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Social Recovery in Early Psychosis: Assessment and Intervention Dr Jo Hodgekins
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Social Recovery in Early Psychosis: Assessment and Intervention Dr Jo Hodgekins.

Dec 18, 2015

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Page 1: Social Recovery in Early Psychosis: Assessment and Intervention Dr Jo Hodgekins.

Social Recovery in Early Psychosis: Assessment and Intervention

Dr Jo Hodgekins

Page 2: Social Recovery in Early Psychosis: Assessment and Intervention Dr Jo Hodgekins.

Acknowledgements

Page 3: Social Recovery in Early Psychosis: Assessment and Intervention Dr Jo Hodgekins.

Social disability as a primary target?

Page 4: Social Recovery in Early Psychosis: Assessment and Intervention Dr Jo Hodgekins.

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)

Page 5: Social Recovery in Early Psychosis: Assessment and Intervention Dr Jo Hodgekins.

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”

Page 6: Social Recovery in Early Psychosis: Assessment and Intervention Dr Jo Hodgekins.

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?

Page 7: Social Recovery in Early Psychosis: Assessment and Intervention Dr Jo Hodgekins.

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

Page 8: Social Recovery in Early Psychosis: Assessment and Intervention Dr Jo Hodgekins.

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

Page 9: Social Recovery in Early Psychosis: Assessment and Intervention Dr Jo Hodgekins.

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

Page 10: Social Recovery in Early Psychosis: Assessment and Intervention Dr Jo Hodgekins.

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

Page 11: Social Recovery in Early Psychosis: Assessment and Intervention Dr Jo Hodgekins.

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)

Page 12: Social Recovery in Early Psychosis: Assessment and Intervention Dr Jo Hodgekins.

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)

Page 13: Social Recovery in Early Psychosis: Assessment and Intervention Dr Jo Hodgekins.

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)

Page 14: Social Recovery in Early Psychosis: Assessment and Intervention Dr Jo Hodgekins.

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)

Page 15: Social Recovery in Early Psychosis: Assessment and Intervention Dr Jo Hodgekins.

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)

Page 16: Social Recovery in Early Psychosis: Assessment and Intervention Dr Jo Hodgekins.

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

Page 17: Social Recovery in Early Psychosis: Assessment and Intervention Dr Jo Hodgekins.

Individual trajectories

Hodgekins et al. (in prep)

Baseline 6 months 12 months

Hou

rs p

er w

eek

in

Str

uctu

red

Act

ivity

Page 18: Social Recovery in Early Psychosis: Assessment and Intervention Dr Jo Hodgekins.

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)

Page 19: Social Recovery in Early Psychosis: Assessment and Intervention Dr Jo Hodgekins.

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%

Page 20: Social Recovery in Early Psychosis: Assessment and Intervention Dr Jo Hodgekins.

Conclusions

A large proportion of individuals remain socially disabled following 12 months of EI service provision

Requires specific targeting?

Hodgekins et al. (in prep)

Page 21: Social Recovery in Early Psychosis: Assessment and Intervention Dr Jo Hodgekins.

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)

Page 22: Social Recovery in Early Psychosis: Assessment and Intervention Dr Jo Hodgekins.

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

Page 23: Social Recovery in Early Psychosis: Assessment and Intervention Dr Jo Hodgekins.

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

Page 24: Social Recovery in Early Psychosis: Assessment and Intervention Dr Jo Hodgekins.

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)

Page 25: Social Recovery in Early Psychosis: Assessment and Intervention Dr Jo Hodgekins.

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

Page 26: Social Recovery in Early Psychosis: Assessment and Intervention Dr Jo Hodgekins.

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

Page 27: Social Recovery in Early Psychosis: Assessment and Intervention Dr Jo Hodgekins.

Improving Social Recovery in Early Psychosis: pilot study of SRCBT

Page 28: Social Recovery in Early Psychosis: Assessment and Intervention Dr Jo Hodgekins.

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

ity

Page 29: Social Recovery in Early Psychosis: Assessment and Intervention Dr Jo Hodgekins.

Instilling hope and a positive sense of self

Page 30: Social Recovery in Early Psychosis: Assessment and Intervention Dr Jo Hodgekins.

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

Page 31: Social Recovery in Early Psychosis: Assessment and Intervention Dr Jo Hodgekins.

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)

Page 32: Social Recovery in Early Psychosis: Assessment and Intervention Dr Jo Hodgekins.

Thank you for listening!

[email protected]