towards attaining milestones in a timely manner coinciding with the developmental timeline of peers without mental health issues. Additional research is needed to understand how the identified factors promote empowerment among adolescents with mental health issues. Narrative research has implications for clinical social work because it illuminates strengths that can be beneficial in promoting positive interventions.

associated with mental health concerns (Morton & Montgomery, 2013;Wong, Zimmerman, & Parker, 2010). Despite the ubiquity of stigma, some adolescents with mental health issues manage to escape being stigmatized or are somehow able to mitigate or deflect stigma. Examining factors that promote well-being among non-stigmatized youth could raise awareness and improve health outcomes by making services more amenable to the needs and concerns of stigmatized adolescents. Adolescents who mitigate mental health stigma may become more resilient in dealing with future challenges and have higher educational success (Aspy et al., 2004;Hinshaw, 2009).
Recent research has taken a shift by devoting more scholarship to identifying factors that promote empowerment among youth (Wong et al., 2010). Empowerment consists of psychological components involving self-esteem or self-efficacy and a social action component involving aspects of engagement in meaningful opportunities and control over one's life situation (Corrigan, 2005;Rusch, Lieb, Bohus, & Corrigan, 2006). A systematic review of evidence regarding impacts of youth empowerment programs on adolescents concluded that there is a paucity of research examining empowerment programs outside of education contexts (Morton & Montgomery, 2013). Additionally, a gap still exists within the literature that pinpoints successful outcomes associated with those adolescents who feel empowered (Ozer & Schotland, 2011). Since research is lacking on adolescent empowerment, qualitative research in the form of narrative analysis is a starting point to explore knowledge and identify core constructs of the phenomenon. Frank's (1993) approach of describing illness experiences in narrative form has been used to increase understanding of individuals' course of illness with various physical, mental, terminal and/or chronic conditions (Charmaz, 1994;Crossley, 2000;Taylor, 1996;Wilkinson, 2000). The illness narrative is an individual reaction to being diagnosed and experiencing the illness. Typically, a new sense of self replaces the old self. Frank believes that the events and experiences associated with illness are occasions and pivotal moments for a transformation in one's overall sense of self. Frank (1993) describes four types of self-change rhetoric: 1) "The self as what I always have been"-continuity between former and present self; 2) "A self who I might become"-a radically changed self; 3) "Cumulative epiphanies"-whatever the individual has become has been formed in and through illness; and 4) "Reluctant Phoenixes"-those who indicate minimal to no change in self -perception due to illness. The narrative rhetoric of "A self who I might become" was selected for this analysis because adolescents are at the passage to adulthood. The decisions they make, their methods of coping with stressors and illness, and potential for change and growth may all dictate some of the most formidable years of their lives and a self who they might become. The other three types of rhetoric from Frank's (1993) narrative model were not used for this analysis because "The self as what I always have been"-continuity between former and present self, and "Cumulative epiphanies"-whatever the individual has become has been formed in and through illness--have a temporal component of living with their illness for a longer period of time than the adolescents in the present case studies. The rhetoric on "Reluctant Phoenixes"-who indicate minimal to no change in self from illness, was also not a good fit for the adolescent case studies featured in this analysis. Frank (1993) lists guidelines/criteria by which narratives qualify as the rhetoric of "A self who I might become." For instance, the element of "wholly new radically changed self" implies that the narrator has become a different person because of the illness experience. The narrator may speak of how his/her perspectives on the world have changed as a result of living with the illness. Second, "the former view of disease from without is inadequate" implies that the narrator can only perceive the world through the lens of living with an illness. He/she can no longer see the world as his/her old self without having a disease. Third, "new relation of self to others" implies that the illness experience allows the narrator to connect with others on a different level. Some individuals may have cut off or limited connection with others because they were overwhelmed with the onset of their illness: however, incorporating their illness into their new sense of self allows him/her to move the focus from the self to external stimuli.

