Social Therapy Improves Engagement in Early Psychosis Treatment

Considerable evidence shows that involvement in early intervention programs improves social and functional outcomes in patients who have experienced first-episode psychosis. However, many individuals will continue to experience social problems even after a successful intervention.

A study published in the January 2018 issue of Lancet Psychiatry suggests that combining early psychosis intervention with social recovery therapy may help to further improve patient outcomes, particularly in individuals who lack the motivation or ability to engage in existing psychosocial interventions.

Lead study author David Fowler, M.Sc., of the University of Sussex noted that while most early intervention programs include components to improve social functioning, these programs often center on helping patients to secure jobs or develop job skills. Fowler and some colleagues in the United Kingdom wanted to see if they could develop an intervention that encouraged patients to get involved in additional structured activities, including sports, volunteer work, child care, and leisure activities with friends.

The social recovery therapy is delivered in three stages. First, the therapist and patient establish a good working relationship and assess the patient’s hopes and expectations. Next, the patient and therapist work together to identify ways to initiate meaningful new activities, while addressing the patient’s negative beliefs and fears about doing activities. Finally, as the patient participates in new activities, the therapist provides positive feedback to the patient, so that he or she develops a sense of ownership in the activity.

“The key is focusing on motivation and hope, while managing ongoing symptoms as the person engages in an activity,” Fowler told Psychiatric News.

Fowler and colleagues recruited patients aged 16 to 35 with non-affective psychosis who had participated in early intervention services for 12 to 30 months and had low levels of structured activity (defined as ≤30 hours a week on the Time Use Survey). Structured activities assessed by the Time Use Survey include work, education, voluntary work, leisure, sports, housework or chores, and child care.

The researchers assigned 155 patients to either early intervention services alone or in combination with social recovery therapy for nine months.

After nine months, participants who received both early psychosis intervention and social recovery therapy engaged in eight more hours of structured activities each week compared with those receiving only early intervention (an average of 26 activity hours/week compared with 18 activity hours/week). The gains with social recovery therapy included 5.8 additional hours of what the authors termed “constructive economic activities” (job, school, child child care, and/or housework) with the remaining 2+ hours reflecting additional recreational activities.

“The effect size after treatment is clearly of clinical benefit, especially given the extreme social withdrawal present at baseline,” Fowler and colleagues wrote. They noted that the participants engaged in about only 12 hours of activities a week at baseline. “The size of the effect is twice that identified by consensus groups of users and clinicians as the minimum clinically important difference and represents an amount of activity equivalent to a working day.”

As a secondary outcome, Fowler and colleagues assessed whether these improvements persisted six months after the social recovery program ended (15 months postbaseline). These results were difficult to interpret since many participants, especially from the control group, dropped out after the first nine months. The available data pointed to no difference between the groups, although computer modeling that estimated the missing data suggested that social recovery therapy may confer sustained improvements.

In a commentary accompanying the article, Merete Nordentoft, Ph.D., and colleagues at the University of Copenhagen commended the study design and the findings.

“Fowler and colleagues have succeeded in recruiting a large group of the most vulnerable and disabled patients with first-episode psychosis,” Nordentoft and colleagues wrote. Still, they added more research is needed to fully understand the benefits of social recovery therapy.

“An intervention targeted at increasing the weekly level of structured activity might engage the participants receiving the intervention better with services, therefor making them more likely to report back on the activity,” they wrote. “A future reproduction of the study should carefully consider whether this potential source of bias should be addressed.”

Fowler noted, “This was a very disabled group with ongoing symptoms of psychosis (paranoia and voices), depression, and social anxiety, as well as severe withdrawal.” He said, “In such cases outreach alone and indeed even formal individual placement have less evidence of efficacy.”

This study was funded by a grant from the National Institute for Health Research. ■

“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” can be accessed here. The accompanying commentary, “Social Functioning in Patients With First-Episode Psychosis,” is available here.