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June 2016
Vol. 61, No. 6

 
A Grand Challenge for Social Work

Isolation seen as critical social problem

Social isolation can occur during any stage of life, experts say, and is seen as a critical social issue and one of the 12 Grand Challenges for Social Work.

A child claims to feel sick to avoid going to school. A man with a chronic illness is not taking his medications because there is no one to take him to the pharmacy. An older woman living alone becomes depressed because she has no one to talk to.

These scenarios illustrate some of the effects of social isolation, and also show it is not just older people who experience it. In fact, social isolation can take a toll at any stage of life, said James Lubben, MSW, who also has a Ph.D. in social welfare.

“Isolation is something that occurs throughout the life course; infants, teens, adults,” said Lubben, inaugural holder of the Louise McMahon Ahearn Chair in Social Work at Boston College, founding director of the Boston College Institute on Aging and professor emeritus at UCLA.

Social isolation is not a new problem. But as attention to it grows, efforts to diagnose and treat it are increasing. And social workers are on the front line, helping patients, developing treatment techniques and programs, and calling for cross-discipline attention and action as they work to help older adults, people with health problems or chronic illnesses, children and youths, and those isolated because of technology or social media.

“I have a lot of passion for this topic, because I think it’s so critical,” Lubben said. “It’s finally getting the attention it deserves.”

The impact is critical because social isolation can be a killer, he said, and the number of people suffering from it are not known.

A ballpark estimate is at least one in 10 older adults is experiencing at least some form of isolation, Lubben said.

“Those numbers are hard to get, because we don’t have generational surveys,” he said. “That part of the message is very important, because the health issues it can create are on par with smoking. It’s something we don’t always give a proper status to in our regular lives, but it’s just as critical to our overall health.”  

Eradicating social isolation is one of the 12 Grand Challenges for Social Work, outlined in the national initiative from the American Academy of Social Work and Social Welfare.

Lubben

Lubben, an NASW-Massachusetts member who was on the executive committee that produced the initiative and took the lead on the social isolation challenge, said another reason the problem is important is because people are social creatures.

“There’s the idea that Americans are rugged individuals,” he said, “but none of us is capable of living alone. And those resources are needed when we have critical needs.”

“The first thing we have to do is recognize (social isolation is) important,” Lubben said. “Nurses, doctors and social workers need to start asking about it. That sends a message to clients that it’s important.”

Social isolation needs to be publicized so more people are aware of it, Lubben said, and he believes the issue can be successfully tackled.

“Whether we do or don’t depends on whether we respond to the grand challenge, mobilize resources and address the problem,” he said.

Numerous studies dating back decades have documented the impacts of social isolation on health.

A Kaiser Health Care study released in 2008 found social isolation was predictive of cognitive impairment, Lubben said.

“Some people think if they do crossword puzzles they will keep their cognitive abilities, but it’s conversation that does that,” he said. “When you’re in a conversation, first you have to listen, then you have to think, and then you respond.”

And a 1979 study showed people with weaker social connections had a greater mortality rate, Lubben said, adding that there is strong evidence that social health, mental health and physical health are connected.

The American Academy of Social Work and Social Welfare, as part of its Grand Challenges for Social Work initiative, released Working Paper No. 7 in February 2015, titled “Social Isolation Presents a Grand Challenge for Social Work.”

Its findings include:

  • Social support networks, or the lack of them, affect a person’s well-being.
  • The connection between social networks and health is consistent despite the differences in social network definitions and health care outcome measurements.
  • Prevention is possible if protocols are added that include the importance of social networks, and interdisciplinary and cross-sector collaboration is necessary.
  • Social workers are well positioned to meet the challenge, but innovation will be required.

In its conclusion, the paper notes the World Health Organization, National Institutes of Health and AARP have all studied social isolation and called for it to be addressed because it is a major health-risk factor.

Social workers already are addressing the issue as they treat the populations they serve.

