Positive Approaches Journal, Volume 9, Issue 4
Murray | 9-27
Volume 9 ► Issue 4 ► 2021
Lessons from COVID-19: The Importance of Social Networks
Michael J. Murray, MD
Abstract
Social connectedness is an important factor in overall health and wellness. The COVID-19 pandemic has revealed the wide health disparities in our country and the enhanced vulnerability from poorly integrated social networks that many individuals with Intellectual and Developmental Disabilities (IDD) experience. This article reviews the structural and functional components of strong social networks, including a review of different types of social capital. Suggestions for evaluating and strengthening social networks according to an individual’s expressed goals are offered.
In 1988, three researchers from the University of Michigan made what was for that time a startling claim, which was published in the prestigious journal, Science1. Their work suggested that “social relationships, or the relative lack thereof, constitute a major risk factor for health—rivaling the effects of well-established health risk factors such as cigarette smoking, blood pressure, blood lipids, obesity, and physical activity.” While the importance of social connectedness for good physical health is relatively well accepted today, this idea was somewhat shocking at the time. Moreover, fostering relationships as a critical component to safety and well-being remains a challenge today, especially for those disadvantaged by circumstance and/or need. 2
Social isolation activates chronic stress reactions in the brain. This causes marked elevations in cortisol, the body’s main stress hormone. Chronic and repeated exposures to elevated cortisol have negative downstream effects in the body including heightened cardiovascular and inflammatory responses—such as elevated blood pressure and heart rate, chronic pain, and increased susceptibility to illness. Furthermore, this chronic elevation in cortisol—essentially a constant hyper vigilant state, the famed “fight or flight” response—results in greater tendency for impulsive behaviors which can further potentiate these health risks through poor lifestyle choices such as smoking or overeating. Epidemiological research done with large community samples consistently demonstrate that those who are more socially connected live longer and healthier lives.3
The COVID-19 pandemic has made even more clear the wide health disparities which exist in our country.4 Individuals who are Black, Latinx, or Indigenous have more than twice the risk of dying from COVID-19 than White individuals. Additionally, there are also socioeconomic vulnerabilities associated with COVID-19 mortality risk with individuals from disadvantaged backgrounds at highest risk. The pandemic and the enacted infection control/containment strategies have been especially challenging for intellectually and/or developmentally disabled (IDD) communities.5 At a time of extreme stress, individuals with very complex needs who benefit from high support and consistent routines were frequently provided neither. Furthermore, the community access restrictions enacted to limit the transmission of the virus revealed the social integration vulnerability many with IDD experience which increases their stress reactions (and all of its downstream ill effects) for a population already at high risk.
Social Integration Patterns for Individuals with Intellectual and/or Developmental Disabilities
Adults with IDD face greater challenges with social integration. Despite desiring a range of social relationships, they experience greater difficulty achieving true engagement due to skills deficits, inadequate supports, lack of opportunity, or some combinations of these factors. Lippold and Burns found that despite being involved in more community-based activities, adults with IDD have more restricted social networks than adults with physical disabilities. 6 Additionally, adults with physical disabilities had a greater balance of relationships with disabled and non-disabled people than adults with IDD. Social support and companionship for adults with IDD is mainly provided by family/caregivers, other individuals with IDD, and paid supports. For individuals with IDD, a key factor in determining successful social integration is the quality of their friendships—frequently by achieving greater balance in interactions with disabled and non-disabled peers.7
As the recent community restriction measures have painfully demonstrated, physical presence in a community through participating/attending community-based activities is not adequate for achieving true social integration in that community. As sites were restricted due to public health concerns, many individuals with IDD experienced heightened marginalization during the pandemic as their social integration was highly dependent on physically attending/accessing their familiar routine(s) rather than from the resultant relationships from community participation. In other words, much of their social connections relied on the scaffolding of shared experience (i.e. both doing the same the same thing at the same time) as would be seen with an acquaintance rather than shared friendship which would be less dependent on external structuring.
