INTRODUCTION AND OVERVIEW

‘Connectedness’ is a term denoting the level of social support experienced in one’s life, or the connection we feel to the people, society and social institutions around us. The most important areas of connectedness vary with one’s age, and include family, friends, school, workplace and workmates, and one’s local community. The opposite of connectedness is social isolation.

Human beings by nature are social creatures. Original hunter-gatherer communities have steadily grown into the urban environments we now know. As a species our survival and continued productivity depend upon our ability to live and work as functioning groups, and so connectedness is deeply etched into our natures genetically, psychologically, socially and behaviourally. An indication of the importance of connectedness is the fact that social isolation is a significant risk factor for mental and physical illness, even independent of other lifestyle factors.

Social isolation is not the same as solitude. Solitude can be healthy, such as when we need time to reflect, or to enjoy peace and space. We can feel ‘connected’ and be in solitude at the same time. Conversely, we can be among many people and feel ‘socially isolated’ at the same time, if we do not feel at ease in the environment or are not relating to people in the way we wish to. Therefore, social isolation is more related to our internal state than our external state.

Connectedness can be expressed and fostered in many ways. This chapter looks at the impact of connectedness on health at different stages in the life cycle. This chapter also examines the use of ‘social support’ in healthcare settings.

TAKING A SOCIAL HISTORY

Doctors learn to take a ‘social history’ in medical school as a part of a full history, although the importance of a social history has not always been appreciated. A full social history includes questions such as the following:

More important and telling can be open-ended questions such as:

If we wait to listen and follow up on cues, such questions can reveal a lot more than just information about the practicalities of family, social and work structures. Rather than just describing our external circumstances, they can be windows into the inner world of our social interactions.

SOCIAL ISOLATION AND STRESS

Social isolation is painful, so much so that it figures prominently among the top 10 stressors in the Holmes and Rahe scale.¹ Top among stressors is the grief associated with the loss of a family member. Next come a range of issues related to marriage and workplace stress. Conflict at work is also among the most stressful events in most people’s lives. Most of us will wish, at various times, to shun social connection, but the pain associated with feeling socially isolated indicates that the need for connection is part of human nature. As such, it is expressed in many ways, including physical illness, anxiety, depression, low productivity, substance abuse and domestic violence.

SOCIAL ISOLATION AND ILLNESS

Until recent times, the importance of connectedness—or the lack thereof—as a causal factor in illness has been under-recognised. It is important to remember that although social isolation is a precipitator or aggravating factor for many illnesses, social support is equally protective. Further, social support does not just determine whether we become ill but also significantly contributes to our lifestyle and how we cope with illness.

Social isolation, being a considerable stressor, has a significant impact upon our emotional state and therefore on our physical state. The chapter on mind–body medicine (Ch 8) gives a more detailed account of this. Some of the illnesses and problems associated with social isolation include:

Although social isolation can contribute to various illnesses, it should equally be noted that these illnesses can contribute to people becoming socially isolated. As risk factors, social isolation and socioeconomic factors make a major contribution to many common illnesses.^2,3 They are as important as smoking, being overweight or hypercholesterolaemia. Equally, connectedness is protective against the same illnesses. Some examples:

Some factors that are particularly important include being married, having contact with family and friends, group affiliation and church membership. Even if someone has a chronic illness such as heart disease, the progression of the illness is significantly slowed or accelerated depending on the level of connectedness. The effects are especially significant for the elderly, with the risk of death among those who were isolated being increased fourfold in the months after a heart attack.⁸ Such findings are largely independent of access to medical care.

THE SOCIAL GRADIENT

Research, conducted largely through the work of Michael Marmot and colleagues, has consistently demonstrated that one’s social position or class has a significant effect on health outcomes.⁹ This is not explainable simply in terms of access or lack of access to health resources, particularly in countries with a good standard of universal health cover. It is also not just related to occupational exposure and unhealthier lifestyle, which are more common in lower socioeconomic groups. Other explanations for the findings include:

If social isolation contributes significantly to illness, then the solutions to these problems lie in social structures, attitudes and community values. If, for example, relationships are not valued, or if working conditions do not make it easy for parents to spend time with their families, or if an increasing number of parents have to bring up children as a sole parent, then problems are being bred not just for the current generation but also for those coming after.