Older Adults
Crewe

“I think one of the greatest challenges as we age is, somehow there’s the misperception it is a time of isolation,” said Sandra Edmonds Crewe, professor and dean at the Howard University School of Social Work and director of the Multidisciplinary Gerontology Center at Howard. “It’s seen as being normal, and it’s only reported as problems emerge from it.”

Crewe believes the extent of social isolation is undercounted because of this perception that it’s the normal process of aging. It also is possible that some patients who are diagnosed as having depression really may be suffering from social isolation, she said.

“They’re not looking at the causes of depression,” said Crewe, an NASW member. “But just living alone doesn’t mean they’re isolated, because so many who do (live alone) are OK.”

Johnson

Carrie Johnson, assistant director of the Hartford Center of Excellence in Geriatric Social Work at the Boston College School of Social Work, also is a practicing clinical social worker.

Many of her patients are referred by nurses, physical therapists and primary care physicians, or when they are being discharged from hospitals. But the assessments they have undergone have “not happened in an evidence-based way,” the NASW Massachusetts Chapter member said.

“Typically, older adults are screened for a lot of things, but social health is not typically being screened for,” Johnson said. “Social isolation is often not discussed at all. Often times it comes up at a time of crisis.”

Sometimes factors like living alone or being widowed are used, so she believes “the problem lies in definition.”

“Too often we’re getting, ‘This person has a son who’s living locally,’” Johnson said. “The reality may be quite different. The son might be local but estranged, or he might travel for work.”

“There isn’t a shared language, a definition, a screening tool that’s shared,” she added.

Crewe agreed that having family members is not always the final answer; family members need to be available and willing to help. But the patient also needs to be open to them helping, she said.

“The value of independence seems to be strong in older persons,” Crewe said. “A lot of baby boomers are independent. That’s a mind-set. Many don’t want to move in with their children.”

She believes that feeling is more acute now than it was in the past.

“That was not the expectation of my grandmother,” Crewe said. “With my grandmother, (moving in) was the expectation. But her children also were in the same proximity.”

Other social support systems that were once prevalent also seem to be diminishing, she said, like friends, church members, neighbor networks and even the mail carrier, who people always used to know, particularly in rural America.

“We used to call them the gatekeepers,” Crewe said. “I think that (diminishing) also promotes social isolation.”

Berry-Edwards

Being cut off from social contacts can affect a person both psychologically and physically, said Janice Berry-Edwards, who has a Ph.D. in clinical social work.

“When you’re cut off from your social contacts, there is a deterioration in your mental state,” said Berry-Edwards, an NASW member and associate professor at Howard University School of Social Work. “Depending on how the manifestation is, you might also see a deterioration in physical condition.”

If a patient is not physically active, they can take on drastic changes like overeating to the point of heavy weight gains, or the opposite: not eating or even starving themselves, she said.

What causes social isolation is “one of the major cruxes of the issue,” Johnson said. “We’re now working with training local agencies on social isolation.”

Screening tools allow a practitioner to “get into more nuanced categories of social isolation,” she said.

“We’re never going to have a one-size-fits-all, because there are so many causes,” Johnson said. “Using a screening tool allows us to identify what pieces of the social network are lacking. We can identify what is unique about that person and tailor our intervention to that person to address what’s missing. It is so case-specific.”

Patients often have a variety of needs, she said, like who’s doing the grocery shopping.

Social workers have multiple tasks when working with this population, Berry-Edwards said.

“First, you have to identify it,” she said. “You see how the behavior manifested and find the social components of this person. You have to know where it comes from, the context of their experience. You can’t treat it if you don’t know where the behavior comes from.”

“The paradigm is behavior doesn’t occur in a vacuum. Social workers use all the tools developed in their training to determine where that behavior comes from. The person didn’t become isolated for no reason.”

One of the biggest challenges is to identify the isolates, Lubben said.

“It’s not like they’re knocking on your door,” he said. “That requires us in our routine assessments to look out for this issue.”