Evaluating Social Networks
Post-pandemic, opportunities to safely reintegrate individuals with IDD with their communities will create opportunity for reevaluating community participation activities and the needed supports to achieve greater social integration. Realizing the vulnerabilities that many individuals with IDD face due to their lack of social integration, supporting individuals to develop more robust social networks—comprised of different types of relationships with different types of social partners serving different needs and functions— is of high priority.
When considering social networks, there are a few key concepts to keep in mind. Social integration refers to any type of social connection or relationships. Of note, this can range from the most superficial acquaintance to lifelong
deep friendships. Social networks refer to the web of social relationships surrounding a person. This web crosses domains, settings, and includes relationships of varying degrees of integration. Structural characteristics of
social networks include8,9:
• Reciprocity: extent to which support is received and given in a relationship
• Intensity: extent to which a relationship offers emotional closeness
• Complexity: extent to which a relationship serves many functions
• Formality: extent to which relationships exist within organizational or institutional supports
• Density: extent to which network members interact with one another
• Homogeneity: Extent to which network members are similar to one another demographically
• Dispersion: extent to which network members live in proximity to focal person of the network
• Directionality: extent to which members of the social dyad share power and influence
Individuals with strong social networks display variability across these domains; in other words, an individual with a strong social network would have some relationships with high reciprocity and intensity and some with low. The pandemic experience has demonstrated that many individuals with IDD social networks are dominated by relationships which are low in reciprocity, intensity, density, and bidirectionality, and high in formality and homogeneity leaving them highly vulnerable to social isolation when, due to public health measures, community settings and activities were not available to scaffold their social interactions.
Social relationships are collections of social behaviors superimposed over interpersonal emotions and attachment. These relationships can serve different social functions for an individual—that is what that relationship gives to the individual. Social capital refers to the impact of close, bidirectional relationships through providing high-value interactions and resources. Relationships which result in social capital are highly reciprocal and trusting. There are four primary forms of social capital: (1) emotional capital provides empathy, love, and caring; (2) instrumental capital provides tangible services or aid; (3) informational capital provides advice, suggestions, and information which can address problems; and (4) appraisal capital provides constructive feedback and affirmation.10 Relationships can provide more than one type of social capital and the type(s) of social capital can change with time and circumstance.
There are other potential social functions to relationships. Social influence is the process by which thoughts, emotions, and/or actions are changed by the actions of others; this influence can be negative—such as imitating an acquaintance’s smoking behavior—or positive—such as exercising with a friend. Social hindrance is the process by which one’s attainment of goals is hindered by another’s expressed criticism or negative affect—such as an acquaintance making fun of the choice of a salad for lunch when someone is trying to lose weight. Companionship is sharing leisure and other activities with social partners—this is the function of many peer-peer relationships existing within highly structured social/leisure activities such as participating on a bowling team. Social support is giving and/or receiving support to another in the context of an ongoing relationship. This differs from social capital in that these relationships are not highly reciprocal and typically are unidirectional and highly formalized. Most consumer-support professional relationships have this function.
