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“Oh, it was excellent. Your psychologist takes you swimming, how good is that? You can’t get any better than that.”
Samir, SRT participant, Lancashire
Taking a trip to the leisure centre with your therapist may not be a traditional approach to mental health.
It is, however, the kind of activity that can happen in Social Recovery Therapy (SRT), a new psychological intervention for psychosis developed by clinical practitioners and researchers from UEA and other institutions, including the National Institute for Health Research, the Medical Research Council, the University of Sussex, Greater Manchester Mental Health NHS Foundation Trust, Sussex Partnership, NHS Foundation Trust, Norfolk and Suffolk NHS Foundation Trust.
Jo Hodgekins, a Clinical Associate Professor in Clinical Psychology at UEA, is one of those researchers and explains that SRT differs from standard treatment methods for psychosis in its focus on social impact. So while people may not necessarily be psychotic any more, they can still be “quite depressed, very socially anxious and potentially quite traumatised by their experience”, leaving them at risk of further mental health problems exacerbated by isolation and lack of engagement with the outside world.
A new approach to psychosis recovery
The 2014 National EDEN study sparked the development of the research, Hodgekins explains, after following up 1,000 young people who had had access to Early Intervention Services after experiencing psychosis.
“We found that 60 per cent of young people still had significantly low levels of activity after 12 months of quite intensive input,” she says. “There were other groups that were doing better, but there was this core group that came into the service with poor functioning, not doing very much with their time, even after a year, even if the psychosis itself had remitted. So we decided to focus on that.”
"I don’t really see anything bright [in my future] but I’m trying not to dwell on it…One day I’m alright, the next day, well I just sit there and I cry and I don’t even know why I’m crying, and I think 'Well can I actually function within a job?' And then I think 'Well I’m just a dole-dosser then', because physically there’s nothing wrong with me.”
Megan, SRT participant, Lancashire
“Often people will have dropped out of work or college and maybe lost friends because it's something that they feel quite stigmatised by,” Hodgekins continues. “We’re thinking about the impact of psychosis on identity and challenging some of those narratives about how it makes you damaged or odd or different, and looking at how they have actually survived this really traumatic experience. That comes with a lot of skills.”
Positive beliefs
SRT is “quite an active intervention”, she continues, with a basis in cognitive behavioural therapy (CBT), and positive social engagement. So where other psychological interventions often focus on challenging negative beliefs, SRT is also about building up positive beliefs for participants, both about themselves and other people.
"We also talk about what people want to achieve in the future. Often those things will be very realistic: they'd like to live independently, have a partner, go to college or work and so on. And then we talk about what gets what gets in the way of that. Often it’s fear about relapse, about being permanently changed by the experience of psychosis – we find people can be orienting themselves around their fears rather than want to achieve.”
Exactly what that looks like will depend entirely on the person and their interests and aims, Hodgekins continues, so their individualised approach could include a trip to the comic book shop, a walk in nature or, as one of the study participants recalled, a sober karaoke trip.
"The most memorable point was when I was made to do karaoke…stone-cold sober. That was the most memorable point for me, and that was quite hard. I did find that tough. There was a lot of anxiety beforehand...but that was quite a good learning experience. If you think to yourself ‘Well, if you can make that much of a fool of yourself’ then other stuff’s a lot easier.”
Lee, SRT participant, Birmingham
In line with its basis in CBT, information from these “experiments” is then used as “evidence” to build an individual’s sense of mastery and achievement. The sessions are delivered by psychologists or CBT therapists, working at the delicate midway point of helping participants to do as much as they can without pushing them too much.
“We use activities that are meaningful to the person to test out some of those fears and worries, without feeling pressured that getting you need to get back to work right now, because that's often not an easy thing to do,” Hodgekins continues.
Back on track
The results are promising: compared to standard treatment approaches, people who received social recovery therapy improved by an average of eight hours per week in terms of their functioning, as measured by the amount of “structured activity”.
“Other research has focused on functional outcomes, but it has tended to focus more on getting people back into work or getting people back into education,” Hodgekins says. “And while that is obviously an important marker of outcome and recovery, our definition of social recovery is broader than that, so we would also consider spending time with friends, engaging in sports, leisure and hobbies as important aspects of social functioning and recovery, essentially getting your life back on track after this quite traumatic event.”
“Just going back over 12 months, I’ve passed extra qualifications, and my NVQ2 and I’m in the running for [a] driving licence. And 12 months ago, they weren’t in the pipeline, so in another 12 months, who knows?”
Rob, SRT participant, Lancashire
So what next? The National Institute for Health Research has released a “signal” publication recommending that SRT be used in Early Intervention for Psychosis services, and some specialist CBT for psychosis courses are including elements in their training. And although the government's NICE guidelines - which offer recommendations on how healthcare and other professionals should care for people with specific conditions - haven’t been updated since the approach was developed, Hodgekins is hopeful that SRT could be a candidate for inclusion in the next iteration.
“There is now a broader understanding and an acceptance that we don't just want to focus on symptomatic outcomes,” she says. “Obviously that's really important, but we also want to think about the broader impact of psychosis on people's lives.”
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