social recovery in early psychosis: assessment and intervention dr jo hodgekins
TRANSCRIPT
Social Recovery in Early Psychosis: Assessment and Intervention
Dr Jo Hodgekins
Acknowledgements
Social disability as a primary target?
Delayed social recovery: the clinical picture
Very low levels of activity Amotivation Depression and loss of hope Drug abuse Social anxiety, withdrawal, avoidance Residual “schizotypal” symptoms: anomalous
experiences, voices, paranoia (Hodgekins et al, 2012)
Possible Selves
Hoped for “Go back to work”“Have a girlfriend”“Be well, not be ill”“Meet Mrs Right, have a family and settle down” “Lose weight and be healthier”“Be free of anxiety, be able to manage it successfully”
Feared “Not manage to do anything and end up on benefits”“Homeless and living in a night shelter”“Not get a job”“Be on medication forever”“To go into hospital again and have another breakdown”
Research Questions
1. How can we assess delayed social recovery?
2. When do social functioning difficulties occur?
3. What is the prevalence of delayed social recovery in early psychosis services?
4. What are the predictors of delayed social recovery?
5. How do we intervene?
Assessing functional recovery following psychosis: a problem
Traditional measures focus on the deficit syndrome– Young people with first episode psychosis have
different difficulties
Or focus specifically on work and education– Whilst work and education are important outcomes,
they aren’t the only markers of recovery
“Structured activity” is broader and more inclusive
Non-clinical norms
Assessing social recovery using the Time Use Survey
Large study of time use in UK (Office for National Statistics)
Structured interview Norms provided for different age groups
– Average amount of time (hrs per week) spent in different activities (work, education, hobbies, leisure, sport…)
Compare time use in early psychosis to the general population
Why Time Use?
“Measuring time use is an important way of measuring participation in a range of activities which may have significant economic, societal, and personal benefits” (International Association for Time Use Research)
Time spent in structured activity has previously been shown to be associated with increased mental wellbeing (Fletcher et al, 2003)
Engaging in activity gives meaning to people’s lives
Psychometrics: Validity
Structured Activity
Quality of Life 0.43**
SOFAS 0.31**
Time Budget 0.53**
PANSS Positive -0.03
PANSS Negative -0.21
PANSS General -0.02
*p <0.05, **p <0.01
When do social functioning difficulties occur?
Compare weekly hours in structured activity across samples of individuals at different stages of psychosis with an age-matched non-clinical sample:– ONS non-clinical sample (N = 6388)– EDIE-II At-risk mental state (N = 288)– EDEN First episode psychosis (N = 1027)– ISREP Delayed social recovery (N = 77)
Hodgekins et al. (submitted to Schizophrenia Bulletin)
Results
0
10
20
30
40
50
60
70
Non-Clinical At-risk MentalState (EDIE-II)
First EpisodePsychosis
(EDEN)
DelayedRecovery(ISREP)
Hou
rs p
er
week in
S
tru
ctu
red
Acti
vit
y
Hodgekins et al. (submitted to Schizophrenia Bulletin)
(ONS)
30 hours per week as a cut-off
Use of ROC curves to determine best cut-off to distinguish clinical and non-clinical groups
Hodgekins et al. (submitted)
Conclusions
Individuals with psychosis spend significantly less hours per week engaged in structured activity than an age-matched non-clinical comparison group
This reduction in activity begins before the onset of psychosis and is clearly present in the at-risk mental state stage
Time use discriminates between clinical and non-clinical groups and can be used to assess social disability
Hodgekins et al. (submitted to Schizophrenia Research)
What is the prevalence of social disability in first episode psychosis
National EDEN study Longitudinal cohort study of individuals with
first-episode psychosis receiving early intervention from services across the UK between 2006-2010 (N = 1027) – Birmingham, Norwich, Cambridge, Cornwall,
Lancashire Time Use assessed at baseline, 6 months
and 12 months
Hodgekins et al. (in prep)
Whole group (N = 1027)
Hodgekins et al. (in prep)
Baseline 6 months 12 months
Hou
rs p
er w
eek
in
Str
uctu
red
Act
ivity
Individual trajectories
Hodgekins et al. (in prep)
Baseline 6 months 12 months
Hou
rs p
er w
eek
in
Str
uctu
red
Act
ivity
Trajectories of social recovery
Recovery is heterogeneous (large SDs) Identifying a sub-group of individuals who
may be at risk of poor social recovery would be useful in treatment planning
Use Latent Class Growth Analysis (LGCA) to identify smaller homogeneous subgroups (aka “latent classes”) in larger sample (Jung & Wickrama, 2008)
Hodgekins et al. (in prep)
Subgroups
Hodgekins et al. (in prep)
0
10
20
30
40
50
60
70
80
90
100
Baseline 6 months 12 months
Low Stable
Moderate/IncreasingHigh/Decreasing
Ho
urs
per
wee
k in
S
tru
ctu
red
Act
ivit
y
66%
27%
7%
Conclusions
A large proportion of individuals remain socially disabled following 12 months of EI service provision
Requires specific targeting?
