Social Psychology and Anthropology

Social connection is a pillar of lifestyle medicine. Humans are wired to connect, and this connection affects our health. From psychological theories to recent research, there is significant evidence that social support and feeling connected can help people maintain a healthy body mass index, control blood sugars, improve cancer survival, decrease cardiovascular mortality, decrease depressive symptoms, mitigate posttraumatic stress disorder symptoms, and improve overall mental health. The opposite of connection, social isolation, has a negative effect on health and can increase depressive symptoms as well as mortality. Counseling patients on increasing social connections, prescribing connection, and inquiring about quantity and quality of social interactions at routine visits are ways that lifestyle medicine specialists can use connection to help patients to add not only years to their life but also health and well-being to those years.

It is time to appreciate and utilize connection and social bonds as part of lifestyle counseling. Individuals need connections in their lives in the workplace and at home. Fostering these connections is critical to health and wellness. Lifestyle medicine is the growing specialty that works to formalize the counseling and prescriptions for healthy habits, including regular exercise, nutritious foods, stress management, smoking cessation, and moderate alcohol use. Incorporating social support and connections is critical for overall health and for healthy habits to be sustainable. The social ecological model of change stresses that we exist in communities and these groups have an important impact on individuals and their behaviors. There are decades of research that support the importance of social connection. Moreover, humans have lived in groups for thousands of years. In a meta-analysis by Holt-Lunstad and colleagues at Brigham Young University, they examined 148 articles published on the effects of human interactions on health outcomes, and they reported that social connections with friends, family, neighbors, or colleagues improves the odds of survival by 50%. High social support and social integration are associated with the lowest relative odds of mortality compared to many other well accepted risk factors for cardiovascular disease. The review article by Holt-Lunstad and colleagues is a powerful demonstration of the evidence base behind social connection and health. Low social interaction was reported to be similar to smoking 15 cigarettes a day and to being an alcoholic, to be more harmful than not exercising, and to be twice as harmful as obesity. In addition, the devastating effects of loneliness and social isolation have been well researched.

Prescribing social interactions and encouraging friendships has the potential to have a healing effect on patients. Social connection should be viewed and treated as a vital sign much like physical activity. The “Exercise Is Medicine” campaign helped bolster support for the exercise prescription. The time is right for a “Connection Is Medicine” campaign. Asking patients how many close friends they have, if they belong to any organizations or groups that meet regularly, and how often they spend time socializing with others is one way to ensure that social connection receives the attention it deserves. Answers to these questions can be used to improve a patient’s weight management, diabetes control, hypertension, mood, and even immune function. By exploring the research from 50 years ago as well as the most recent data, this article strives to highlight the power of social interactions and to introduce the concept of the connection prescription as an integral part of the health care equation.

Connection as a Basic Human Need

Seminal psychological theories, such as Maslow’s “Hierarchy of Needs,” included the concept of social connection. Abraham Maslow documented and explained the importance of connection, which he called “love and belongingness,” in his book Motivation and Personality, published in 1954. In his hierarchy, there are 5 important needs for psychological growth and development: (a) physiological, (b) shelter, (c) love and belongingness, (d) esteem, and (e) self-actualization. As Maslow describes it, feeling part of a group larger than oneself such as a work community, religious affiliation, community center, volunteer organization, team, interest group, or club is an essential component in the self-actualization process. Close associations with other, smaller groups or even dyads, such as immediate family, close friend, or a life partner, and specifically feeling close to someone, not lonely, are also important for human health and happiness. The self-determination theory developed by psychologists, Edward Deci and Richard Ryan, focuses on 3 basic human needs for sustained, volitional motivation: (a) autonomy, (b) competence, and (c) relatedness. Relatedness is referred to as feeling socially connected to others. This is similar to the love and belongingness in Maslow’s “Hierarchy of Needs.” According to Ryan and Deci, when 1 of these 3 basic needs is obstructed, then a person suffers. It is only when all 3 needs are met that a person feels motivated to tenaciously pursue goals and can thus achieve optimal performance, creativity, and well-being.

Many prominent psychologists and psychiatrists have written extensively about social interactions and their importance in human development. For example, Dr Robert Brooks, a Harvard psychologist, clearly demonstrates the profound effect of just one charismatic adult in a person’s life in his books, Raising Resilient Children, The Charismatic Advisor, and the Power of Resilience. Dr Brooks defines a charismatic adult as a person who a child feels connected to and from whom the child gathers strength. This strength helps children manage through adversity and to persevere despite setbacks. Children are not the only ones who need charismatic adults in their lives. Adults need these people too. The term charismatic adult was originally coined by the late Dr Julius Segal, a psychologist and trauma expert who wrote Winning Life’s Toughest Battles: Roots of Human Resilience,” published in 1986. Dr Brooks carries forward the importance of the charismatic adult and the value of this influential connection in his works and writings today. Connections to others have the potential to propel us forward in our goals and encourage us to persevere when times are difficult.

Physiological Basis of Connection

From the beginning of our lives, we are wired to connect. First, as a newborn, the sound of her baby’s cry, prompts the production of oxytocin in the mother. Oxytocin is the hormone produced in nerve cell bodies in the hypothalamus and then released into the bloodstream from the posterior pituitary. This hormone serves as a signal for the mother to bond with her child, as it causes milk let down for breastfeeding. Oxytocin is not just released in a mother when she hears her baby crying, but it also has other functions in addition to milk let down. There is evidence that oxytocin is released with holding hands, hugging, massaging, and sexual intimacy, Researchers have discovered that petting an animal can cause the release of oxytocin and a pleasant feeling results. There is evidence that oxytocin works in concert with other neurotransmitters such as γ-aminobutyric acid (GABA)–inhibitory neurons for anti-anxiety, through serotonin, a neurotransmitter involved in mood regulation, and through dopamine, a neurotransmitter involved with the nucleus accumbens and the reward system creating feelings of pleasure. Oxytocin seems to facilitate a social attunement, activating more for social stimuli (faces) and activating less for nonsocial stimuli (cars). For these reasons, oxytocin is often called the “bonding hormone.”