Relationships can have more than one function at any given time. Additionally, relationships are dynamic, and the functions of a relationship are likely to change as the relationship evolves. Most relationships which have a social capital function initially start with a lower function such as companionship or social influence; it takes time and shared experience to develop the reciprocity and trust needed for social capital. However, relationships with social capital are the ones most individuals find most meaningful and which enhance quality of life. Research has demonstrated that social capital is also most influential on health behaviors.2,10,3
Supporting Social Networks
A helpful step in supporting the development and enhancement of social networks is to evaluate an individual’s current significant social partners and map how they potentially interact in his/her social network. Table 1 provides a tool to evaluate the structure, function, and potential social capital for an individual’s significant social relationships. Given the unique circumstances resulting from the pandemic, space is provided to provide assessment for relationship prior to enacted public health restrictions (“Pre-COVID-19”) as well as plan for the initial community reintegration (“Post-COVID-19”) and any long-term goals for relationship development (“Goal’). The individual should actively participate in the identification of significant social partners as well as plans/goals formation for potential relationship development as he/she is able. After completing these assessments for all significant relationships, any challenges to developing a strong social network for that person may be more apparent such as little variability in one or more structural components of the person’s network or little identified social capital. Table 2 provides opportunity to begin mapping the positive and negative components (contained across the sum collection of a person’s relationships) of the individual’s social network. Space is provided to document any identified missing components of the individual’s network; of note, any identification of missing components should reflect the individual’s self-determined social integration goals. This mapping might help identify goals for the individual and her/his support team. For example, increased planning for diversifying community exposures may be needed to address high homogeneity and low density across relationships. Similarly, identified social skill deficits interfering with the development of social capital can guide ISP or other goal-setting planning.
Typically, social network interventions in support of health behaviors take one of four form8,9,11:
1. Enhancing existing network linkages. These types of interventions are useful when an individual identifies a change, he/she would like to see to an existing relationship such as hoping to develop more intensity or less formality to an existing relationship. Of note, for this to be successful, both individuals in the dyad need to be open to this change. Examples of interventions for enhancing existing relationships include specific training in effective communication strategies between individuals, supports to promote more time and diversity in interactions, and specific skills building to address identified deficits.
2. Develop new social linkages. These types of interventions are useful when an individual identifies low or absent social connectedness in an important domain such as a place of employment/volunteering or wants to explore new opportunities such as wanting to mitigate negative social influences by exploring new community settings. Intervention strategies here may include mentoring or buddy relationships for new opportunities or facilitating self-help groups for promoting greater self-advocacy.
3. Enhancing networks through use of existing resources. This type of intervention takes a systems level approach to promote greater efficacy of an individual’s network. Frequently this involves increasing density of interactions of members in the target individual’s network or looking for synergistic opportunities between 2 or more individuals’ networks. This may take the form of more team meetings between an individual’s residential staff and employment specialists or creating opportunities for individuals and associated members of their social networks jointly participating in an exercise class (strategically blending networks with shared goals/interests to maximize impact).
4. Enhancing networks through community capacity building. A person’s social network needs may not be easily addressed with exiting community resources. This may require creativity in accessing non-traditional sources of support and/or development of novel services. The supports brokerage model reflects this frequent need for expansion of social networks outside of traditional supports.
Social network interventions should always reflect the individual’s social integration priorities and are typically most productive when they utilize resources most meaningful to that person.
Case Example
Jillian is a 28-year-old woman with Autism Spectrum Disorder (ASD) and a mild Intellectual Disability (ID) who lives in a group home with 2 other individuals. Prior to pandemic public health restrictions, her high-value community activities included working part-time in a grocery store, attending a community center pottery class, and weekly shopping trips with her housemates. She has not done any of these activities for over 6 months. Her social interactions have been restricted to daily contact with her housemates, regular contact with her residential support staff, and weekly video calls with her sister and parents. Of note, she has not had contact with her coworkers from the grocery store—several of whom she identified as being “friends”—and people from the community center.
To prepare for eventual safe return to community-based activities, Jillian and her Supports Coordinator completed relationship matrix assessments for Jillian’s significant social relationships. Jillian identified her two housemates and two most favored staff as being the most significant relationships from her group home setting. She identified her sister, her parents, and one of her aunts as being the most significant relationships from her family. She stated that two of her coworkers and one of her peers from the pottery class as being significant social partners for her from her community activities.