Hodgekins et al. (in prep)
What predicts social recovery problems?
Predictors of poor functional outcome:– Male gender– Younger age of onset– Poor premorbid adjustment in adolescence– Long DUP– Ethnic minority status– Baseline negative symptoms
May be able to identify those at risk and intervene early? But how?
Hodgekins et al. (in prep)
The Social Recovery CBT approach (Fowler, French, Hodgekins et al, 2012)
Formulates the barriers to recovery in terms of avoidance
Intervenes with the system to overcome stuck social position and adverse social circumstances
Fosters hope and motivation and positive sense identity and view of self and future (self as hero)
Promotes specific meaningful individualised activity goals linked to case management and IPS strategies
Works “in vivo” promoting change in activity Encourages behavioural tests to establish positive
sense of self and personal agency while managing social anxiety and paranoia
SRCBT: Specific cognitive behavioural strategies
Negative symptoms: testing expectation of feelings of lack of pleasure or mastery in social situations
Social anxiety/paranoia: overcoming avoidance in response to worries about social appraisals using specific targeted behavioural experiments
Schizotypal symptoms: decreases catastrophising appraisals about relapse associated with minor psychotic experiences
Intervention
Assessment and engagement– Lots of compassion and validation but also…– Optimism for change and hope for the future
Building a “self-as-hero” narrative – You got through it, survivor, hidden resilience– e.g. analogy of favourite computer game character
who “keeps on going” despite adversity Building positive sense of self and self-compassion Identification of values, short and long-term goals
and barriers– Miracle question (job, university)
Intervention contd.
Addressing ambivalence/fears about change Symptoms & beliefs about psychosis
– Information about psychosis – exposure– Normalising – behavioural experiments– Symptom management
Addressing avoidance– Graded exposure re: using the bus– ACT-based metaphors – you can do things AND have
these experiences Behavioural activation
– Increasing activity levels and experience of pleasure
Intervention contd.
Working towards values– Career – researching different careers, link up with
work-based organisations in voluntary sector who arranged a work placement
– Leisure – new activities might like to do– Personal Growth – comfort zone vs. stretching self– Friends/social life – increasing social contacts
Behavioural experiments– Making mistakes– Social anxiety
Improving Social Recovery in Early Psychosis: pilot study of SRCBT
ISREP study results
treatmentcontrol
Allocation
20.00
15.00
10.00
5.00
0.00
-5.00
-10.00
Me
an D
iffe
ren
ce
in h
ou
rs p
er
wee
k in
str
uct
ure
d a
ctiv
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Instilling hope and a positive sense of self
Summary
Delayed social recovery problems are common following a first episode of psychosis and require further targeted intervention
A social recovery focused CBT approach looks promising in addressing these difficulties
The future…
Sustaining Positive Engagement and Recovery in First Episode Psychosis (SuPER EDEN study 3): An RCT of social recovery CBT in individuals with first episode psychosis (N = 75 treatment, 75 control)
– Funded by NIHR Programme Grant
Detection and Prevention of Long-term Social Disability amongst Young People with Emerging Mental Health Problems: an RCT of social recovery CBT (N = 50 treatment, 50 control)
– Funded by NIHR HTA (Fowler, French, Hodgekins et al)