Background of the Narrative Approach
In sum, the rhetoric describes the self as emerging from the discovery of illness as wholly new. For instance, a woman newly diagnosed with type II diabetes must reconstruct a new self to continue living. She will have to account for the ways treating her diabetes may impact her daily routines, eating habits, medical care, as well as self and public perceptions. As the woman integrates the element or experiences with her diagnosis into her transformed sense of self, she may discover a vision of the person she might become. She may decide to become an advocate for individuals who also have diabetes, or she may not accept her diagnosis and decide to isolate herself from others. Her life trajectory will be forever changed because of the type II diabetes. She has a new perspective that impacts her relation of self to others. In this case, the woman's view of herself without having the type II diabetes will no longer be a valid perspective because the element of the type II diabetes alters her life trajectory and must be accounted for in her present perspective because of its impact on all facets of her life.
Frank's narrative approach (1993) has not been applied to the study of youth empowerment but has the potential to provide insight into that phenomenon because of its prior application to identifying novel aspects among individuals with other illnesses. Frank's narrative approach has been helpful in prior analyses of illness experiences to identify overlapping and common attributes. For instance, Thornhill, Clare, and May (2004) applied Frank's approach to adults recovering from psychosis to construct meaning of the illness experience into one of three genres -escape, enlightenment, or endurance. Findings revealed unique aspects of the illness experience not previously found in other types of qualitative and quantitative analyses, while also confirming some previous findings. McMahon, Murray, Sanderson, and Daiches (2012) applied Frank's narrative approach to a study identifying how individuals make sense of living with fibromyalgia and incorporating the illness into their sense of self and identity. This study also found overlapping content in the narratives by recognizing five phases that embodied the illness experience from beginning to present. Researchers who apply Frank's method commonly incorporate findings to address challenges participants experienced with their illness and factors that facilitate treatment and rehabilitation.
This study applied the Frank (1993) method of illness experience as narrative in an effort to increase understanding of the empowerment experiences of youth with a mental health diagnosis. This inquiry aims to identify and connect the critical events that can alter the course of adolescents' trajectory to become empowered and even avoid mental illnessrelated stigma. The analysis applied Frank's mechanism of narrative analysis/rhetoric of self-change in presenting the perspective of three adolescents who felt empowered by psychiatric treatment.