After completing an individual assessment for each of the identified social partners, Jillian and her support coordinator mapped Jillian’s social network:
Function |
Who: |
Where: |
What: Supports to |
---|---|---|---|
Companionship |
Maggie (housemate) Ella (peer) Teresa (coworker/friend) Bill (coworker) |
Group home Community Center Work Work |
No additional supports Transportation to CC Continued employment Continued employment |
Positive Influence |
George (staff) Bill (co-worker) Beth (sister) |
Group home Work Family |
Continued employment Continued employment Way to visit |
Social Support |
George (staff) Anita (staff) Beth (sister) Dominic (housemate) |
Group home Family Group home |
Continued employment Continued employment Way to visit |
Emotional Capital |
Mom Dad Aunt Sue |
Family Family Extended family |
Continued health Continued health Continued health, way to visit |
Instrumental Capital |
Mom Dad |
Family Family |
Continued health and financial stability (both) |
Informational Capital |
Mom Dad Aunt Sue |
Family Family Extended family |
Continued health Continued health Continued health, way to visit |
Appraisal Capital |
Mom |
Family |
Continued health |
Negative Influence |
Negative Influence |
Negative Influence |
Continued employment and overlapping shifts |
They also identified Missing Components:
Function |
Target Who |
Target Where |
Needed Supports and/or Skills |
---|---|---|---|
Increase all types of social capital |
Beth |
Family |
Spend more time together and find more meaningful ways to interact |
Find more positive influences |
Ella |
Community |
Look for additional shared interests and ways to spend time together |
After completing this exercise, Jillian and her team looked for additional ways of strengthening the two relationships which Jillian indicated were priorities for her. After having a discussion with Beth, the sisters decided to spend Saturday afternoons
together as a way of increasing the reciprocity and intensity in their relationship which both admitted could be improved. Jillian was excited to share more of her sister’s life more routinely and soon added her sister’s boyfriend, Mike, to her
list of positive influences as she got to know him better. Jillian’s Supports Coordinator worked with Ella’s supports broker to arrange for the two women to attend a Zumba class together which was also taught at the community center. Additionally,
Jillian and Ella went out to dinner and a movie twice a month to spend time with each other outside of the community center. Ella also occasionally joined Beth and Jillian for lunch on Saturdays. At the three-month check-in when she and her Supports
Coordinator remapped her social relationships, Jillian shared that she felt that her social network was both expanding and strengthening.
Conclusion
The pandemic has created physical, mental, and social health consequences for most Americans. Due to their generally limited social networks, individuals with IDD may have been particularly vulnerable as the resulting social isolation created by needed public health measures led to significant social disengagement resulting in even greater overall health risks. Community reintegration efforts will allow for more thoughtful consideration of individual social integration goals and opportunity to address or strengthen identified relationship priorities. Examining the structural components of social relationships and then determining the function(s) of those relationships are critical to understanding an individual in the context of her/his social world. Mapping the interactions of these relationships helps identifies area(s) of strength and potential need. Supporting individuals with IDD to create robust social networks not only promotes higher quality of life and better health, it also can be highly rewarding work.
Social Network Evaluation and Planning Tools
Table 1.
Individual Relationship Matrix
Social Partner: |
Pre-COVID-19 |
Post-COVID-19 |
Goal |
---|---|---|---|
STRUCTURE: (high/medium/low) |
|
|
|
Reciprocity Shared support |
|
|
|
Intensity Emotional closeness |
|
|
|
Compexity Multiple functions |
|
|
|
Formality Exists within |
|
|
|
Density Interactions with other network members |
|
|
|
Homogeneity How similar to you |
|
|
|
Dispersion Near to where you live |
|
|
|
Directionality Shared decision making |
|
|
|
FUNCTION: Influence: Positive or negative Undermining: Interferes with goals
Companionship: Shared activities and interests Support: Giving/receiving support in relationships |
|
|
|
SOCIAL
CAPITAL: For relationship high in reciprocity, intensity, and directionality |
|
|
|
Table 2.
