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This chapter provides an overview of the methodological challenges in researching social inclusion amongst people with mental health conditions and gives examples of interventions that have been shown to be effective in addressing social exclusion including pre-school parenting programmes, early intervention, peer support, recovery colleges, self-care, self-management, and self-directed care. As with all clinical practice, the starting point is the establishment of a therapeutic relationship that encompasses empathy, understanding, hope, and a willingness to help, along with a recovery orientation encompassing collaborative and strengths-based approaches. Much of this does not require a major reorganisation of services, but rather a refocusing and reprioritisation of existing tools and clinical skills, alongside commitment by mental health organisations to ensure their structures facilitate service-user involvement in the planning and delivery of services
This chapter covers three main areas of activity: the labour market, education, and leisure. These three areas all overlap and interact within the scope of the human life course and have important implications for health and socio-economic outcomes. They are also interdependent with the material factors and the social networks examined in other chapters. All are inequitably distributed and are important for the health and well-being of the general population. People with mental health conditions are disadvantaged in all three of these areas, especially those with severe and enduring conditions, and work, leisure, and education can all play a role in causing and perpetuating mental ill-health. Factors that are integral to the mental health condition may contribute to excluding people from these important activities, but there are additional extrinsic factors that also play a part in this exclusion. The existence of such external factors supports the application of a social model of disability for people with mental health conditions and questions the assumptions of an approach that views exclusion solely in terms of a person’s ‘illness’. This has implications for the rehabilitation and the personal and social recovery of people with enduring mental health conditions.
This study reports on a preliminary evaluation of a cognitive behavioural intervention to improve social recovery among young people in the early stages of psychosis showing persistent signs of poor social functioning and unemployment. The study was a single-blind randomized controlled trial (RCT) with two arms, 35 participants receiving cognitive behaviour therapy (CBT) plus treatment as usual (TAU), and 42 participants receiving TAU alone. Participants were assessed at baseline and post-treatment.
Method
Seventy-seven participants were recruited from secondary mental health teams after presenting with a history of unemployment and poor social outcome. The cognitive behavioural intervention was delivered over a 9-month period with a mean of 12 sessions. The primary outcomes were weekly hours spent in constructive economic and structured activity. A range of secondary and tertiary outcomes were also assessed.
Results
Intention-to-treat analysis on the combined affective and non-affective psychosis sample showed no significant impact of treatment on primary or secondary outcomes. However, analysis of interactions by diagnostic subgroup was significant for secondary symptomatic outcomes on the Positive and Negative Syndrome Scale (PANSS) [F(1, 69)=3.99, p=0.05]. Subsequent exploratory analyses within diagnostic subgroups revealed clinically important and significant improvements in weekly hours in constructive and structured activity and PANSS scores among people with non-affective psychosis.
Conclusions
The primary study comparison provided no clear evidence for the benefit of CBT in a combined sample of patients. However, planned analyses with diagnostic subgroups showed important benefits for CBT among people with non-affective psychosis who have social recovery problems. These promising results need to be independently replicated in a larger, multi-centre RCT.
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