Using timelines as part of recovery‐focused practice in psychosis

Accessible summary•  Timelines are used as a way for people to track the development of mental health problems over time particularly factors from childhood, adolescence and early adulthood. They show what was happening in people's lives at the times when they became ill and also at the times when they were well. •  Timelines can be used by service users and mental health workers to make sense of experiences and facilitate coping, including making best use of medicines. •  For many people in recovery the aim will not be to eliminate experiences associated with psychosis and it is often possible to reduce their negative impact and lead a satisfying life. •  Further research is needed exploring links between timelines, concordance and recovery.Abstract The value of timelines is discussed with regard to the promotion of recovery, particularly emphasizing relapse signature and concordance in medicine‐taking. Recovery approaches in contemporary mental health care rely on understanding motivations, aspirations and decision making. In the authors' experience timelines are a useful way of working together with people to make sense of experiences, of which they may only have partial or intermittent awareness. The mental health workers' philosophical approach, the tools available to them and their skills and attributes, shape the therapeutic relationship. Timelines are a useful tool in helping reach the kind of joint understanding within a therapeutic relationship which characterizes concordance. As this relationship develops, decision making including that around medicine‐taking and relapse signature, can be based on this shared understanding. Timeline examples ( Tables 2 and 3) based on the fictitious experiences of Philip, a young man diagnosed with schizophrenia, show their application in recovery‐focused practice. Further research is needed to enhance the limited evidence base underpinning timelines as a method of facilitating concordance. 2 Short‐term timelineExternal events Changes to thoughts, feeling and behavioursNovember 2005 to January 2006 Age 20–21 Discharged and living on my own taking tablets regularly not speed but a bit of skunk. Living on my own enjoying being my own boss. Although still didn't feel 100% confident I was getting by. Missing my mates feeling a bit lonely but seeing my dad regularly. January 2006 Age 21 Bump into my mates Started increasing use of illicit drugs again to cope with feeling stressed. Feeling less lonely and the skunk relaxes me. February 2006 to December 2006 Age 21–22 Seeing less of my mates now. Starting to feel frightened, keeping myself to myself feeling wary of people. Smoking skunk regularly and taking tablets most days. I was anxious, having difficulty concentrating, feeling perplexed because of strange experiences, wanting to withdraw from company, experiencing emotional changes. Sleep and eating patterns changed and I was having trouble concentrating. January 2007 to August 2007 Age 23–24 Fell out with woman at dole office and ran out. Feeling stressed out I was only sleeping for short periods for months. Started to hear a voice, it was whispering at first and then shouting telling me I'm useless and I'll pay, felt I couldn't trust anyone and that people were out to judge me. Smoking skunk regularly and occasionally taking speed. Missing days of taking tablets. August 2007 to November 2007 Age 24–25 Really lonely during this time taking more speed and only occasionally taking medicine Wasn't sleeping I was checking at night. I couldn't trust anyone and people knew about my past. Felt they would judge me. Thought it must be a cult the voice was shouting telling me I was a bad person. Felt low and very anxious, rarely went out of the flat and when I did I would confront people. The only person I really saw was my dad. November 2007 Age 25 Readmitted following barricading himself in flat. Feeling stressed and vulnerable, believed that a religious group where following me and they planned to kidnap me and then to try me in a special religious court for a crime that I committed. I was really frightened and barricaded myself in the flat. Lots of speed no medicines need to keep alert.3 Life span timelineExternal events Changes to thoughts, feelings and behaviourBorn 2 April 1985 May 1985 to March 1987 Ages 0–3 I now know that mum was depressed and admitted to mental hospital. My dad later admitted that he blamed me for mum's illness. I don't remember how I reacted at this time. October 1991 to August 1993 Ages 6–10 My uncle sexually abused me and threatened me with violence if I betrayed him. This did not seem right, felt ashamed to tell anyone, felt different from other boys and found it difficult to make friends at school. August 1993 Age 8 Told mother about sexual abuse and I was disbelieved Felt afraid, shy and confused and the abuse continued. October 1996 Age 11 Started secondary school and the bullying started. Hated school and felt I would never be accepted, hated break times and skipped school whenever I could. Felt frightened and alone and that I was to blame and it was my fault. October 2001 Age 16 Left school with no qualifications. Had nothing to do and did not have a job so went to the Tech. I was taking speed and skunk to fit in with guys on my course. Feeling more relaxed and enjoyed being part of a group and being accepted at last. My thoughts at times started to be jumbled some days seemed to merge into one. December 2002 Age 17 Assaulted with head injury This came out of the blue, someone hit me. I was found lying unconscious and still don't know why it happened. June 2003 to April 2005 Age 18 Much more on my own friends did not come round much and I was using speed and skunk more. Felt frightened and alone and was convinced it was my entire fault that I had been assaulted and my friends had given up on me. May 2005 to June 2005 Age 21 Got a police caution for confronting neighbour about religious beliefs Felt I was different, and that people don't like me. Becoming more angry, fearful and anxious, I couldn't trust people and kept my distance. August 2005 Age 21 Arrested for chasing and shouting at a woman in town centre, ended up being sectioned and admitted to a mental hospital. Was given medicine that seemed to help but stopped taking them when I felt better. November 2005 to October 2007 Age 21–23 Living in my own flat, isolated taking increasing amounts of speed. Felt frightened not able to trust people, just kept myself to myself. Wasn't sleeping great and listened for noises at night when I would check the flat, the voice was shouting telling me I was a bad person and I thought this was part of a cult. Worried about people knowing my past and judging me. Dad says that he is terrified of me when I am unwell. November 2007 to February 2008 Age 23–24 Re‐admitted. Decided to take medicines because of guilt about my dad. February 2008 Age 24 Discharged and allocated a new CPN key worker. She helped me map out my whole life. I attended training workshop successfully completed training. More confident, felt good about my successes, less worried about people the voice was not as loud and was not there as often and did not threaten me so much. CPN helps me to plot out my life and we worked out the things which are important to keep me feeling good. August 2009 Age 25 Met Janice. Worried about side effects of tablets now that I have a girlfriend. Someone likes me feels great to have a girlfriend. March 2010 Age 25 Dad was diagnosed with lung cancer. CPN uses a grid and my life map to help me decide what do. Worried about scaring dad because doctor is offering me a medicine with less side effects but don't want to terrify dad again now that he is ill. I'm not sleeping, can't decide what to do for the best.Format of timeline. The left hand column represents external events and the right hand column shows the corresponding changes to thoughts and feelings and behaviour. The external events are also expressed in Philip's words.