“People with mental illness have much more going on in their lives than just their mental illness.”
It was a realization Sheila Linz had early in her nursing career, she said, because she spent many years working closely with people struggling with severe cases of schizophrenia, bipolar disorder and other mental health problems. But as the treatment system shifted its emphasis from institutional settings to independent living, Linz, PhD, PMHNP-BC, RN, began to worry that a critical component of mental health was getting lost along the way: social interaction.
That concern led her to choose social isolation in the severely mentally ill as her research focus when she started her PhD program at Seton Hall University as a Robert Wood Johnson Foundation New Jersey Nursing Initiative (NJNI) New Jersey Nursing Scholar.
“When I was younger, I worked in a facility where a lot of people lived, and we had social groups, entertainment, and things for people to do on weekends,” Linz recalled. “But the model is moving away from that. People like to live in their own apartments, and it’s also more affordable. As a nurse and a nurse practitioner, I went into the homes of people with severe mental illness, and they looked very lonely to me. They would always be sitting in their apartments, watching television by themselves. It seemed to me that this was not good for their mental health, and it also left a whole lot more time for their delusions and for responses to their voices.”
Midway through her PhD work, Linz collaborated with Bonnie A. Sturm, EdD, RN, an associate professor of nursing at Seton Hall University, on “The Phenomenon of Social Isolation in the Mentally Ill,” a paper that consolidates a number of scholarly perspectives and analyses. It has been published in the October issue of Perspectives in Psychiatric Care.
“In one way, more people are getting services, because you’re bringing services to the home,” said Linz, who graduated in May—among the first group of New Jersey Nursing Scholars to complete their PhD programs—and now teaches at Seton Hall. “But because of that, people don’t have any real need to leave their homes. There was a situation being created that I thought was pretty serious, especially since it’s so difficult for people with mental illness to be accepted into any kind of community activity, because there’s so much stigma about mental illness.”
A Link Between Social Isolation and Physical Health
Linz said her PhD work was also shaped by research showing that people with severe mental illness live 25 years less, on average, than the general population. “And this was not because of suicide,” she said. “There were a lot of metabolic disorders, and it could not be explained totally by their medications. I also saw that there was a lot of research about the general population having early morbidity and mortality due to social isolation. A lot of studies showed that social isolation was as much of a predictor of mortality, or a risk factor, as smoking or drinking.”
“I came to see social isolation as a problem not only affecting mental health, but also physical health, which is another huge problem,” Linz said.
The paper offers solutions, and describes the implications of implementing them for nursing practice. “It talks about successful methods to help people with severe mental illness engage with the outer world and have a better sense of who they are,” Linz said. “There are also suggestions for what the practitioner can recommend, such as volunteering, or seeking out activities, like art classes or poetry readings, that engage the patients around their interests and their cultural identification.”
“A lot of people with severe mental illness don’t even think they’re sick,” Linz added. “Those are the people who don’t go to medical appointments and end up homeless, or they’re back and forth between hospitals. These are the people who have treatment teams going to their homes. For them, there isn’t enough value placed on the role of social interaction and social integration in the healing of mental illness.”
Much of the information in the paper became part of Linz’s literature review for her dissertation, which explored how the problem of social isolation manifested itself in a group of people being served by the mental health care delivery system known as assertive community treatment, or ACT.
“These are multidisciplinary teams, including a nurse, and the team meets every morning to discuss each of their clients before individually going to the clients’ homes,” Linz said. “These teams have done well keeping people out of the hospital, but there are areas such as social integration where they have not done as well. It’s not a priority.”
Speaking to workers on seven different ACT teams from three agencies in two states gave Linz “a front-line perspective on how they define social integration, how they facilitate it, the barriers they face, how they overcome barriers, and what their own ideas are about ways the model could be changed. I got a lot of very interesting information.”