Rajan, not his real name, is around 50 years old. He lives in a residential rehabilitation center in Bengaluru meant for people with serious mental illnesses, run by a non-profit organization. There are about 20 other residents at the center.
Rajan gets along well with most residents, is pleasant to the staff members and actively participates in all the group activities at the center.
Yet, one afternoon when I asked him if he had friends at the center, without a moment’s hesitation, he shook his head and said wistfully: "No, they are all in the US."
He is in touch with a few of them, but only just.
For people like Rajan, social isolation and loneliness often accompany their mental illnesses.
In people with serious mental illnesses such as schizophrenia and bipolar disorder, psychotic episodes can both lead to and be significantly impacted by loneliness as meaningful social relationships become difficult — in many cases incredibly difficult — to sustain.
In my ongoing research on mental health rehabilitation for people with such illnesses in Bengaluru, the connection between serious mental illnesses and loneliness is emerging as one that needs urgent attention.
Loneliness can lead to an increased risk for mental health issues, but people with existing mental illnesses may be especially prone to social isolation, loneliness and their effects, which might further exacerbate their mental health conditions.
Loneliness is now being recognized as a global public health concern. Recently, the World Health Organization established an international commission to consider and address the impact of loneliness on health, including mental health, across the world.
The co-chair of the commission, US Surgeon General Dr Vivek Murthy, issued an advisory on Our Epidemic of Loneliness and Isolation which noted that people who are socially isolated and experience loneliness are at an increased risk of developing depression and anxiety over time.
Worldwide, loneliness seems to be on the rise, and at the heart of it are complex biological, psychological and social factors.
Double whammy
As we turn our attention to this epidemic of loneliness, we need to consider the double whammy of social isolation and loneliness for those who are rendered especially vulnerable by their existing mental illnesses and the varied ways in which the social environment shapes these experiences.
Rajan completed his Bachelor of Technology and held software jobs in India for a few years until holding a job became impossible due to his condition.
His diagnosis is that of paranoid schizophrenia, a devastating mental illness that affects social and cognitive abilities including performing daily activities, completing education, having a job and maintaining social relations.
In our conversation, Rajan was referring to his college friends, most of whom have relocated to the US with cushy IT jobs. Someday, Rajan hopes to re-enter the social world that he once inhabited with his friends.
There is a close connection between loneliness and social isolation. While social isolation means fewer relationships and less interaction with others, loneliness is the subjective experience and feeling of being disconnected from others.
In the case of a mental illness such as schizophrenia, several factors can lead to both social isolation and loneliness.
In addition to overwhelming social stigma, people with schizophrenia also have higher rates of unemployment, lower rates of marriage and a higher percentage get divorced.
Given this, it may well be that people with schizophrenia are "objectively more socially isolated" than the general population, affecting their perceptions and experiences of loneliness.
The importance of family
The Indian context seems to be more hopeful in terms of social isolation.
Several WHO reports on outcomes of schizophrenia across the world indicated that people with schizophrenia in India and other so-called developing countries have better outcomes than their counterparts in the developed world.
In India, the family is considered a central factor for these better outcomes, with supposedly high levels of support and tolerance.
Families in India seem to protect people with schizophrenia from descending into homelessness and a majority of the study population of a 20-year longitudinal project in Chennai (formerly Madras) found people with schizophrenia to be living with their parents, siblings or spouses.
However, studies have also found that when compared to the general population, rates of divorce are higher among people with schizophrenia in any given sociocultural context.
Further, simply living with the family does not necessarily mean qualitatively better relationships, as a study from Chennai shows divorced or separated women with schizophrenia faced hostility from their immediate family.
The substantive quality of familial relationships is an important consideration when looking at how social isolation and loneliness converge or depart from each other.
Rajan told me that he had a loving and caring mother. She died a couple of years ago and it was then that he and his sister decided that it would be best for him to move to the center. His sister comes to meet him regularly, supports him financially, and as far as I can tell, provides much-needed emotional support to him.
For all practical purposes, Rajan has a relatively robust network of social relations inside and outside the center.
Yet his own thwarted aspirations have distanced him not only from his college friends but also his socioeconomic status, the loss of a job that was central to his identity as a middle-class educated Indian man, leading him to qualify his social relationships inside the center — and say he has no friends there.
Even as schizophrenia and other serious mental illnesses affect people irrespective of class, caste, religion, gender and ethnicity, the social environment in which they live has a significant role to play in the unfolding and experiences of the illnesses.
We need in-depth studies to understand the close but complex relationship between social isolation and loneliness in the context of serious mental illnesses across a range of social environments, ranging from living alone, through staying with families, to rehabilitation centers, to better understand the impact of the environment along with the cognitive and functional decline caused by the illness.
One study conducted in Israel among people with schizophrenia found that more active participation in the community led to decreased feelings of loneliness.
It further found that group homes for people with schizophrenia arranged leisure activities within their premises. While this made the homes self-sufficient, it reduced the community participation of the residents.
Mental health professionals and other researchers have an important intervention to make in terms of thinking about how residential center can be better integrated with the community, and to what effect.
At the same time, we need better social support, resources, and health infrastructure to accommodate and address the impact of loneliness on people with some of the most troubling mental health conditions today.
(The author is an Assistant Professor at the Department of Sociology, Shiv Nadar Institution of Eminence, Delhi-NCR. She completed her PhD in Anthropology from the University of Canterbury, New Zealand. This article was originally published under Creative Commons by 360info)
