Doris has been living in her studio apartment in the Crown Heights section of Brooklyn for the past 15 years. She obtained this apartment after finding herself homeless following the breakup of her marriage and other stressors she was experiencing. Doris is quite humble as she describes how her agency has supported her in so many ways. Yet today, she finds herself feeling anxious and worried about her future. Doris reports her third-floor walk-up studio is adorned with lovely family memorabilia which include pictures of her mother and two children, Thomas, 31, and Mary, 27. She reports not knowing her natural father, and has one sister, Margaret whom she speaks to every now and then. Doris is 54 years old and has had various jobs throughout her life and was in a committed marriage for 12 years. Doris reported her husband cheated on her which caused her to go into a “dark place”. She said that she started drinking at the time and found herself unable to manage her finances and was eventually evicted. Sadly, she told me that her children blamed her for the family break up.
Her apartment is under the auspices of a large social service agency that houses individuals with a wide range of needs including many with a diagnosis of serious mental illness. Doris reports her apartment feels homey. She takes great pride in her ability to cook and says she enjoys sewing and her cat, Leo. Doris explains that her sister always encouraged her to seek counseling because her sister noticed some changes in Doris’s behavior. Truth be told, Doris admitted that she was becoming increasingly sad and that she started self-medicating with alcohol.
Doris enjoys her visits with her Supported Housing Case Manager. She described him as caring and that while she was initially reluctant to open up, she found herself having very few people in her life with whom she can connect with. Distrust of various systems can compromise a person’s sense of control, choice and efficacy and lead to poor health outcomes. For Doris to feel socially connected, the experiences must be accompanied with a sense of stability, safety and trust.
Doris’s Case Manager began to encourage her to seek counseling after noticing her sluggish behavior. According to her Case Manager, Doris often appeared morose and detached and this concerned him. Since she started coming to see me for psychotherapy, she admitted she spends much of the time in her apartment alone. She admitted that she hadn’t spoken to her children in many years. Her youngest son, Thomas, has been incarcerated for the past six years on a drug conviction and her daughter, Mary, recently got married and moved to another state. She shared with me that she has been estranged from her daughter for many years and says there are many reasons for this. Many of our sessions together focused on how Doris felt her husband was emotionally unavailable. She said that they were rarely intimate with each other. Doris felt confused at the time and devoid of social connectedness. Mutuality is important for a healthy relationship. These factors enable social connections to develop and help to offset negative health outcomes. She also said that her relationships with her children became increasingly strained as she felt a sense of malaise and emptiness. After obtaining this family history, I felt it was important to focus on Doris’s strengths and interests. Doris shared that she used to love going to church services but that she now finds the commute increasingly difficult. Together we have explored finding a closer church, but Doris expressed ambivalence and increased hopelessness. As people age, their social support networks often become smaller and their social ties lessen.
It should be noted that when obtaining her history, Doris shared that she was hospitalized twice; once after she lost her job in her 40s and shortly after her marriage ended. She said that she could not get out of bed after this loss and that she felt increasingly paralyzed. While she was given medication at the time, she admitted she did not take it because it conflicted with some of her religious beliefs. Doris did say she soon began to feel better through worship and eventually obtained a part-time clerical position. Doris and I agreed that her religious and spiritual activities were clearly important to her and we began to examine some of the underlying causes of her sadness and what we would later classify as depression. Doris admitted her mother was a heavy drinker and her home environment was often volatile. Doris would often hide in her room growing up and found great solace reading scripture. There were times where Doris even talked about certain passages of the bible that gave her comfort. While I initially felt ambivalent having such discussions, I recognized they were important to Doris so we continued to pursue them. Studies have shown that religion or spirituality are effective in helping individuals cope with major life stressors such as illness, divorce, or mental illness (Harvey & Silverman, Journal of Cross-Cultural Gerontology, 2007). Religious or spiritual beliefs can provide a sense of meaning and connectedness especially to individuals with the least amount of resources who are encountering difficult life circumstances.
Vincent is a 62-year-old male living in the Williamsbridge section of the Bronx. Recently he was hospitalized and referred to a CR/SRO as he found himself homeless with no support. Vincent lived with his parents, Joseph, 86, and Maria, 84 until their death. Vincent was never married, but takes great pride in talking about working in his family restaurant for over 50 years. He completed 10th grade. He said he found it hard to concentrate in the classroom and remembers getting into trouble often.