Original Study Purpose, Practicalities and Context
The original research project was supported by the National Institute of Mental Health (KMH068584A1) and was based at an urban, private college in Ohio. A university hospital Institutional Review Board for Human Investigation reviewed and approved the research protocol. The data from this project were collected from 2006-2008 and originally intended to assess the subjective experience of adolescents using psychotropic treatment (n=40). Adolescent mental health issues were in the beginning stages of being treated with adult dosages of medication, and little was known about how they made sense of the experience. We were curious to know the adolescent perspective of engaging in such treatment. How did the medication impact their social relationships? Were they embarrassed to tell their peers about the use of medications? Did the medication alter their sense of self and how they related to others? Did they reap the intended benefits of taking medication? Did the consequences of taking the medication lead to more or less meaningful opportunities? Collectively, the concerns we wanted to address with the original study align well with the elements of Frank's narrative rhetoric of "A self who I might become." While coding the qualitative portion of the full dataset, patterns emerged of adolescent concerns with feeling "different," and developmental concerns related to attainment of milestones, peer perceptions of mental health treatment, and how they navigated the process of utilizing services. Medication treatment facilitated a quicker maturation process among many of the adolescents. There were also varying levels of stigma among the sample: some reported no stigma while others reported some or high levels of stigma. Within the last decade, a large body of literature examined the experience of stigma among adolescents (Hinshaw, 2009;Kranke et al., 2010;Moses, 2010). However, the perspective of adolescents who have had a positive experience of mental health treatment and who have managed to avoid the cycle of stigma has not emerged in the literature.
In the original study (Kranke, Floersch, Kranke, & Munson, 2011), an adolescent selfstigma process emerged from the data based on developmentally appropriate and sociocultural responses to mental health perceptions and utilization of mental health services. Adolescents who self-stigmatized internalized shame related to their mental health diagnoses and were reluctant to engage in treatment because of how it made them feel "different." The adolescent self-stigma model contained components associated with three critical events from the original adult self-stigma model (Corrigan & Watson, 2002): 1) exposure to perceptions of mental health diagnoses; 2) emotional reaction to mental health diagnoses and the need for treatment; 3) behavioral responses that impact engagement in treatment and meaningful opportunities. The adolescent self-stigma process proposes that adolescents with a mental health diagnosis "stereotype" by applying the mental health label to his/her self; "differentiate" by viewing oneself as inferior to others who are well; and "protects" his/her social capital by hiding the use of medication and the need for treatment to preserve social opportunities in the future and beyond. We were interested in learning from the perspective of adolescents with a mental health diagnosis who managed to avoid self-stigma.
Research Design. A mixed method cross-sectional study of adolescents was conducted. The original study was exploratory in nature and focused on youth's subjective experience with taking psychotropic medications.
Sampling. Recruitment procedures included communication through face-to-face discussions with professional staff as well as flyers and posters targeting patients of an outpatient clinic within the Division of Child & Adolescent Psychiatry at a university hospital, community mental health outpatient settings, and an alternative high school for adolescents with emotional and behavioral problems. We maintained confidentiality of study participants by conducting the interviews in private and secure locations.
Inclusion/Exclusion criteria. Adolescents, age 12 to 17 years, meeting DSM-IV criteria (because the data were collected before 2013) for a psychiatric illness and who were prescribed a psychotropic medication were eligible for inclusion. Since the study focused on adolescents on medication, individuals were excluded from participation when parents reported that the adolescent had not taken psychiatric medication at least once in the past 30 days. In addition to the data produced by a semi-structured instrument, we collected general information regarding adolescent and family demographics and psychiatric/medication treatment history. The K-SADS-PL (Kiddie Schedule for Affective Disorders and Schizophrenia) was administered as a research diagnostic instrument to categorize participant diagnosis (Kaufman et al., 1997).
Interview design. Digital audio recordings of interviews were transcribed and then analyzed using Atlas.ti (Muhr, 1993), a software program designed for qualitative data management and coding. The research team collected qualitative data using the TeenSEMI, a semi-structured interview, to query adolescents about their perceptions of having a psychiatric diagnosis and of taking psychotropic medication. The TeenSEMI was adapted from an adult instrument to obtain narrative data from adults with schizophrenia (Jenkins, 1997) by modifying the 150 questions to be more specific to age-related concerns of adolescents. Interviews lasted between 90-120 minutes and were recorded as audio wave files. Typically, the use of semi-structured interviews may not yield the kinds of rich descriptions necessary for a narrative analysis. However, the semi-structured interview protocol contained questions that pertained to thoughts and feelings associated with taking psychotropic medication and we did not use guided language that may have directed the adolescent participants to describe negative or stigmatizing experiences (Floersch et al., 2009). In addition, interviewers used probing questions to gather additional data when the participants described the course of their treatment experience, with an emphasis on changes in self/peer/family perceptions, as well as feelings about self in a temporal sequence. Interviewers tried to follow the lead of the interviewee as much as possible (see Table 1 for a list of sample interview questions).

