Social Recovery in Early Psychosis:
Assessment and Intervention
Dr Jo Hodgekins
Acknowledgements
Social disability as a primary target?
Delayed social recovery: the clinical
picture
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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.
2.
3.
4.
5.
How can we assess delayed social
recovery?
When do social functioning difficulties
occur?
What is the prevalence of delayed social
recovery in early psychosis services?
What are the predictors of delayed social
recovery?
How do we intervene?
Assessing functional recovery
following psychosis: a problem

Traditional measures focus on the deficit
syndrome
–
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Or focus specifically on work and education
–
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Young people with first episode psychosis have
different difficulties
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
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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?
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“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
Hodgekins et al. (submitted to Schizophrenia
Bulletin)
When do social functioning difficulties
occur?
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Compare weekly hours in structured activity
across samples of individuals at different
stages of psychosis with an age-matched
non-clinical sample:
–
–
–
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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
Hours per week in
Structured Activity
70
60
50
40
30
20
10
0
Non-Clinical
(ONS)
At-risk Mental
State (EDIE-II)
First Episode
Psychosis
(EDEN)
Delayed
Recovery
(ISREP)
30 hours per week as a cut-off

Use of ROC curves
to determine best
cut-off to distinguish
clinical and nonclinical groups
Hodgekins et al. (submitted)
Hodgekins et al. (submitted to Schizophrenia
Research)
Conclusions
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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. (in prep)
What is the prevalence of social
disability in first episode psychosis
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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)
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Birmingham, Norwich, Cambridge, Cornwall,
Lancashire
Time Use assessed at baseline, 6 months
and 12 months
Hodgekins et al. (in prep)
Hours per week in
Structured Activity
Whole group (N = 1027)
Baseline
6 months
12 months
Hodgekins et al. (in prep)
Hours per week in
Structured Activity
Individual trajectories
Baseline
6 months
12 months
Hodgekins et al. (in prep)
Trajectories of social recovery
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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
Hours per week in
Structured Activity
100
Low Stable
90
80
7%
70
60
27%
50
40
30
20
66%
10
0
Baseline
6 months
12 months
Moderate/
Increasing
High/
Decreasing
Hodgekins et al. (in prep)
Conclusions
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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?
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Predictors of poor functional outcome:
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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?
The Social Recovery CBT approach
(Fowler, French, Hodgekins et al, 2012)
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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
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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
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Assessment and engagement
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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.
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Addressing ambivalence/fears about change
Symptoms & beliefs about psychosis
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Addressing avoidance
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Information about psychosis – exposure
Normalising – behavioural experiments
Symptom management
Graded exposure re: using the bus
ACT-based metaphors – you can do things AND have
these experiences
Behavioural activation
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Increasing activity levels and experience of pleasure
Intervention contd.
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Working towards values
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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
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Making mistakes
Social anxiety
Improving Social Recovery in Early
Psychosis: pilot study of SRCBT
Mean Difference in hours per week in structured activity
ISREP study results
20.00
15.00
10.00
5.00
0.00
-5.00
-10.00
control
treatment
Allocation
Instilling hope and a positive
sense of self
Summary
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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)
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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)
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Funded by NIHR HTA (Fowler, French, Hodgekins et al)
Thank you for listening!
j.hodgekins@uea.ac.uk