Social Isolation: An Exacerbating Factor in Mental Health Problems
Too often taken for granted, our social interactions are central to living a full life, helping us to articulate and ventilate our thoughts. When these interactions begin to fail, a person may then fall into social isolation: a condition in which one loses interest in social connectedness. A cohort study by Public Health Pakistan states that any person is liable to social isolation; however, certain individuals maybe more vulnerable, depending on socio-economic factors such as low education and economic status, unemployment, older age, poor health, stigmatization and unconducive political and cultural circumstances (Husain, 2012).
During my Clinical Rotation, I came across a 54 year old single female patient diagnosed with schizophrenia. Every time I tried to build a conversation with her, or get her to participate in activities, she would refuse preferring to remain alone. Her case file revealed that she was pre-morbidly self-entitled since childhood and exhibited impulsive attention seeking behavior. She also had a history of long term disturbed family relationships and odd behaviors over the past twenty years. Upon inquiring of the concerned staff, I was told that this patient would mostly withdraw to her room, seldom interacting with other patients.
Following up on the case showed me the extent to which social isolation may contribute to mental illness, and the consequent need to fully understand its impacts and look upon strategies and solutions to overcome it.
A study by SANE Research Australia reported that people with mental illness find it 7% ‘easier’, 8% ‘no change’, 30% ‘a bit harder’ and 55% ‘much harder’ to maintain close relationships. Additionally they reported that social isolation is 20% ‘sometimes’, 33% ‘all the time’ and 36% ‘often’ common among people with mental illness (Mental illness and social isolation, 2016).
A quick and successful tool in a clinical setting to determine the extent of social isolation is the Lubben Social Network Scale (LSNS-6). It measures three components of social networks: emotional, tangible and actual network size, which relate to the individual’s family and friends separately (Lubben & Gironda, 2003). On this scale my aforementioned patient scored 7 out of 30, i.e. was significantly socially isolated.
This case scenario can be further reviewed using theoretical framework of Charles Horton Cooley, “The Looking Glass Self Theory”, which states that a person constructs his self-concepts based on their understanding of how others perceive them (Cooley, 1902). In the case of this patient, her impulsive attention-seeking behavior and feeling of worthlessness stem from an insecure self-image reinforced by family members who discount her presence and constantly fault her for her behavior.
Social isolation can be considered both a cause and an effect of mental illness and may hit at any point across a life course of an individual. (Nicholson, 2013) In early years and adolescence, it may be associated with adverse childhood experiences – bullying, poor academic records or even failure to achieve developmental milestones. In adulthood, its consequences include unemployment, relationship breakups and mental distress. In older age, social isolation may exacerbate feelings of loneliness and risk of depression (Mullen & Flaming, 2011).
Fortunately social relationships are fluid, and even the most reclusive individual retains the capacity to reconnect. This capacity however must be brought out, honed and facilitated by the rest of us. Professional help by psychiatrists and counselors would comprise of psychotherapy, specifically Cognitive Behavioural Therapy (CBT). This would aim to help clients consciously change their detrimental social behavior pattern to a healthier one (Hopwood, 2010). We can ask client to list down the reasons why they resist interacting with anyone and then we can work on each, one by one.
As nurses are in direct contact with such patients especially in hospice settings, it becomes their responsibility to build a rapport and trusting relationship in order to encourage patients to verbalize their problems. At community level as per the Social Resilience Model (Leitch & Sutton, 2013), psychiatric health care settings can use skills-based approach to (1) improve social skills by encouraging client to build small conversations with peers or simply by saying thank you or complimenting other; (2) enhance social support and (3) provide opportunities for social contact by using group therapies, trust building activities, anonymous positive feedback activity, organizing focus groups to reduce stigmatization, and (4) address maladaptive social cognition by underlining their negative thoughts and resistive behaviors. A community nurse can also create awareness about how to manage problems by adopting positive thinking and communication skills.
Family counseling can be conducted to ensure a supportive network exists for socially withdrawn patients. On a national level, TV programs, live radio shows and health-related channels can help the society be more receptive to the mentally/socially challenged.
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