CONNECTEDNESS AND MENTAL HEALTH

Study findings have suggested that, of young people who present to a general practitioner for any reason, over 20% will have had suicidal ideation in the preceding fortnight.¹⁰ In addressing issues such as youth suicide, much attention has been given to identifying risk factors and intervening with at-risk individuals. Risk factors for suicide include:

Such statistics, along with the almost ubiquitous presence of risk factors, can contribute to the creation of a sense of fear and a tendency to overreact to the ordinary vicissitudes of adolescence. Risk factors generally come in multiples and when they do, they have a synergistic effect, making the risk of suicide much greater. Equally important in a positive sense are protective factors. Protective factors, such as employment or connectedness at home, help to neutralise the effects of risk factors. Always thinking of risk rather than protection is not only symbolic of our community’s concentration on illness rather than wellness, but also leads to an atmosphere of negativity. A major study of the effect of connectedness on adolescents showed it to be tremendously protective not just against youth suicide and emotional distress but also against substance use and violence.¹¹ The protective effect was significant regardless of ethnic or socioeconomic background. Connectedness at home and at school were the two most important factors. The effect of multiple risk factors in the absence of protective factors is enormous, but the effect of multiple protective factors, even in the presence of multiple risk factors, is to reduce risk to near normal. The most protective aspect of family connectedness was having a parental presence in the house at important times in the day, such as on waking, after school, at dinner and at bedtime. Having shared activities between parents and their children was also very important. A lack of parental presence, especially where the child had access to drugs and guns at home, was associated with a range of risk-taking behaviours.

Promoting protective factors will require the cooperation of a great many individuals and groups in society. Policy makers, politicians and funds providers need to create conditions that are conducive to community building and strong family structures. Researchers need to provide evidence that community building is a major health priority and also to help guide policy. Schools need to recognise connectedness as a core educational objective. Parents need to acknowledge the importance of connectedness and be supported in the community and workplace to make family and community a priority. Healthcare professionals need to identify those at risk and provide therapy or referral as appropriate. General practitioners can also play a number of other roles, such as:

POVERTY

Studies examining the impact of income on health status have found that poverty is associated with a significantly increased risk for mortality over a given period compared with high-income groups,¹² and that this is not explainable by other risk factors. As a risk factor for illness, poverty is at least as significant as smoking, drinking, being overweight and being inactive. The reasons are complex but include the fact that those from less affluent backgrounds:

RELATIONSHIPS AND EMOTIONAL EXPRESSION

People have a basic need to belong to families and communities and also to get along well with others. Relating poorly to others is both a risk factor for mental health problems and an indication of them. Bullying, for example, is common at all ages. In children it tends to be more open and transparent; in adults, consciously or unconsciously, it tends to be more concealed. Although bullying is common, it is not ‘normal’ behaviour or a sign of healthy psychology. Studies of children suggest that bullies are as depressed as their victims.¹³ Depression among bullies is four times as common as in the general population and they are far more likely to have suicidal ideation and psychosomatic symptoms. Bullying, whether perpetrated by individuals, groups or countries, rather than being an expression of strength is really an expression of aggression masking emotional weakness and vulnerability.

Developmentally, how we learn to deal with difficult emotions like anger during our upbringing has major implications for the rest of our lives. Two particularly important periods for the development of emotional health are early childhood and adolescence. A lack of warmth and nurture as a child means that important pathways from the prefrontal lobes that govern reasoning and emotional regulation will not be laid down adequately. Even in a normal adolescent these pathways are not well developed, in part explaining why adolescents have difficulty controlling impulses and empathising with others at this age.

There are healthy and unhealthy ways of dealing with anger. Among the unhealthy ways are suppression and aggression; and even ‘catharsis’ can engender more anger in the longer term.¹⁴ These will tend to be destructive to oneself or others. Healthy ways of dealing with anger include education, improving one’s communication skills, cognitive behaviour therapy, mindfulness-based therapies, assertiveness training and many other approaches. There are also useful and regulated outlets for pent-up emotions, such as sport, provided the expression is within the laws of the game.

Anger and hostility have detrimental effects on health. Apart from being pro-inflammatory and immunosuppressive, they also accelerate the progression of cardiovascular disease. For example, a study of young adults (18–30 years) followed up for 10 years clearly showed that hostility was associated with a significantly higher rate of coronary calcification independent of other lifestyle factors.¹⁵ Hostility is defined as a personality trait associated with an attitude of cynicism and mistrust, high levels of anger, and behaviour such as overt or repressed aggression.

MARRIAGE AND LONG-TERM PARTNERSHIPS

In the adult years, the marital or long-term partner relationship is probably the most important relationship with regard to physical and mental health. The fact that virtually every culture fosters the family unit based upon the marital relationship suggests that it is written deeply into human biology and psyche.