Methods
The present inquiry emerged as a result of the development of the self-stigma model from the initial study (Kranke et al., 2011). Twenty-seven adolescent narratives were considered "complete and consideration of alternative perspectives (i.e., before and after receiving diagnosis), and display of sufficient evidence" (Yin, 2009, p. 185-188) in describing attributes/components of the self-stigma process. However, three of the adolescent narratives did not endorse any stigma themes commonly found among stigmatized individuals; namely secrecy, shame, and/or limiting interaction (Kranke et al., 2010;Link, Cullen, Struening, Shrout, & Dohrenwend, 1989). These three cases were considered unique from the other 24 narratives, thus were explored in greater depth in this inquiry. Focusing on adolescents in the study who experienced the positive effect of mental health treatment could delineate factors that might facilitate a more positive trajectory for others. This perspective of examining "what worked" was timely and innovative as the social work field moves in the direction of appreciative inquiry for changing social systems: "1) a focus on changing how people think instead of what people do; and 2) a focus on supporting self-organizing change processes that flow from new ideas" (Bushe & Kassam, 2005, p. 161).
The sample for this present inquiry (n=3) consisted of one adolescent who identified as a 17-year-old White female with Major Depressive Disorder, a 14-year-old White female with Bipolar Disorder, and a 12-year-old African American male with Attention Deficit Hyperactivity Disorder. It is worth noting that the three adolescent cases in this study were not re-contacted after the initial study was completed.
The author's analysis of the three cases for this current inquiry began with identifying themes. "Thematic analysis is a method for systematically identifying, organizing and offering insight into patterns of meaning (themes) across a data set" (Braun, Clarke, & Terry, 2014, p. 95). The cases needed to contain similar elements of empowerment as those conceptualized in the extant literature, namely: supportive family and friends, school success, positive outlook/attitude, and involvement in treatment. These themes appeared to work together in helping participants to have a positive perception of their lives. The author conducted the narrative analysis by reading each interview in its entirety several times before assigning codes. The identified quotations pertaining to empowerment were coded in Atlas.ti (Muhr, 1993). The same quotes were then copied and pasted from different parts of the interview, using the hyperlink tool in Atlas.ti, to connect the codes and quotations of each empowerment story into a word document.

Results
The narrative rhetoric matching "A self who I might become" (Frank, 1993) was hypothesized as the most suitable prior to analysis, and was confirmed as the most suitable rhetoric after data analysis per the attributes that embody this particular rhetoric. Two of the adolescent narratives contained all three of the attributes, and one adolescent narrative contained two of the attributes (See Table 2). The excerpts included in each narrative consisted of the turning point related to the adolescent receiving a diagnosis, which was the impetus for self-change, and youth self-reflection throughout the course of their illness (See Table 3).  Components of adolescent empowerment process A: (17-yearold White female with MDD) "The first time I applied it (label) to me was probably after reading a big thick book. Like The Ultimate Guide to Teenagers or something. It was going off like oh your child might be depressed if it's this and this and this. So I checked out the list of stuff. I'm like, ha, well that's interesting. I may be depressed. Okay, let's go tell mom, so I did." Turning point/illness diagnosis Diminish negativity of label and/or stereotypes.
"If it (medication) didn't really work, then I would not have improved. I would say that just an example that, look at me, cause my mom sees a big difference in how I used to be so horribly grouchy and now I'm a lot happier." Radically changed self and new relation of self to others Normalize need to address emotions.
"I used to spend all the time in my room, and now I'm upstairs with my family more. I spend more time with them, don't fight as much." Radically changed self and new relation of self to others Attribute positive changes and well-being to psychiatric treatment. "My home teacher mentioned that he wasn't sure what to tell people about the improvement in mood, cause he didn't know if I wanted to keep it a secret, which I don't. It's like go ahead and tell them. I would much rather be on the medication and be happy and be happy with myself and happy about life than a grouchy little demon hiding in my room." Her radically changed and new self is more of an extrovert and has enhanced confidence.
Using narrative to change perceptions of mental health treatment among peers.
B: (14-yearold white female with bipolar disorder) "At first I was like, no, I can't be Bipolar, That's just not me. I don't want to be it. And then, when I started actually seeing what was really going on, I'm just like, oh my God, I can't believe I said that I wasn't this and now I am. My mom sat down and explained (diagnosis) to me, and we went and got some books from the library and we pretty much just read up on them."

