The promise of social recovery therapy in non‐affective psychoses
Authors: David Fowler
Journal: World Psychiatry (2024)

Non-affective psychoses (schizophrenia and schizophreniform disorders) are the health conditions of working age adults most frequently associated with poor social outcomes. Long-term follow-up studies suggest that less than 50% of people with these conditions achieve social recovery, less than 15% achieve sustained recovery in both symptomatic and social domains, and only 10-20% of people return to competitive employment, despite the majority reporting that they wish to work1. Social recovery therapy (SRT) is a psychosocial treatment to promote social recovery in people with non-affective psychosis who are socially withdrawn, have complex and comorbid problems, and are unresponsive to existing interventions. It is based on a model in which social disability evolves as a result of lifestyle patterns of low activity, adopted to achieve behavioral avoidance, and maintained by lack of hope, agency and motivation. Social disability in psychosis typically occurs in the context of persistent positive and negative symptoms and cognitive impairment, often accompanied by depression, anxiety and other psychopathological manifestations. Alongside such issues are complex social circumstances and systemic issues, including problematic family dynamics, victimization, social threat and social deprivation. In the face of such problems, individuals adopt lifestyle patterns of extreme social withdrawal, leaving work or education and losing contact with social networks. SRT is described in a manual2 and delivered individually across 9 months. Sessions take place in participants' homes and community locations. Interim telephone and email contact usually occurs. SRT delivery is structured in three stages. Stage 1 includes assessment and development of a shared social recovery formulation. Stage 2 involves identifying and working towards medium- to long-term goals guided by a systemic formulation of barriers to recovery, with a focus on promoting a sense of agency, hope and motivation, and encouraging activity while managing psychotic symptoms. Stage 3 involves the active promotion of structured activity linked to meaningful goals, while still managing symptoms. The focus of the intervention is on the individual's personal values and goals, identifying problems and barriers to these, then promoting hope for meaningful behavioral change and activity toward these goals. There is a strong emphasis on the use of behavioral strategies (including behavioral experiments, graded exposure and behavioral activation) to overcome avoidance and promote meaningful lifestyle change in vivo whilst managing symptoms as necessary to implement a concrete pathway to social recovery. Evidence and experiences from this behavioral work are used to further instill hope and promote positive beliefs about self as the individual works towards achieving meaningful change in his/her life. As SRT aims to engage people with psychosis into structured activity, it often includes supporting them to access employment, education, training, voluntary and/or leisure opportunities. Much of SRT takes place in community settings. It is often useful for the therapist to drive the client to new locations and settings or accompany him/her on public transport. To achieve gains in social recovery against a background of often years of withdrawal and social disadvantage means that therapists have to integrate techniques typically associated with assertive community treatment and supported employment. Working systemically with families and stakeholders surrounding the individual to promote opportunities in the social environment is also important. Behavioral activation and behavioral experiments are conducted in line with the client's identified goals and values and at a pace respecting the nature of the difficulties faced. The therapist works alongside the client to aid motivation and engagement in identified activities that can be incorporated into daily life, and work out collaborative strategies to manage ongoing symptoms in vivo. To date, we have conducted two assessor-blind randomized controlled trials of SRT in people with psychosis with severe social disability. In the Improving Social Recovery in Early Psychosis (ISREP) trial3, 77 participants with affective or non-affective psychosis presenting social withdrawal were randomized to receive either SRT plus treatment-as-usual (TAU) or TAU alone. TAU consisted of case management from a secondary mental health care team. In the non-affective psychosis group, SRT showed a significant and clinically beneficial effect on the primary outcome of weekly hours in structured activity, as well as on positive and negative symptoms. There was also an effect of SRT on hopelessness and positive beliefs about self, with improvements on these variables being a mediator of the change in structured activity. The intervention was also cost-effective4. SUPEREDEN35 was a larger (N=154) phase 2 trial aimed to enhance social recovery in patients who had not responded to early intervention service (EIS) treatment, by combining standard EIS provision with SRT. The primary analysis indicated that the SRT plus EIS was associated with an average increase in structured activity over 8 hours per week greater than EIS alone (95% CI: 2.5-13.6; p=0.005). The size of the effect represents an amount of activity equivalent to a full working day. There is evidence from both the above trials that the gain from SRT may be maintained 6 months beyond active treatment. In a further separate longer-term follow-up study on the ISREP group6, none of the 24 cases in the TAU group had engaged in paid employment in the year following the end of the intervention period, compared with 5 out of 20 (25%) cases in the SRT+TAU group. SRT offers most promise in promoting social recovery in complex cases of non-affective psychoses in which there is little evidence of response to other interventions. Although the results from the two available randomized controlled trials are positive, further large scale pragmatic studies are needed, possibly being expanded to more chronic cases. There may also be promise in combining SRT approaches with other psychosocial interventions, such as cognitive remediation therapy7. We designed SRT so that it can be delivered in task-sharing formats by a less costly and more widely available workforce than that involved in the above trials. We have now developed extensive training materials, including videos as well as adherence and supervision guidance, which we have collated on a website8. Through this and related work, we have found that it is possible to train "non-expert therapists" in key elements of the SRT approach, which can then be successfully implemented following the manual. What is needed in the future is to build on the promise of the existing trials of SRT toward further research and implementation involving non-expert therapists and extending into wider populations of people with non-affective psychosis in the community.