Since the introduction of early intervention services, 40-60% of people experiencing their first episode of psychosis have made a full or partial recovery (Craig et al., 2004). However, some people continue to not respond well with routine early intervention services and still have problems in their social functioning. This can lead to long-term social difficulties, such as withdrawal, isolation, and lack of integration into the community.

Traditional Cognitive Behavioural Therapy (CBT) is recommended by the National Institute of Health and Clinical Excellence (NICE) for people with psychosis and has been demonstrated to be effective in helping with the symptoms of psychosis (NICE, 2014; Shepherd, 2014; Wykes et al, 2008). However, the traditional CBT approach does not explicitly aim to improve social functioning, which is extremely important to the recovery needs of people experiencing psychosis (Pitt et al, 2007). In particular, gaining meaningful employment, accessing education, spending time with friends and family, are important.

This study aimed to see if a social recovery CBT intervention, delivered within early intervention teams, could help improve social activity for people experiencing psychosis.

Methods

This study is a single-blind randomised controlled trial in four early intervention teams (Birmingham, Lancashire, Norfolk and Suffolk). Participants were people with psychosis who had been with early intervention services for 12 to 30 months, had current psychotic symptoms (operationally defined by the PANSS (Kay et al, 1987) score ≥4 ), and difficulties in social functioning (operationally defined by ≤ on the Time Use Survey; Gershuny, 2011).

Participants were randomised to either:

• The social recovery CBT intervention plus early intervention service,
• Or early intervention services only (usual treatment).

Therapeutic intervention

The intervention was social recovery CBT, which was delivered in three stages:

1. Development of a detailed assessment with a particular focus on behaviours, therapeutic engagement and the development of a formulation, and identification of a problem list.
2. Participant and therapist working together to prepare for meaningful activities including, e.g. referrals to vocational agencies and community sport activity groups. Cognitive work involved tackling stigma, negative self-belief, improving agency, and undertaking behavioural experiments.
3. Engagement in new activities, fostering feelings of mastery and agency, problem-solving, and working systemically with the participant’s social network.

Outcomes

Participants completed outcomes at:

• Baseline
• Post therapy (9-months)
• Follow-up (15 months)

The primary outcome was structured activity at 9-months (measured by the Time Use Survey (Gershuny, 2011)), which examines the number of hours spent in meaningful activity per week.

Secondary outcomes were general pathology and negative symptoms (measured using the PANSS; Kay et al, 1987), anxiety (Social Interaction Anxiety Scale; Mattick & Clark, 1998), depression (Beck Depression Inventory; Beck, Steer & Brown, 1996), hopelessness (Beck Hopelessness Scale; Beck & Steer, 1988), hope (Adult Trait Hope Scale; Snyder et al., 1991) and meaning in life (Meaning in Life Questionnaire; Steger. Frazier, Oishi & Kaler, 2006).

Results

Quality of data

Missing data for the primary outcome was low post-therapy (7%) and follow-up (16%) demonstrating acceptable rates. Higher rates of missing data was reported for other secondary measures such as the PANSS (20% post-therapy and 35% at follow-up), which may demonstrate a risk of bias on this outcome.

Sample

155 participants were randomly allocated to either receive CBT social recovery therapy (n=76) or early intervention services alone (n=79). Baseline characteristics were similar in both groups. The majority of the sample were male, white British, had English as a first language, and were single.

Therapy

Participants received an average of 16.49 sessions, and 81% of participants received an adequate ‘dose’ of therapy. The researchers reported that therapists had excellent fidelity to the treatment model. Seven participants dropped out of therapy and seven did not receive an adequate dose.

Main findings

• The primary outcome of time in structured activity was significantly higher by 8.1 hours in the group that had social recovery CBT compared to the control group post-therapy, but this improvement was not maintained at follow-up.
• Constructive economic activity (time in employment) also improved post-therapy for the social recovery CBT group (compared to the control group), but this was not maintained at follow-up
• All other outcomes showed no benefit for the social recovery CBT intervention with the exception of hope at follow-up.

Conclusions

Social recovery CBT demonstrated improvements in structured activity post-therapy over usual treatment, but this was not maintained at follow-up. All secondary outcomes, except for hope at follow-up, did not demonstrate any significant improvements for social recovery CBT. The authors state that it may be the high level of missing data which had impacted on the findings.