Turning point
Supportive parent helps adolescent to diminish any negativity associated with label and need for treatment.
"I was getting brainwashed by one of my friends, by 2010, almost everybody in the world's going to be on medicine. And then I started to see the truth, and it's just all like, I feel like why would they put me on it if it really didn't work." Old view of disease from without no longer adequate Normalize illness and need for treatment by comparing the adolescent to millions of others in the world who use meds. "I started taking medicine and I would see {myself as} a total different person when I took the medicine. I mean I wasn't so angry and I was able to have a good time and laugh and just have fun. I know for a fact that if I didn't take my medicine that I'd be more aggravated and get in more fights. . . When I was off the medicine, I'd always get in trouble for aggression. Right now I'm loving life. I have great friends. I mean there's nothing better that I can ask for right now. I've made honor roll, moved from making straight F's to straight A's." Wholly new self and relation of self to others Radically changed self Attribute health and well-being to psychiatric treatment. C: (12-yearold African American male with ADHD) "When I went to the doctor I was okay cause he told me what it was (diagnosis) and I wasn't scared no more."

Turning point of diagnosis
Diminish negativity of label after taking proactive approach to consult with doctor. "She (mother) said (treatment) was for me paying attention and doing my work and focusing and stuff. It'll help me. I won't get distracted so easily."

Radically changed self
Mother diminished any potential fears of treatment by saying it would improve child's well-being. "I got a lot of friends and mostly everybody that I knew had it, and they wasn't ashamed of it, so I started to not be ashamed of it either. They just said, so what? and they just looked at it like a cold, not like a disease."

New relation of self to others
Normalize the illness as any other disease and as a shared experience.
"My friends want me to take it (medication), because they want me to go on field trips with them." Old view of disease from without no longer adequate "I want to take my medicine cause I realize it'll help me now. . . because of the medicine, now I got a full scholarship to go to camp." New relation of self to others Radically changed self Attribute improvements to the psychiatric treatment.

Constructing the Empowerment Process
Identifying the most suitable rhetoric among Frank's (1993) four different types allowed for recognition of the underlying components of each case that led to feelings of empowerment. It was necessary to start the analysis among individual cases, and then assimilate these personal experiences to create a unifying general view (Herzlich & Pierret, 1987).
Each narrative contained a turning point when the adolescents were given a mental health diagnosis. Indeed, their lives would be forever changed. Supportive environments facilitated the adolescents to diminish negativity associated with the label. As the 17-yearold adolescent with MDD described, "Ha, well that's interesting, I may be depressed." The positive exposure to perceptions of mental health diagnoses may have motivated these adolescents to further investigate and learn about their illness. Therefore, the two older adolescents searched for more information in books and all three consulted with individuals they trusted as available sources to help normalize the need for treatment, identify their mental health diagnoses, and to realize they were not the only ones dealing with mental health diagnoses. As the 14-year-old female with bipolar describes, "By 2010, almost everybody in the world's going to be on medicine." Their engagement in mental health treatment had an overt effect on their anger, depression, and/or outlook on life. As the male adolescent with ADHD says, "I want to take my medicine cause I realize it'll help me now." Shifting the focus from their illness allowed the adolescents to engage in similar age-appropriate activities as their peers. They attributed their growth to the medication and treatment (see Figure 1).

Constant Comparative Method
After the analysis of each narrative was completed and assigned the rhetoric "A self who I might become," two independent researchers with expertise in the areas of qualitative research and youth mental health conducted a constant comparative check (Boeije, 2002). They independently examined the three cases and were instructed to assign their own rhetoric and write up their own rationale. Then the researchers independently examined the appropriateness of the author's rationale of the assigned rhetoric type. No discrepancies occurred in the constant comparative check of the rhetoric aspect. Afterwards, the independent researchers determined the appropriateness of the components of the empowerment process based on commonality. When there were differences, we met Attribute as a group to expand particular components, so they were inclusive of characteristics that were meaningful and gave a more holistic description of the process (Boeije, 2002).