Johnson agreed and said social workers are “uniquely positioned because our training has us looking at patients holistically.”

“Medical professionals look at the physical side mainly,” she said. “Our training has taught us to look deeper, more broadly, at a person’s situation. Social workers look at social health, mental health and physical health as a complete picture.”

Health Care and Chronic Illness
It can be difficult to identify social isolation in children and youths, social workers say. A clinician can start to determine if social isolation is a probelm by seeing emotional and social pushback. A child who is socially isolated also may often make excuses not to attend school.

Health care and chronic illnesses are thought of as risk factors, Crewe said.

For example, if an older man loses his spouse and she was the driver, it could be difficult for him to shop for groceries, pick up medications or go to medical appointments.

“If you’re living alone and have reduced social networks, transportation — how you get to and fro — really matters,” Crewe said. “Literature basically states that (health care and chronic illness issues) really is a growing problem because we have a growing number of older people.”

Where a person lives also could matter, she said. If they feel vulnerable and hear a knock on the door, or if they live in areas of higher crime rates, they’re not going to even take the chance of going out or interfacing with people they don’t know.

“That’s good common sense, but it also can interface with isolation,” Crewe said. “If they live in high-security buildings, they may be afraid to go out, so the spontaneity of visiting has been altered. Poor health is one of the things that contributes to social isolation.”

She said if someone is showing symptoms of dementia or has a chronic condition, the number of visitors does not increase.

“If you’re ill, you have a number of visitors,” Crewe said. “If it’s a chronic condition, the number of visitors falls off.”

That’s because visitors often do not know what to do — whether to visit or not, she said. Conversation with those feeling social isolation or depression may be truncated, and visitors to nursing homes may feel uncomfortable there.

“Even if a person is living in their own home and the conversation is not engaging, visitors do not know what to do, so people don’t continue to visit,” she said.

Johnson said since people with medical issues who also are socially isolated are more at risk, checking with other provider agencies — like the Visiting Nurse Association — could help. And coordination between social workers and other agencies could ensure that the individual maintains good health care practices and is eating well.

Children and Youth
Pledger

These challenges are not limited to the older adult population; they affect chronically ill children and youths as well, said Drew Pledger, coordinator of mental health services for the Wake County, N.C., School System.

“Chronically ill kids are highly prone to having this struggle,” said Pledger, who serves on the NASW board of directors. “They have needs that make them stand out, medical situations that cause them to be isolated.”

Pledger said since people generally don’t respond very well to people who are different from them, these children often “don’t have the same opportunities for interaction.”

Ill youngsters do get the opportunity for interaction once they go out and get to school, he said, and they have access to transportation.

“My school district is very large,” said Pledger. “Kids can ride the bus an hour or more. Those school friendships they have are important, and social media makes it easier to keep up with friends while they are at home.”

There are a number of challenges when working on social isolation issues with children and youths, Pledger said.

“Number one is finding them,” he said, “but social isolation is so hard to identify.”

Standing apart from others may be a family norm, so it might be a copy mechanism, Pledger said.

“You need that information from life away from school to make that determination,” he said. “I think, in general, there is more trauma that adults and children live through, and trauma can impact your self-concept, and I think families are struggling to maintain.”

Bonilla-Galdamez

Ana Bonilla-Galdamez, a licensed clinical social worker who works at Charles Barrett Elementary School in Alexandria, Va., said she has seen the problem at the high school level.

“Due to gentrification, the student had to move and all of a sudden was removed from the known environment,” she said. “In elementary … there’s more social anxiety rather than social isolation.”

“That manifests with general anxiety,” she added. “I’ve had several cases triggered by one parent being deployed or a parent being sick. There’s a pushing away and withdrawing.”

Bonilla-Galdamez, who was NASW’s Social Worker of the Year last year, said it’s difficult to find and identify social isolation in children.

