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:

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