Social Relationships Integral to Recovery in First Episode Psychosis

Research finds patients of first-episode psychosis report benefits from social relationships where their personhood is respected.


Research involving socio-cultural factors in psychosis is sparse, despite evidence that points to the importance of social interactions in recovery. A new study investigates these factors by examining the social relationships of young adults with first-episode psychosis. The study finds that participants reported benefits when their uniqueness was acknowledged and their personal preferences respected by the professionals. Alternatively, they reported negative experiences with mental health workers when they felt unheard.

The study, led by Hege Hansen of the Western Norway University of Applied Sciences, was recently published in Social Work in Mental Health. It conducted a qualitative analysis of the experience of ten young adults recovering from first break psychosis. It examined the role of their social relationships within and outside the mental health system. Participants found the professionals to be helpful, but only when they felt that their personhood was validated. They considered their family and friend networks integral to their recovery but also reported feeling lost in the system. The authors write:

“Partnership-based relationships seem to promote personal recovery more than traditional expert–patient relationships. Our findings also indicate that mental health services need to be organized, more individually tailored, and “bottom-up,” starting with the needs, preferences, and goals of service users.”

Photo Credit: Tom Dowse, Creative Commons

In the past decade, alternative understandings of psychosis have become increasingly popular. Researchers are beginning to question the assumptions of the bio-medical model, and critique the efficacy and the ethics behind the use the psycho-pharmaceutical interventions. Others have questioned the benefits of these approaches in the face of crippling side effects like akathisia, and there is also a push to understand the first-person experience of psychosis.

Studies have noted the positive effects of exercise and even arts and culture therapy in recovery from psychosis. This is relevant because one of the primary side effects of neuroleptics is weight gain, which can, in turn, lead to cardiovascular problems. Alternative approaches like Open Dialogue have reported significant success in terms of reducing hospitalization and duration of untreated psychosis with patients of first-episode psychosis. Such an integrated model that focuses on psycho-social measures with minimal use of neuroleptics works equally well or better than the one that utilizes neuroleptics.

Many of the assumptions of the biological approach, with the individual as its primary focus, are being subverted. Research has attributed psychotic breaks to psychological factors like past traumatic experience, especially childhood trauma, and socio-cultural factors like violent crime victimization and social adversity. In the last decade, studies have started to track differences in the content and experience of hallucinations across cultures.

The current study comes amidst these conversations and uses a hermeneutic-phenomenological approach to examine the experience of first-episode psychosis and the place of social relations in it. This involves exploring participants’ lived experiences and the role of relationships in their recovery. The researchers conducted a thematic analysis on in-depth interviews with ten participants, three men, and seven women, who were recruited from an early detection team for psychosis at Haukeland University Hospital in Norway.

The authors of the study identified a few major themes. Participants considered social relations and people, in general, to be an integral part of their recovery – whether positively or negatively. Many reported adverse interactions with mental health workers when they felt unheard, and more importantly, when they thought they were not being taken seriously.

Participants emphasized the importance of “simply being met” in that they valued being treated as individuals with agency. At the same time, they were grateful when professionals took responsibility to alleviate some of the distress caused by paralyzing uncertainty.

Consistent with older findings, many appreciated it when professionals attended to them as people, and not merely to their symptoms. They believed that the language professionals used to talk about their patients’ experience was alienating and disempowering; further, the lack of flexibility from these professionals was felt as frustrating. Attention to the patient’s “personhood,” which is otherwise threatened by psychosis, was considered key to recovery.

“Being seen as a unique person was also linked to being regarded as a person with preferences, which points to another important aspect of personal recovery: self-determination or being active agents in one’s own recovery process,” the researchers write.

Another important theme that emerged was that participants reported feeling lost in the system, especially when they were unable to verbalize their problems. Some noted the importance of continuity; they said it was beneficial to have only one professional who would help them throughout the process.

It is interesting to note here that the Open Dialogue approach caters to both these desires – having patients find the rights words for their challenges and also providing them with one team that helps them throughout the recovery period. Further, some participants deeply valued how helpful it was to talk to other patients about their psychotic experience.

The researchers note that most participants found professional help to be inadequate, and depended heavily on the support of their social circle, that is, their family and friends, to cope with distress. The participants were well aware that their family and friends did not have any expert insight into their condition. Despite that, they stated that the concerns, check-ins, and practical help provided by their support group was itself a significant factor which contributed to their recovery.