References:

Holt-Lunstad J, Smith TB, Layton JB. Social relationships and mortality risk: a meta-analytic review. PLoS Med. 2010;7(7):e1000316. (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2910600/)

Shavelle RM, Paculdo DR, Strauss DJ, Kush SJ. Smoking habit and mortality: a meta-analysis. J Insur Med. 2008;40:170-178. (https://pubmed.ncbi.nlm.nih.gov/19317324)

Critchley JA, Capewell S. Mortality risk reduction associated with smoking cessation in patients with coronary heart disease: a systematic review. JAMA. 2003;290:86-97. (https://pubmed.ncbi.nlm.nih.gov/12837716)

Holman CD, English DR, Milne E, Winter MG. Meta-analysis of alcohol and all-cause mortality: a validation of NHMRC recommendations. Med J Aust. 1996;164:141-145. (https://pubmed.ncbi.nlm.nih.gov/8628131)

Fine MJ, Smith MA, Carson CA, et al. Efficacy of pneumococcal vaccination in adults. A meta-analysis of randomized controlled trials. Arch Intern Med. 1994;154:2666-2677. (https://pubmed.ncbi.nlm.nih.gov/7993150)

Taylor RS, Brown A, Ebrahim S, et al. Exercise-based rehabilitation for patients with coronary heart disease: systematic review and meta-analysis of randomized controlled trials. Am J Med. 2004;116:682-692.

Socialization isn’t a one-time or even a short-term event. We are not “stamped” by some socialization machine as we move along a conveyor belt and thereby socialized once and for all. In fact, socialization is a lifelong process.

In Canada, socialization throughout the life course is determined greatly by age norms and “time-related rules and regulations” (Setterson 2002). As we grow older, we encounter age-related transition points that require socialization into a new role, such as becoming school age, entering the workforce, or retiring. For example, the Canadian government mandates that all children attend school. Child labour laws, enacted in the early 20th century, nationally declared that childhood be a time of learning, not of labour. In countries such as Niger and Sierra Leone, however, child labour remains common and socially acceptable, with little legislation to regulate such practices (UNICEF 2011).

Many of life’s social expectations are made clear and enforced on a cultural level. Through interacting with others and watching others interact, the expectation to fulfill roles becomes clear. While in elementary or middle school, the prospect of having a boyfriend or girlfriend may have been considered undesirable. The socialization that takes place in high school changes the expectation. By observing the excitement and importance attached to dating and relationships within the high school social scene, it quickly becomes apparent that one is now expected not only to be a child and a student, but a significant other as well. Graduation from formal education—high school, vocational school, or college—involves socialization into a new set of expectations.

Educational expectations vary not only from culture to culture, but from class to class. While middle- or upper-class families may expect their daughter or son to attend a four-year university after graduating from high school, other families may expect their child to immediately begin working full-time, as many within their family have done before.

In the process of socialization, adulthood brings a new set of challenges and expectations, as well as new roles to fill. As the aging process moves forward, social roles continue to evolve. Pleasures of youth, such as wild nights out and serial dating, become less acceptable in the eyes of society. Responsibility and commitment are emphasized as pillars of adulthood, and men and women are expected to “settle down.” During this period, many people enter into marriage or a civil union, bring children into their families, and focus on a career path. They become partners or parents instead of students or significant others.

Just as young children pretend to be doctors or lawyers, play house, and dress up, adults also engage anticipatory socialization, the preparation for future life roles. Examples would include a couple who cohabitate before marriage, or soon-to-be parents who read infant care books and prepare their home for the new arrival. As part of anticipatory socialization, adults who are financially able begin planning for their retirement, saving money and looking into future health care options. The transition into any new life role, despite the social structure that supports it, can be difficult.

Socialization is ongoing throughout adulthood in another sense as well. The study of contemporary society reveals an increasing fluidity of roles, as opposed to previous eras when one could expect to be married only once, live in one location, or to have a single career. This experience is part of what Zygmunt Bauman has called liquid modernity. As opposed to previous eras when one could expect to have a career that spanned one’s entire working life, the expectation today is that the individual will experience an increasing fluidity of roles. It is more difficult to view socialization as a smooth and uninterrupted process. Rather, life is increasingly fragmented, “cut into a succession of ill-connected episodes” (Bauman 2004). As a result, social identities have become more flexible, more adaptable to unpredictable transitions, and more open to taking on new roles or picking and choosing from a globalized palette of cultural values and practices.

References:

Bloom, Lisa. 2011. “How to Talk to Little Girls.” Huffington Post, June 22. Retrieved January 12, 2012 (http://www.huffingtonpost.com/lisa-bloom/how-to-talk-to-little-gir_b_882510.html).

Cooley, Charles Horton. 1902. “The Looking Glass Self.” Pp. 179–185 in Human Nature and Social Order. New York: Scribner’s.

Durkheim, Émile. 2011 [1897]. Suicide. London: Routledge.

Erikson, Erik. 1963. Childhood and Society. New York: W.W. Norton.

Freud, Sigmund. 2000 [1905]. Three Essays on Theories of Sexuality. New York: Basic Books.

Gilligan, