Deakin, Emilia
(2023)
Mixed methods exploration of how people who have experienced psychosis develop a social identity as a ‘person in recovery’.
PhD thesis, University of Nottingham.
Abstract
Introduction
Personal Recovery involves the development of new meaning and purpose in one’s life as a person grows beyond the effects of mental illness. A key recovery process is redefining and rebuilding a positive sense of identity. The Social Identity Approach provides a theoretical framework for understanding identity changes in recovery. The overall aim of the thesis was to develop a model of social identity change in recovery from psychosis.
The original thesis aims (Unfold 1) were to assess digital data collection methods to evaluate prospective assessment of identity change and to characterise the processes involved in developing an identity as a ‘person in recovery’ with particular attention to social identity and sense of wellbeing. The Unfold 1 study was closed at the recruitment stage due to the impact of COVID-19 on health research.
The Unfold 2 study was designed in accordance with NIHR guidance for reopening research studies during the pandemic. The aims were to characterise the processes involved in developing an identity as a ‘person in recovery’ for people with experience of psychosis who are in the Rebuilding and Growth recovery stages. The study had three research objectives: 1) to explore the role of social identity change processes in recovery from psychosis; 2) to investigate the relationship between social identity change, wellbeing and recovery; and 3) to develop a theory of social identity change in recovery from psychosis.
Methods
Unfold 1 and 2 were mixed methods studies with convergent designs. They were informed by the philosophy of pragmatism. Unfold 1 was planned as a 19-month prospective longitudinal study and also included a systematic review of experience sampling methods (ESM) used in psychosis. An ESM study was then designed based on the resulting typology of design choices used in ESM studies. Participants used the RADAR-base app installed on their Android smartphone which prompted them to answer questionnaires several times a day about their social contact and level of wellbeing. Social identity was measured using the social identity mapping tool (SIM-tool). Some participants were expected to participate in semi-structured interviews regarding experiences of social identity change over the previous nine months and their experience of using the RADAR-base app.
The Unfold 2 study was a retrospective study, with two distinct interactive phases. First, quantitative data were collected about social groups using the online social identity mapping (OSIM) tool. Second, semi-structured interviews were conducted about experiences of social identity change and recovery.
Quantitative data were analysed using the Wilcoxon signed-rank test to measure group differences and a Spearman's rank correlation coefficient to measure relationships between groups, wellbeing and recovery. Interview transcripts were analysed using Reflexive Thematic Analysis. Qualitative and quantitative results were integrated using a joint display table to develop the Unfold Model of Social Identity Change in Recovery from Psychosis.
Results
In Unfold 1, the systematic review resulted in a typology of design choices used in ESM studies. The typology comprised three superordinate categories of design choice: Study context, ESM approach and ESM implementation. Design decisions found to predict data completeness include type of ESM protocol used, length of time participants are enrolled in the study, and if there is contact with the research team during data collection. The Unfold 1 study was paused due to COVID-19 after 13 participants had been recruited, however no interviews were conducted.
In Unfold 2, qualitative analysis of responses from 36 participants identified three themes: 1) ‘Illness identity is incompatible with positive social identity’, 2) ‘Illness identity becomes less salient’ and 3) ‘Positive social identity’. Quantitative results from 50 participants showed that, as they recovered, the number of social groups increased by 1.20 groups. Increases in the levels of positivity (0.86 out of 5) and social support (0.27 out of 5) were identified. The results also showed that participants were more likely to report higher levels of wellbeing if they had increased their number of social identity groups (ρ=0.316, p=0.023). Integration of the findings resulted in the Unfold Model, which illustrates processes of social identity change during recovery from psychosis. Key components of the model are that it builds on previous literature by describing the consequences of not maintaining multiple social identity group memberships during a significant life change. It also illustrates the specific processes involved in gaining new social identity groups.
Discussion
This is the first study to used mixed methods to explore the processes involved in developing a social identity as a ‘person in recovery’ from psychosis.
This thesis produced five knowledge contributions. First, the typology of design choices used in ESM studies and predictors of data completeness. Second, identification of experiences of social identity change in recovery relating to illness identity being incompatible with positive social identity, illness identity becoming less salient and positive social identity. Third, identification of total number of social identity groups, group positivity and group supportiveness as measurable aspects of social identity change in recovery from psychosis. Fourth, identification of the relationship between social identity change, wellbeing and recovery. Finally, the Unfold Model of Social Identity Change in Recovery from Psychosis was produced.
The typology fills a knowledge gap related to design decisions for ESM studies recruiting people with psychosis. The classification of design choices provides knowledge and guidance for researchers designing future ESM studies. Identification of design decisions which predict data completeness will enable researchers to make informed design decisions to maximise opportunities for data completeness.
The Unfold Model of Social Identity Change in Psychosis can be used to characterise and further investigate social identity processes involved in recovery in psychosis. The Unfold Model can be used to inform clinical decisions when treating people with psychosis. This may include informing criteria for service entry or assessment processes for group interventions.
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