It has long been acknowledged that marriage is associated with positive health outcomes even if it is only moderately happy.¹⁶ Most studies have focused on heterosexual relationships, but similar findings are likely for other long-term and cohabiting relationships. For example, a growing number of countries have introduced a form of marriage or civil partnership registration for same-sex couples. It is argued that legal and social recognition of same-sex relationships may reduce discrimination, increase the stability of same-sex relationships and lead to better physical and mental health for gay and lesbian people.¹⁷

Marriage is protective for both sexes, although in male–female partnerships it may be relatively more protective for men than for women.^18–20 Roles within a relationship also have a different effect for men and women. Greater companionship and equality in decision-making have a strong positive influence on women, but less so on men. A significant part of the positive effect of marriage on the health of men is related to the role that marriage has in improving men’s lifestyle, hygiene and health behaviours. Although a significant life transition in itself, marriage largely acts as a buffer for stress and is protective for depression and other mental health problems.^21,22 Obviously, chronically unhappy marriages do not exert a positive health influence and in such a situation an unmarried person is likely to be happier and healthier than an unhappily married one.²³ A patient’s response to the question, ‘How critical is your spouse of you?’²⁴ is a very strong predictor of depression relapse. Living with a partner who is constantly undermining one’s self-esteem is not conducive to self-development and empowerment. The level of confidence in a relationship is also predictive of the development of mental health problems.²⁵ The recalling of marital conflict, particularly for women, has a significantly negative effect on blood pressure, and induces many of the effects of the fight-or-flight response, as would be expected.²⁶ An unhappy marriage is therefore a significant contributor to high allostatic load if prolonged.

Stable long-term relationships are associated with lower all-cause mortality and cause-specific mortality from cancer and heart disease.²⁷ Recent bereavement or a chronically unhappy cohabiting relationship, on the other hand, is a significant risk factor for death from a whole range of causes.²⁸ This is illustrated by the fact that women with heart disease had a three times higher chance of further relapse and death over the following 5 years if they had a stressful marital or other cohabiting relationship.²⁹ Marriage also has effects upon immunity. For example, recent bereavement is associated with poor immunity and response to immunisation, whereas happy and stable relationships are associated with better immune function.³⁰ Recent separation or divorce is associated with a significant increase in the risk of infectious disease, such as a six-fold increase in the chance of death due to pneumonia.³¹ There is even more significant immunosuppression during marital separation.^32,33 In summary, the stress of negative relationships and hostility in marriage produces a clinically significant compromise of immunity.³⁴ Marriage can also, for better or for worse, affect the progression of chronic fatigue syndrome,³⁵ the experience of acute and chronic pain³⁶ and the progression of cancer. Social support in the form of marriage or a committed long-term relationship, or frequent daily contact with others, and the presence of a close confidant, seem to have a protective effect against cancer progression.³⁷

Relationship counselling needs to be sensitive to the differing needs and approaches of men and women. This is one of the main reasons that some men will avoid marriage counselling. Women, for example, may feel more comfortable in speaking about emotions than men, and men may wish to take a more pragmatic or cognitive approach. Considering the varying ways in which men and women tend to respond to stress (see the section on the ‘fight-or-flight’ and ‘tend-and-befriend’ responses in Ch 8), there may be biological as well as socially conditioned reasons for this. This does not preclude the fact that it is likely that communication skills and emotional sensitivity will need to be enhanced, particularly in men.

Relationship counselling will also need to take into account the religious and cultural background of the individual, couple or family. These factors can have an enormous impact on attitudes to roles, sexuality, family structures and divorce. The counsellor and patient(s) may be unaware of the other’s perspective or have widely divergent views on a range of matters. This can make unbiased and patient-centred counselling difficult and may mean that it is sometimes appropriate to refer a patient or couple to a culturally appropriate counsellor.

Important adjuncts to relationship counselling will also include building social and psychological skills and capacities, including emotional intelligence, mindfulness, positive psychology and communication skills.

SOCIAL SUPPORT IN HEALTHCARE

Social support can be provided in healthcare settings in a number of ways. First, many people find visiting the doctor an important source of emotional support, as the doctor plays the role of a close confidant. The medical consultation in itself provides perspective, a sympathetic ear, reassurance and comfort.

In a more formal sense, social support is built into healthcare through the use of support groups, group therapy and group-based education. These are important vehicles for healthcare that have been far under-recognised by practitioners and the healthcare system alike. There are formal and informal support groups related to just about any condition. Support groups are generally built on a few basic principles.

Doctors interested in running support programs or group-based activities would be advised to receive further training in these approaches as they require different skills in facilitation and communication than those required for individually delivered interventions.

Accessing information is one of the most important reasons for accessing support. Studies suggest that the most important information sources are doctors, but family members, nurses, friends, the internet, other medical personnel and other patients are also very important sources.³⁸ Information technology is becoming an increasingly important means of accessing support and information, although it has its risks and is no substitute for people connecting personally. In spite of this limitation, the internet may play an important and beneficial role, particularly for young people who are reluctant to speak to healthcare professionals.³⁹ It can also be a cost-efficient way of delivering services to an audience who would otherwise not access them.

Incidental social support is provided in an informal way through one’s daily social interactions, employment, being a member of an organisation or club and by being a member of a family. An approach to dealing with any health issue should include an examination of the extent and quality of the person’s social interactions and an exploration of how to improve their quality and possibly their quantity.