He reported that he felt great joy in joining his three siblings who also worked in the family business. It should be noted that Vincent is the youngest of four siblings. His two brothers, Angelo and John, are both married and each have children and grandchildren of their own. His sister, Theresa, is also married with children. Vincent talks about his relationships with his nuclear family with a sense of longing. While he reports they spend Christmas and Easter together he admitted that it is difficult to visit them due to his complex medical issues and what he now calls being labeled as the “crazy one”. He reported having diabetes, hypertension, and obesity. Vincent spoke quite openly about being over 400 pounds but never saw this as a problem. Eventually it was at the recommendation and urging of his primary care physician and Case Manager that Vincent decided to see me. Vincent reported his doctor felt his obesity may be tied to some underlying issues. Health effects impacted by social isolation have been known for some time. Recent evidence indicates that there is an association between a lack of social connectedness, obesity and diabetes (Nonogaki, Nozue & Oka, Endocrinology, 2007)
During our initial sessions together, Vincent said that he was often bullied in school and never had many friends. While he did admit to feeling different from others, he never felt he had a problem. After school he would immediately go to his family’s restaurant. There he would be smothered with attention by his “Nona” who would have an abundance of food waiting. He said that it was a joyous time being in the restaurant and that school was never a priority. Taking care of Vincent’s parents was also something that he spoke a lot about in our sessions. Vincent vacillated between feelings of guilt and admiration. At times it seemed as if the roles were being reversed. Clearly Vincent parents were quite worried about him and his lack of fundamental life skills. Moreover, there were clear signs that Vincent’s parents adored him and fostered a type of co-dependency that may have in fact prevented Vincent from moving forward. He wondered why most of his siblings were rarely available. At times Vincent said he felt tired after being in the restaurant. He did admit that his sister Theresa was his favorite sibling and it was she who first recommended that Vincent seek counseling. At age 20, Vincent reported to Theresa that he was hearing voices coming from the television and that he felt scared leaving the home. He was hospitalized in his early 20s and prescribed medications for what was eventually labeled as paranoid schizophrenia.
My work with Doris and Vincent was similar in that they were both interested in attaining goals related to their housing, integrated health and social connectedness. Today, health care professionals often refer to these factors as social determinants of health and it’s noteworthy to highlight components that contribute to positive outcomes.
- Collaborative partnerships such as Health Home Care Coordination, regular communication with housing providers, on-going dialogues with both behavioral health and primary care professionals, and discussions with natural supports such as friends, families, clergies/spiritual leaders.
- HCBS (Home and Community-Based Services cover a myriad of skills development, activities that can benefit the overall health and well-being of people served. These include Community Support and Treatment, Peer Support Services, and Habilitation Services.
- Therapy Models – there are a number of effective treatment interventions that may assist with social isolation. As discussed in the aforementioned vignettes, one may consider a strengths-based approach to treatment, wellness self-management, family systems psychotherapy, and grief/bereavement counseling.
Social isolation is a growing concern in today’s society and it is noteworthy that people with a diagnosis of serious mental illness often die 25 years earlier than the general population. At ICL, this has played a significant role in the way we approach care. Social isolation or having few social contacts has significant health implications on one’s overall health. For example, Case Managers are trained to pay equal attention to both behavioral health symptoms as well as medical conditions. Moreover, it is recommended when considering review of risk, that staff maintain an integrated health lens.
Social isolation is different from loneliness although they are intricately linked. Social isolation is defined by the level of social connections such as small social networks, infrequent social interaction, and lack of participation in social activities whereas loneliness involves the subjective nature of these social disconnections. Research findings indicate that loneliness and social isolation are similarly bad for one’s health. However social isolation poses more significant health risks and higher likelihood of premature mortality. On average, people who are socially isolated have a 29 percent increased risk of death compared to 26 percent for those who are lonely (Holt-Lunstad, Smith, Baker, Harris & Stephenson, Perspectives on Psychological Science, 2015). Of note is the finding that there was no distinction between subjective or objective measures of social isolation when predicting mortality (Holt et al., 2015). A recent study reported findings that socially isolated individuals were on average 30 percent more likely to have a heart attack or stroke compared to individuals who had strong personal relationships (Valtorta, Kanaan, Gilbody, Ronzi & Hanratty, Heart, 2016). Other findings noted higher rates of infection, depression, and cognitive decline (York Cornwell & Waite, Journal of Health and Social Behavior, 2009).
The discussion on social isolation is indeed complex as noted in the cases of Doris and Vincent. In today’s changing health care climate, social service providers must take into account the impact of Managed Care, Value Based Purchasing, and Medicaid Redesign (MRT). Rather than seeing these changes as barriers, we must be proactive and creative around conceptualizing new program models that may ultimately reduce social isolation, improve whole health, and attain better outcomes.