Many participants further reported that sometimes, the social connection could lead to bullying and stigma, and yet they still valued a relationship with others. The subjective experience of disengagement and disconnection was felt as detrimental to the healing process.

In conclusion, the researchers maintain that social relationships, both professional and personal, played a significant role in the recovery of participants experiencing first break psychosis. Neither were considered sufficient on their own, but together the positive forms of these relationships were felt to be profoundly beneficial. They write:

“The findings underline the ambiguity of relationships in recovery processes: the positive impact of being seen, supported, and respected as a unique individual and the highly painful experience of having no one you can trust to be there for you, take you seriously, or help you out.”

Thus, the authors contend that a shortcoming of the current mental health services is their sole focus on the individual, which must be rectified to include approaches that emphasize on social relationships of people who have psychosis. They also point to the main limitation of the study, which was its small sample size, thus leading to concerns about generalizability.

In the light of these findings and other researches which have brought forth the significance of psycho-social factors in psychosis, exposed the limitations of solely using neuroleptics, and called for attention to cultural factors in understanding and intervening with psychotic patients, it is vital that we re-visit our conventional understanding of psychosis. As some have suggested, it might be time for a paradigm shift.



Hansen, H., Stige, S.H., Davidson, L., Loberg, E., & Veseth, M. “Needing different things from different people” – a qualitative exploration of recovery in first-episode psychosis. Social Work in Mental Health. Published Online First: 16 October 2019. DOI: 10.1080/15332985.2019.1679324 (Link)


  1. “it is vital that we re-visit our conventional understanding of psychosis.” Very true. There is no test for psychosis, no way to prove someone is “psychotic.” And today’s “mental health” workers are delusional lunatics who, according to my medical records, believe that all dreams, gut instincts, and mere thoughts are “voices” or “psychosis.” According to this staggeringly broad definition of “psychosis,” all human beings could be considered “psychotic,” since we all dream, and many of us think.

    And once misdiagnosed as “psychotic,” the “mental health” poisoners coerce, force, and threaten people to take their neuroleptic drugs. A drug class which does, in fact, create “psychosis,” via antipsychotic induced anticholinergic toxidrome poisoning.

    But all the doctors, unless this is specifically pointed out to an ethical and intelligent doctor, deny the reality that the antidepressants and antipsychotics can create “psychosis,” especially when given in combination or at high doses. Likely largely because anticholinergic toxidrome is NOT an insurance billable DSM disorder.

    I agree, “Partnership-based relationships seem to promote personal recovery more than traditional expert–patient relationships.” My former “experts,” who knew nothing about me, nor about the medically known adverse effects of the drugs they forced upon me, defamed me to my husband with their “bullshit” stigmatizations and hope destroying “lifelong, incurable, genetic disorder” lies. They destroyed my marriage, told me to stop all my volunteer activities, stop exercising, and “concentrate on the meds.”

    I didn’t take that insanely bad “expert” advice, and continued to stay very busy volunteering with my friends, raising my young children, and working on my portfolio. The only noticeable difference between anticholinergic toxidrome poisoning, and the “invalid” DSM disorders, is “hyperactivity” vs “inactivity,” but our “mental health” workers are ignorant of this fact. And I did find my friends, and staying “hyperactively” busy with my friends, as well as “hyperactively” working on my portfolio, was critical in allowing me to eventually convince my highly deluded psychiatrist into weaning me off his neurotoxins.

    But I did relatively quickly learn that complaints, speaking the truth, about the psychiatric drugs was consistently met with more and higher prescriptions, rather than a decrease in the prescriptions. And this is a problem, seemingly, for all “mental health” workers, who seemingly worship their “wonder drugs.”

    Having a definition of “psychosis,” which implies all people are “psychotic,” is definitely a too broad definition of “psychosis.” And the only people I found who discriminate against someone who was “psychotic” is our “mental health” workers, the lawyers who refuse to take cases against those iatrogenic illness creators, and the religious leaders, who are child abuse cover uppers and profiteers in partnership with the “mental health” workers.

