Recovery style and outcome in first-episode psychosis

Abstract

Our study aimed to investigate how recovery styles influence 12-month clinical outcome in first-episode psychosis patients. We hypothesised that patients who use an integrative recovery style would have better outcome than those who seal over. A total of 196 first-episode psychosis patients from the Early Psychosis Intervention Centre (EPPIC) participated in the study. Each patient was interviewed at stabilization of their acute psychotic episode, and then again 12 months later, using an Integration/Sealing-over measure. Our results suggest that recovery style may be a useful predictor of outcome. Integrative patients had better outcome and functioning at 12 months. These results were influenced by diagnosis and, unlike previous studies, recovery style changed over time, suggesting it was not a stable trait. The capacity for recovery style to change challenges the suggestion it is a personality trait and raises the need for psychoeducation and other psychological interventions that could improve outcome.

Introduction

Patients' understanding of their psychosis can impact the therapeutic process. During recovery, patients tend to either integrate their illness experiences into their wider life situation, or ‘seal over’, or keep them separate, so as to maintain their mental integrity and protect themselves from the stigma associated with psychosis. The way patients integrate their illness into their self-identity influences their response and acceptance of treatment, and recovery and outcome. In many ways, this process is related to insight because it involves patients' understanding of their illness and has important implications for therapeutic strategies. Our study investigates how recovery style influences 12-month outcome in first-episode psychosis patients. This study is novel because it uses McGlashan et al.'s (1976) measure to prospectively examine recovery style in first-episode psychosis patients. Previous studies have either used a different approach to assess recovery, or focussed on more chronic samples.

Integration and sealing over are two recovery styles that are typically observed in patients with psychiatric illnesses McGlashan et al., 1976, McGlashan and Levy, 1977. Patients that use an integrative style are characterized by a flexible thinking style, which incorporates psychosis (or other illness) into their wider life experience. These patients use these experiences as a new source of information about themselves and turn it into a positive situation rather than something that needs to be avoided. In contrast, patients who tend to seal over isolate their psychotic episode from the rest of their life and treat it as an inconvenient disruption to their lives. These two stereotypical recovery styles represent two extremes on a continuum, and it should be recognized that many patients present as a mixture of the two styles. From this perspective, recovery style is seen as a personality trait that is stable across time (McGlashan, 1987).

To our knowledge, the only major prospective study conducted to date that has focussed on recovery style reported that 15 years after discharge from an inpatient facility, psychiatric patients who integrated their experience of psychosis generally had a better clinical outcome. This finding was mediated by diagnosis, as patients with schizophrenia tended towards a sealing-over approach (McGlashan, 1987). On the basis of this study, McGlashan (1987) concluded that recovery style was a personality trait that could be a useful predictor of outcome. Other studies that have examined related constructs in first-episode patients have reported improved insight at 6-month follow-up, with fewer patients with schizophrenia showing any change in insight over time (Fennig et al., 1996).

Our study aimed to investigate how recovery style related to clinical outcome in first-episode psychosis patients. We hypothesized that patients who used an integrative recovery style would have better functioning and clinical outcome at follow-up than those that sealed over. More patients with schizophrenia were expected to use a sealing-over approach. To some extent, recovery style was expected to predict outcome. We also sought to explore its trait-like nature.