Early intervention for psychosis: social recovery

Social, or functional, recovery is a key component of recovery for people experiencing psychosis. It is an especially important consideration for early intervention, as it can significantly affect a person’s future.

‘Social recovery’ from an episode of psychosis, also called functional recovery, refers to a person achieving meaningful outcomes in terms of work, education and social activity. Personal social recovery is perhaps best defined as time spent by someone in activities that they value, that add meaning and purpose to their life.

Ensuring social recovery should be the heart of early intervention for psychosis. Without early intervention, the social outcomes following a first episode of psychosis can be poor. In services with long inpatient admissions and a lack of community-based multidisciplinary interventions, only around 15 per cent of people make a social recovery within two years of their first acute episode of psychosis. This means that for many, the key personal developmental milestones of young adulthood are missed. The loss of social, vocational and educational opportunities can alter their life course.

By contrast, when inpatient acute admissions are avoided (or minimised whenever possible) and optimal community-based care packages of pharmacological, psychological and social interventions are provided, up to 60 per cent of young people with first episode psychosis make a social recovery at two years. This is a massive change for young people, which has health economic gains for society aswell as for the individual in terms of personal gains in obtaining work and educational achievements over both the medium and long term..

In a clinical setting, social recovery intervention done well, is a gentle review of what is meaningful for an individual in terms of activities, and helping them get to where they want to go.

Early intervention for social recovery should start as early as possible to prevent loss of key social and interpersonal roles as a result of an acute episode. So what works? The key is thinking about how the whole early intervention system can promote social recovery. It is not a single, special intervention.

It starts with maintaining a consistent message of hope for recovery – to the individual, their family, and those all around them – even when things feel difficult in the first psychotic episode. Messages of realistic hope are important to overcome stigma. This may be particularly important in some cultural contexts, especially where shame is associated with psychosis, which can lead people to withdraw from services.

Deliberate actions also need to be taken to ensure a young person’s key personal contacts, friends and family are not lost as a result of the acute episode, and that existing educational, work and social opportunities remain open.  If lost, such opportunities are very difficult to rebuild anew. Small interventions done with the young person and family, such as calling their workplace or education institution and helping negotiate a part -time return, can help. Similarly, support with phone calls to friends or contacts can help.

Deliberate discussion is sometimes needed to work around fears held by the young person or their family, who can be understandably protective. It is about finding a reasonable balance between maintaining hope, encouraging activity and respecting the young person’s need to rest and strategically withdraw from their usual activities for a time. They may fear relapse, and be sensitive to emotional issues such as anxiety and low-level paranoia, which can be triggered on returning to avoided activities. However, it is important to prevent persistent patterns of avoidance occurring after an episode of psychosis, as these not only lead to a loss of social opportunities but can also, in turn, lead to vicious cycles of additional stress and vulnerability.

Preventing loss of key social and interpersonal roles is crucial in the first phase of psychosis, and continues to be important throughout, but it does become progressively more difficult at later stages. Even with the best service provided, a large minority do not make rapid social recoveries. Often these cases have had longstanding social difficulties before the first acute episode, sometimes with long durations of untreated psychosis.

Sadly, often people most in need of social intervention are the least likely to engage or seek help. In busy services, the focus naturally is on acute care, and people who are withdrawn and avoidant might be discharged when a more detailed assessment might show residual positive and negative symptoms associated with social disability. These cases are not easy to help, and can require a gentle but persistent, assertive approach to build a relationship and re-engage them in treatment and activity.

Our Supereden3 study showed this is possible, and the message is to continue offering social intervention across the course of psychosis, and where possible, specifically target those who have persistent social disability problems as a second phase of early intervention.

Encouragingly, we have shown in our recent Prodigy study that young people with severe and complex mental health problems and social disability at an earlier stage, who have not yet had an acute psychotic episode but including those who have subthreshold psychotic symptoms, can make very good social recoveries if offered hope, a detailed assessment and guidance to take up the therapy and vocational services that are routinely available in UK services.

All participants in the trial, which included those with extreme social withdrawal who were hardly ever leaving the house to engage with any meaningful activity, made clinically significant gains in both symptoms and social recovery, when such structured routine help was offered by a combination of general practitioners, mental health workers and voluntary sector providers. Additional, highly specialised therapy that focused on social recovery was not needed.