    I hadn’t realized my childhood religion had partnered up to profiteer – in the tune of billions – with the child abuse covering up, iatrogenic illness creating “mental health” workers. I hadn’t even realized covering up child abuse was the primary actual societal role of our so called “mental health” workers. Especially since covering up child abuse and making people sick for profit is illegal, unethical, and immoral behavior. I was saddened to learn of the systemic nature of this “dirty little secret of the two original educated professions.”

    Especially since our religions’ and “mental health” workers’ systemic aiding, abetting, and empowering of pedophiles has resulted in huge societal pedophilia and child sex trafficking problems.

    We should take power away from the pedophiles and those who profit off of covering up child abuse, and return to letting the police arrest the child molesters instead. From the communist manifesto:

    “Transfer some of the powers of arrest from the police to social agencies. Treat all behavioral problems as psychiatric disorders which no one but psychiatrists can understand [or treat].”

    The problem is the social agencies and psychiatrists are “arresting” the innocent, while aiding, abetting, and empowering the criminals, because that’s what’s profitable and easiest for them. We need a return to the rule of law instead, communism doesn’t work.

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  2. Hello Ayurdhi,

    there is so much in your article that is positive, but it’s just a start. I do hope this vein of thinking will be pursued further as our family has validated many of the concepts and findings you bring up.

    I’ve never really cared for the term psychosis as I find it to be an judgmental term, almost a pejorative, by those on the outside to absolve them from entering the experience of another. If my wife is ‘psychotic’ then I have no responsibility to try to understand what she is experiencing. But I never took that route, and instead deeply entered her experience, and once there, I found that so much of her experience made sense. And from that point, she and I could walk together to find a way out of the things that were dysfunctional and yet we also found many new ways of seeing things that added to our relationship and life. It really wasn’t all bad, though it was very difficult.

    I might point you to attachment theory and its concepts of proximity maintenance, affect regulation and safe haven. They were absolutely critical in helping me steady my wife thru her ‘extreme states’. Once I learned to be the ‘calm in her storms’, her storms began to calm as well, and then that was the place at which real and deep healing began for her.

    I wish you well,

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  3. ““Partnership-based relationships seem to promote personal recovery more than traditional expert–patient relationships. Our findings also indicate that mental health services need to be organized, more individually tailored, and “bottom-up,” starting with the needs, preferences, and goals of service users.”

    This is a very euphemistic way of saying that seeing a doctor is not likely to be helpful, and that services that ARE actually helpful are ones that start from the client’s needs and preferences. Is this news to anyone? But good for them for making it explicit.

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  4. As someone who once suffered from psychosis, I have found friendships to have been crucial to my recovery. Family members, however well-meaning, can’t help but be part of the problem. Friends are people who take you as they find you, appreciate you for who you are, help you to discover for yourself who that is. And now that I have my own family, there is more love and security available than I could have imagined – although I am always aware that as someone who was emotionally traumatised as a child, I have to be very careful not to unintentionally pass on my own negative experiences to my children.

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  5. This “psychosis” study concludes that positive social relationships are helpful and negative social experiences are unhelpful; this supports the contention that lived experience affects human psychology. This is an astonishing prerequisite for considering whether “psychosis” pathologizes natural emotional suffering (sadness).

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  6. Back before the 19th century it was understood that love and care could “cure” someone who was out of it. Shakespeare had Cordelia love King Lear back from his madness. Mary Shelley had Victor Frankenstein’s friends nurse him back in Frankenstein as well as Prince’s Adrian’s in The Last Man.

    Lucky for shrinks people don’t read much nowadays.

    My “psychosis” was caused by the SSRI they had me on. After the drug induced episode they doped me up on 10 mg of Haldol and everyone at college shunned me.

    Forced to live with my parents who found my zombie state hard to cope with and Mom took my psych label personally. Total alienation. It’s amazing I “came back” at all.

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  7. Surprising that people do better being accepted with all their weirdness and not seen as a pathology. Every bit of evidence points to psychiatry as a failure and worse, as a harm. I went to ER and the doctor informed me that Psychiatry is a science. Well how the heck does anyone respond to that? Funny when they say that, they are waiting for something, a response? A recognition? Psychiatry is not only not science, but a bag of wishful thinking that they hope people keep buying. There is only ONE single way they can keep business going and that is to view all behaviour and talk as a deviation from the norm, the norm they created.

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