Strengths and limitations

Strengths

The study followed best practice procedures, for example described by Consolidated Standards of Reporting Trials (CONSORT; Schulz et al, 2010) for conducting a trial which improved the reliability and validity of results. This included; prospectively publishing the research protocol, transparent reporting of results, following good clinical practice guidelines, recruiting from a variety of sites, participants being randomly allocated to conditions by people external to the research team, researcher assistants being blind to allocation, blind break monitoring, and use of intention to treat analysis.

The researchers were also able to recruit a vulnerable group of people with moderate to severe difficulties in their social functioning.

Limitations

• The prospective protocol did not state at what time point (post-therapy or follow-up) the primary and secondary outcomes would be examined
• After publishing the protocol, but prior to the study commencing, the authors chose to look at the primary outcome of structured activity use at post-therapy (9 months) as their primary outcome
• Additional secondary outcome were added that were not on the original protocol. However, the authors of the study were transparent about this
• Another potential limitation is the missing data at follow-up, which is likely to increase the risk of bias in the study findings.

Implications for practice

This study provides some evidence for focusing on social recovery in people receiving care from early intervention services. It shows that people experiencing psychosis who also struggle with social functioning can and are willing to engage in a therapy that aims to improve their activity levels. It also demonstrates that social recovery is an important issue that participants wanted to talk about and focus on in therapy.

Conflicts of interest

Lisa is currently a post-doctoral research fellow, which is funded by the National Institute of Health Research (NIHR) Higher Education England North Central East London (HEENCEL) Collaboration in Leadership and Applied Health Research and Care (CLAHRC).

Links

Primary paper

D Fowler, J Hodgekins, P French, et al. (2017) Social recovery therapy in combination with early intervention services for enhancement of social recovery in patients with first-episode psychosis (SUPEREDEN3): an assessor-blind, phase 2, randomised controlled trial. Lancet Psychiatry (2017) published online Dec 11. http://dx.doi.org/10.1016/S2215-0366(17)30476-5

Other references

Beck, A. T., & Steer, R. A. (1988). Beck Hopelessness Scale manual. San Antonio, Texas: The Psychological Corporation.

Beck, A. T., Steer, R. A., & Brown, G. K. (1996). Beck Depression Inventory. San Antonio: Psychological Corporation.

Craig, T., Garety, P., Pwer, P., Rahaman, N., Colbert, S., Fornells-Ambrojo, M., & Dunn, G. (2004). The Lambeth Early Onset (LEO) Team: randomised controlled trial of the effectiveness of specialised care for early psychosis. The BMJ, 329(1067).

Gershuny, J. (2011). Time use surveys and the measurement of national well-being. Oxford: Centre for Time Use Research.

Kay, S. R., Fiszbein, A., & Opler, L. A. (1987). The positive and negative syndrome scale (PANSS) for schizophrenia. Schizophrenia Bulletin, 13(2), 261-276.

Mattick, R. P., & Clarke, J. C. (1998). Development and validation of measures of social phobia scrutiny fear and social interaction anxiety. Behaviour Research and Therapy, 36, 455-470.

NICE. (2014). Psychosis and schizophrenia in adults: treatment and management. London: National Institute of Clinical Excellence.

Pitt, L., Kilbride, M., Nothard, S., Welford, M., & Morrison, A. P. (2007). Researching Recovery from Psychosis: A User-Led Project. Psychiatry Bulletin, 31, 55 – 60.

Schulz, K. F., Altman, D. G., & Moher, D. (2010). CONSORT 2010 Statement: updated guidelines for reporting parallel group randomised trials. Trials, 11(32).

Shepherd, A. (2014). Psychosis and schizophrenia in adults: updated NICE guidance for 2014: https://www.nationalelfservice.net/mental-health/schizophrenia/psychosis-and-schizophrenia-in-adults-updated-nice-guidance-for-2014/.

Snyder, C. R., Harris, C., Anderson, J. R., Holleran, S. A., Irving, L. M., & Sigmon, S. T. (1991). The will and the ways: Development and validation of an individual-differences measure of hope. Journal of Personality and Social Psychology, 60, 570-585.

Steger, M. F., Frazier, P., Oishi, S., & Kaler, M. (2006). The meaning of life questionnaire: assessing the presence of and search for meaning in life. Journal of Counseling Psychology, 53, 80 -93.

Wykes, T., Steel, C., Everitt, B., & Tarrier, N. (2008). Cognitive Behavior Therapy for Schizophrenia: Effect Sizes, Clinical Models, and Methodological Rigor. Schizophrenia Bulletin, 34, 523-537.

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