Discussion
The use of a narrative approach provided depth and increased understanding of empowerment among adolescents with a mental health diagnosis. Findings illustrated that supportive family and friends, a positive outlook/attitude, and involvement in treatment were critical aspects to generating an environment that facilitated feelings of empowerment. The narrative approach espoused by Frank (1993) was conducive to identifying a sequence of events that precipitated change and revealed a radically changed self. Ultimately, the illness experience allowed each adolescent to take on more ageappropriate activities and mature perspectives.
Findings are consistent with several outcomes associated with adolescent empowerment. The analysis showed that actively participating in age/developmentally appropriate activities, such as forming friendships and connecting with peers who allow the adolescents to be themselves, put the adolescents on a trajectory towards attaining milestones in a timely manner that coincides with the development timeline among peers without mental health diagnoses (Leavey, 2005). Involvement in these activities also promoted a sense of normality-which was counterintuitive to stigma -and helped these adolescents avoid feelings of differentness.
An additional nuance beyond willingly disclosing their need for treatment, was that the adolescents openly attributed their improved well-being to treatment. The treatment positively impacted the adolescents' well-being, social relationships, and academic success. Peers and family members were drawn to interact with these adolescents. Attributing improvement to treatment likely restructured peers' and family members' destigmatized perceptions about the need for treatment.

Limitations
First, the data were collected a decade ago. Therefore, discussion around mental health stigma may in fact be very different at the present time. For instance, organizations such as the Born This Way Foundation, L.e.t.s. (Let's erase the stigma) and Active Minds have come to the forefront in encouraging youth with mental illness to have pride in possessing characteristics associated with feelings of differentness. Consequently, youth with mental illness are exposed to more positive messages in the media about living with mental illness. Future research should assess how these organizations impact adolescent feelings of stigma.
Although the Frank method (1993) is designed to organize narratives in such a way that demonstrates self-change, researchers must be mindful that the adolescents' circumstances and backgrounds were not homogenous. Two of the three adolescents identified as White. The one African American participant did not describe his race and/or culture as influencing his perspective. In contrast, the constructed self-stigma model among the other 24 participants contained aspects of race and culture as influencing attitudes toward treatment (Kranke et al., 2011).
Using a narrative approach to understand the impact of illness and treatments can raise awareness of practical dimensions that must be taken into account when trying to empower adolescent clients. However, one must be cautious about these findings because the sample size (n=3) and qualitative nature limit generalizability. In addition, this study assessed only those adolescents who voluntarily engaged in treatment. Adolescents who do not engage in treatment may have very different experiences.

Implications for Social Work Practice
Narrative analysis has implications for clinical social work. The practice of documenting responses during a client interview, note-taking, and assessing client responses are part of a process to make an informed treatment recommendation. Using narrative methods can inform social workers of the value or application of qualitative research integrated with their own practice skills. In doing so, they may realize a holistic and novel approach of understanding their clients' background.
The Frank narrative approach (1993) illustrates the particular areas of strength within each of the three cases. For instance, the narrative approach highlighted how the 14-yearold female with bipolar disorder used books and other educational resources to enhance her understanding of her illness. She had a knack for reading and a propensity for learning. This behavior foreshadowed how applying herself academically would also reap benefits in school, as she made the Honor Roll. As a clinician, encouraging the adolescent in this case to apply herself academically improved her well-being but also opened the door for a self who she might become by maximizing her potential with opportunities in education. Ultimately, the three case studies illustrated the power of self-reflection for improving difficult times in these adolescents' lives while also increasing the likelihood of being able to succeed in overcoming future obstacles.
Adolescents have many competing forces that impact their ability to withstand stigma. Although the three cases presented here did have similar attributes, clinicians must be mindful to approach each adolescent client individually. Clinicians can help adolescents embrace a positive, empowering perspective of their illness by taking a strengths-based approach. Encouraging adolescents to build on positive aspects of their lives could improve their outlook and increase the prospects of a self who they might become to sustain a satisfying life.