“Being by yourself and taking a moment to reflect is not a mental health issue,” she said. “Some children like to spend time with themselves. That’s not a problem. But over a long period of time, if they no longer see other people, that leads to the question are they more introverted or is it a situation of social isolation?”

With children, a clinician can start by seeing emotional and social pushback, Bonilla-Galdamez said.

“There are a lot of negative thoughts, and because of a defense mechanism, they’re self-doubting all the time, unwilling to communicate,” she said.

Other issues can include attendance: They don’t want to come to school, telling their parents they have a headache or stomach ache, Bonilla-Galdamez said.

“Noise in the classroom can become unbearable for them,” she said. “Usually, that leads to complaints of a headache and going to the school nurse, who lets them rest then sends them back to class. The more isolated just want to go home.”

Bonilla-Galdamez believes societal changes play a part.

“Kids are overscheduled, parents are overworked, it’s just one thing after another,” she said. “When I was growing up, I don’t remember parents asking for play dates. You’d just go out and play. Now, it’s a different way of interacting. Now you have to ask for a play date. That’s how isolated we are.”

Pledger said it all starts at home. If you come from a family where you are encouraged and exposed — like being taken to church or to the park — that’s good.

“If parents don’t do that, you not only don’t normalize, but you don’t have the capacity to do so,” he said. 

Schools are stepping up to the challenges, using programs and techniques to address the problem.

“I think the challenge is the same across the board: learning how to meet the child where they are, having a genuine acceptance of where they are that’s not judgmental,” Pledger said. “The first task is establishing therapeutic alliance and getting them to learn to be present in that time and space that we’re there with them.”

What’s not helpful is “having someone telling you that’s not the way the world works,” he said.

One common-sense and useful technique is to teach children to practice mindfulness, which helps the brain adjust, he said. The brain is not learning, but it is reviving and growing stronger, which can help with depression and anxiety, and being able to put trauma in perspective.

“Mindfulness is a skill. It takes practice, and if your friends don’t do it, if your family doesn’t do it, it’s hard for you to do it — to explore,” Pledger said. “If it’s used in school, everybody’s doing it, and you’re going to do it.”

When children enter the classroom every day, if the teacher begins with “let’s have a moment of quiet” then “let’s have a moment of stretching,” it becomes normal, he said. “Research shows that it does work, but it requires practice. We’ve been doing it but not practicing it — like take a deep breath and count to 10. It’s not like we’re reinventing the wheel.”

Bonilla-Galdamez said she and a school psychologist run an anxiety group that includes teaching the children how to have positive self talks, like if your brain tells you you’re scared to go to school, you learn how to tell your brain it’s OK.

“We give them tools like mindfulness techniques, breathing, muscle relaxation and learning how to have a flexible brain instead of a rock brain,” she said.

‘Superflex’ is a social skills program that teaches children to be flexible in their thinking instead of overreacting, said Ana Bonilla-Galdamez, a licensed clinical social worker who works at Charles Barrett Elementary School in Alexandria, Va.

Trust-building skills are included, as is a social skills program called “Superflex,” which teaches kids to be flexible in their thinking instead of over-reacting, Bonilla-Galdamez said. 

It teaches that “you know these things are going to happen, but you know you can deal with them” lesson, she said.

Social workers are the right professionals to help these students, Bonilla-Galdamez said.

“We have the training, we have the team approach, we have the resources, we are the bridge between the family, community and the school,” she said. “Whether it’s doing an interview or going into the home, social workers have the training to see a child holistically.”

Pledger also believes social workers are in the best place to help isolated children, because of their roles and training.

“Our basic foundation is based on meeting people as they are and not being judgmental about where they are,” he said. “We look at their total environment, their families, their friends, all the things that impact the individual.”

Pledger thinks universal screening might be a good way to proceed.

“If you do it with everybody, then you haven’t isolated anybody,” he said. “I think it would be an important first step, and I think it would be easier to work with some students, too.”