Positive Network Components
Function |
Who: Relationship(s) |
Where: Domain(s) |
What: Supports to Maintain Bond |
---|---|---|---|
Companionship |
|
|
|
Positive Influence |
|
|
|
Social Support |
|
|
|
Emotional Capital |
|
|
|
Instrumental Capital |
|
|
|
Informational Capital |
|
|
|
Appraisal Capital |
|
|
|
Negative Network Components
Function |
Who: Relationship(s) |
Where: Domain(s) |
What: Supports to Maintain Bond |
---|---|---|---|
Negative Influence |
|
|
|
Social Hindrance |
|
|
|
Missing or Underrepresented Network Components
Function | Target Who | Target Who | Target Who |
---|---|---|---|
References
1. House J, Landis K, Umberson D. Social relationships and health. Science. 1988;241(4865):540 545. doi:10.1126/science.3399889.
2. Cacioppo JT, Cacioppo S. Social relationships and health: The toxic effects of perceived social isolation. Social and Personality Psychology Compass. 2014;8(2):58-72. doi:10.1111/spc3.12087.
3. Holt-Lunstad J. Why social relationships are important for physical health: A systems approach to understanding and modifying risk and protection. Annu Rev Psychol. 2018 Jan 4; 69:437-458. doi: 10.1146/annurev-psych-122216-011902. Epub 2017 Oct 16. PMID: 29035688.
4. Berkowitz SA, Cené CW, Chatterjee A. Covid-19 and health equity — time to think big. New England Journal of Medicine. 2020;383(12). doi:10.1056/nejmp2021209.
5. Baweja, R, Brownm S, Edwards, E, and Murray, MJ. COVID-19 pandemic and impact on patients with autism spectrum disorder, Journal of Autism and Developmental Disorders, under review.
6. Lippold T, Burns J. Social support and intellectual disabilities: a comparison between social networks of adults with intellectual disability and those with physical disability. J Intellect Disabil Res. 2009 May;53(5):463-73. doi: 10.1111/j.1365-2788.2009.01170.x. Epub 2009 Mar 19. PMID: 19302469.
7. Green FP, Schleien SJ, Mactavish J, Benepe S. Nondisabled adults’ perceptions of relationships in the early stages of prearranged partnerships with peers with mental retardation. Education and Training in Mental Retardation and Developmental Disabilities, 1995;30: 91-108.
8. Glanz K, Rimer BK, Viswanath K, Heaney CA, Israel BA. Chapter 9. In: Health Behavior and Health Education: Theory, Research, and Practice. San Francisco, CA: Jossey-Bass; 2008:189-210. https://edc.iums.ac.ir/files/hshe-soh/files/%5BKaren_Glanz%2C_Barbara_K._Rimer%2C_K._Viswanath%5D_Heal(BookFi.org)(1).pdf#page=227. Accessed January 4, 2021.
9. Stough LM, Ducy EM, Holt JM. Changes in the social relationships of individuals with disabilities displaced by disaster. International Journal of Disaster Risk Reduction. 2017;24:474-481. doi:10.1016/j.ijdrr.2017.06.020
10. Forrester-Jones R, Carpenter J, Coolen-Schrijner P, et al. The social networks of people with intellectual disability living in the community 12 Years after resettlement from long-stay hospitals. Journal of Applied Research in Intellectual Disabilities. 2006;19(4):285-295. doi:10.1111/j.1468-3148.2006.00263.x.
11. Simplican SC, Leader G, Kosciulek J, Leahy M. Defining social inclusion of people with intellectual and developmental disabilities: An ecological model of social networks and community participation. Research in Developmental Disabilities . 2015;38:18-29. doi:10.1016/j.ridd.2014.10.008.
Biography
Dr. Murray is an associate professor of Psychiatry and Behavioral Health at Penn State College of Medicine. He is the director of the division of Autism Services for Penn State Health and the director of the central region ASERT collaborative.
Contact information
Michael J. Murray, MD
Penn State Health/Central ASERT
717-531-8338