This likely shows the benefit of all providers routinely offering comprehensive help and guidance about social recovery, as early as possible, and before the onset of psychosis (where such cases can be identified). Both the Prodigy and Supereden trials show there is real hope for meaningful change and social gains even with the most complex presentations, and highly complex interventions aren’t always needed if the message is right.

What is available and possible in services obviously varies, depending on resourcing, the availability of different interventions – and the social, economic and cultural context. It was well established some time ago by Richard Warner that the social course of psychosis is associated with the economic climate. The availability of work opportunities in wider society affects the opportunities open to those with the additional burden of recovering from psychosis.

The availability of community youth services and access to education opportunities is also key, and such factors are influenced by health inequalities and economic austerity.

The way psychosis is regarded culturally is also a factor that can significantly change what opportunities are made available to someone socially after an episode. However, some cultures, especially those with familial links to flexible working patterns, can work in someone’s favour. For example, if a return to work part time can be negotiated with a relative.

What works in clinical early intervention services is creativity and flexibility when using the resources that are available, and keeping realistic hope in mind. What also works is recruiting community and family stakeholders wherever they are willing to offer help in a constructive way. By working this way to build a social recovery ‘web’ within whatever is available in local communities, even a single case worker in a less resourced setting can make important changes for the young people in their care.

Professor David Fowler is one of the original pioneers of cognitive behaviour therapy and early intervention in psychosis services.  He currently leads a programme of research developing and evaluating psychological interventions and services for young people with severe mental illness and social disability.  His work has informed the development of novel youth services in the UK and globally. Fowler also continues to contribute to development and evaluation of psychological interventions in psychosis which has completed a series of large national multicentre trials. Prof Fowler leads the youth mental health theme of the NIHR Kent Surrey and Sussex Applied Research Collaboration (KSS ARC) which links researchers with NHS and social service providers across the region and NIHR mental health researchers nationally.

References 

Fowler D, Hodgekins J, French P, Marshall M, Freemantle N, McCrone P, Everard L, Lavis A, Jones PB, Amos T, Singh S, Sharma V, Birchwood M. Social recovery therapy in combination with early intervention services for enhancement of social recovery in patients with first-episode psychosis (SUPEREDEN3): a single-blind, randomised controlled trial.  Lancet Psychiatry. 2018 Jan;5(1):41-50. doi: 10.1016/S2215-0366(17)30476-5. Epub 2017 Dec 11. PMID: 29242000 Free PMC article. Clinical Trial.

Fowler D, Hodgekins J, Howells L, Millward M, Ivins A, Taylor G, Hackmann C, Hill K, Bishop N, Macmillan I. Can targeted early intervention improve functional recovery in psychosis? A historical control evaluation of the effectiveness of different models of early intervention service provision in Norfolk 1998-2007.  Early Interv Psychiatry. 2009 Nov;3(4):282-8. doi: 10.1111/j.1751-7893.2009.00146.x. PMID: 22642731

Hodgekins J, French P, Birchwood M, Mugford M, Christopher R, Marshall M, Everard L, Lester H, Jones P, Amos T, Singh S, Sharma V, Morrison AP, Fowler D. Comparing time use in individuals at different stages of psychosis and a non-clinical comparison group. Schizophr Res. 2015 Feb;161(2-3):188-93. doi: 10.1016/j.schres.2014.12.011. Epub 2014 Dec 23. PMID: 25541138

Lower R, Wilson J, Medin E, Corlett E, Turner R, Wheeler K, Fowler D. Evaluating an early intervention in psychosis service for ‘high-risk’ adolescents: symptomatic and social recovery outcomes. Early Interv Psychiatry. 2015 Jun;9(3):260-7. doi: 10.1111/eip.12139. Epub 2014 Apr 11. PMID: 24725258

Killackey E, Allott K, Jackson HJ, Scutella R, Tseng YP, Borland J, Proffitt TM, Hunt S, Kay-Lambkin F, Chinnery G, Baksheev G, Alvarez-Jimenez M, McGorry PD, Cotton SM. Individual placement and support for vocational recovery in first-episode psychosis: randomised controlled trial. Br J Psychiatry. 2019 Feb;214(2):76-82. doi: 10.1192/bjp.2018.191. Epub 2018 Sep 25.
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Warner, R., Recovery from Schizophrenia:Psychiatry and the Political Economy. Third edition. Brunner Routledge. Hove and New York. 2005.

Declaration of Interests: None

Acknowledgements:

This project was made possible thanks to a sponsorship from H/Lundbeck A/S. The opinions expressed in these materials do not necessarily reflect those of H.Lundbeck.