Social recovery therapy increases structured activity, such as work, education or sport, by eight hours per week for people with severe social withdrawal following a first episode of psychosis. This cognitive behavioural type of treatment was added to other early interventions and might be particularly useful for those lacking motivation or living with other conditions that prevent them engaging with mental health services.
This NIHR-funded trial included 154 young adults with first episode of psychosis under the care of early intervention services in England. These are specialist multidisciplinary mental health services which aim to help people make a full mental, physical and social recovery. The participants had been under their care for at least a year and had extreme social withdrawal, which often limits their capacity to engage in therapy.
Social recovery therapy not only increases structured activity levels but also appears to keep people in contact with services in the critical first nine months. It could be incorporated into early intervention services for people with persistent social withdrawal.
Why was this study needed?
In England, there are over 1,000 referrals to early intervention services each month. The services are holistic and typically include psychological therapy, medication, family therapy, and offers to tackle social support, employment or housing issues. They tend to look after people for up to three years. They aim to prevent the episode from recurring and developing into long-term schizophrenia but also help people develop skills to cope with residual symptoms.
Social recovery can be particularly challenging because of continued symptoms and the social withdrawal that is typical in people with first episode psychosis. This study aimed to see if social recovery therapy in addition to early intervention services increased the time spent in structured activity. This was defined as constructive economic activity (work, education, voluntary work, housework or chores, and child care) and structured activity (constructive economic activity plus leisure and sport).
What did this study do?
The SUPEREDEN3 phase two randomised controlled trial included 154 adults with first episode psychosis, aged 16 to 35. They had been under the care of four early intervention services in England for 12 to 30 months. All continued to have severe social withdrawal.
The participants were randomly allocated to either a control group who continued early intervention services or the intervention group who also received social recovery therapy. The intervention group had on average 16 sessions of social recovery therapy which used cognitive behaviour therapy techniques. The three stages included; developing a therapeutic relationship, referral to education, vocation or leisure/ sports providers, and practical help in overcoming obstacles to engaging. These are more fully described in the definitions section.
The high dropout of 24% in the control group may have masked the effectiveness of the intervention at the 15-month assessment.
What did it find?
- At nine months, time spent in structured activity had increased more in the social recovery group, from 11 hours to 26.6 hours per week, compared to increasing from 12 hours to 18 hours in the control group (mean difference [MD] 8 hours, 95% confidence interval [CI] 2.5 to 13.7).
- Constructive economic activity had also increased more in the social recovery group, from 7.5 hours to 20.1 hours compared to increasing from 7.9 hours to 14.1 hours (MD 5.9, 95% CI 0.8 to 11.0).
- There was little difference in either activity level between the groups at 15 months. Structured activity occurred for 23 hours per week in the social recovery group compared to 22.5 hours in the control group.
- At nine months, fewer people in the social recovery group had positive symptoms such as hallucinations or negative symptoms such as difficulty concentrating.
What does current guidance say on this issue?
NICE guidance updated in 2016 recommends that all young people with suspected first episode psychosis are urgently referred to an early intervention service. These services do not routinely include social recovery orientated therapy.
An individualised care plan should be agreed, including activities that promote physical and mental wellbeing. In addition to medical and psychiatric care, the team should help the person to set and achieve realistic social activity targets.
The Five year Forward View policy for mental health published in 2016 supports early intervention services as a priority for the NHS.
Depending on the severity of the illness and capacity to engage, the service can try to facilitate alternative education or supported training or employment until the person can re-join mainstream services.
What are the implications?
Social recovery therapy increases the amount of structured activity per week at nine months for people who continue to have severe social withdrawal. Early intervention services could consider incorporating elements of the therapy into their package of care.
This is a particularly challenging group of people to engage in therapy because of the extent of social withdrawal, apathy and complex symptoms. The low level of dropout in the intervention group of 9% by 15 months was impressive. Though no difference was seen at 15 months in activity level between the groups, there was a much higher dropout rate in the control group, which might partly explain the lack of a difference.
The social recovery therapy, therefore, helped more people to increase their structured activity and remain in contact with services. This is an important outcome regarding quality of life and improving social inclusion in this vulnerable group of people.
Citation and Funding
Fowler D, Hodgekins J, French P, et al. 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;5(1):41-50.
This project was funded by the National Institute for Health Research under the Programme Grants for Applied Research programme (RP-PG-0109-10074).
NICE. Psychosis and schizophrenia in children and young people: recognition and management. CG155. National Institute for Health and Care Excellence; 2013 (updated 2016).
NHS England. Statistical Press Notice: Early intervention in psychosis waiting times November 2017. NHS England; 2017.
Produced by the University of Southampton and Bazian on behalf of NIHR through the NIHR Dissemination Centre