When it comes to extreme behavior, like recent incidences of school shootings, Pledger said, “we’re focused on can we identify and can we prevent it?”

“What we have to do is figure out how to change the environment so it can’t happen,” he said. “Adults saw that (the shooters) stayed to themselves, and other kids sometimes know but don’t share, or think they’re just (joking) and don’t come forward. We have to identify those kids.”

Technology

While technology like social media may help students who would otherwise be isolated stay in contact with friends outside of school, it can also isolate people.

“Technology gives us more access, but it doesn’t give us face-to-face access,” Crewe said. “That face-to-face contact has diminished.”

Teenagers sometimes do not see the difference, according to Bonilla-Galdamez.

There’s a snapshot app where they take pictures and exchange them with their friends who also have the app, she said.

“You perceive that you’re interacting, but in reality you’re not,” she said. “Now you see technology in preschool — they have tablets.”

There’s one program where you see a duck, she said. They press the duck and it quacks.

“It used to be that Mom would say, ‘What does a duck say?’ to get the response from the child,” Bonilla-Galdamez said.

What’s missing is Mom’s voice, the tone of the voice, and the listening and response on the part of the child, she said. “With the tablet, it’s not the same thing. It’s not social interaction. But it’s the new normal.”

With a lot of parents working and children having electronics, they can be isolated and nobody knows it, Bonilla-Galdamez said.

When it comes to social networks, Pledger said “I think they’re nonsocial.”

“Kids do a lot of their communication electronically,” he said. “It’s a matter of degree. I think social networking is changing the structure of how we communicate, how we’re connected, and I think that changes our ability to interact.”

It also allows people to think they are well-connected, Pledger said.

When children see a stranger, they know it. But they do not see that when connecting with a person online. They don’t recognize the potential danger, he said.

Pledger said you can be sitting with a young person and think they’re talking to you, while the entire time they’re constantly tapping on their electronic devices. And you see that everywhere.

“It’s difficult to detect if they’re socially isolated or not because they’re normal, so to speak,” he said. “Young people have access to electronic communications across the board. They’ve grown up with it as being normal.”

Finding solutions

The World Health Organization recognizes the social component of health, Lubben said.

“Other countries got to this recognition before the United States,” he said. “They’re ahead of us in recognizing its importance. Various cultures have developed policies and programs.”

One example, Lubben said, is when they’re building housing, it’s not enough to just have adequate apartments. There must be access to other neighborhoods, parks and shopping.

The importance of social health needs to be raised, Johnson said.

“It’s as important as physical health and mental health, but we don’t think of social health in the same way,” she said. “We really need to understand how important social health is for our needs, for our clients and for ourselves.”

The role of social workers is vital in tackling social isolation, Lubben said.

“To say social isolation kills draws people’s attention to it,” he said. “To find out how and why it kills and develop the interventions that can alleviate it, that’s why the grand challenge is important. Who better than social workers to address this topic of social isolation?”

Johnson remembers a patient, a woman in her 80s. “She was widowed and lived alone, so people might think, ‘Oh, she’s socially isolated,’” Johnson said. “No. She had family locally and she had friends who were able to look in on her regularly. She had social support.”

Her family often came to see her and check on her, as did a neighbor, and she received Meals on Wheels. She also had various social connections supporting her.

“That’s what stands out about her: It was a best-case scenario,” Johnson said. “That’s what we’re striving for in terms of support.”

Lubben said some athletes think about reserve capacity and bank some of their energy for later in the game.

“We need the same thing in terms of our social capacity,” he said. “Some people are OK when things go well. But when they’re skating on thin ice; these are the ones who sometimes fall through the cracks. The slings and arrows of life get in their way.”

There are some bright spots in the battle against social isolation, like a campaign in California that promotes the saying “Friends are good medicine,” Lubben said. 

And, he added, remember what The Beatles said.

“We all get by with a little help from our friends,” Lubben said. “None of us can go it alone.”

 
 
 
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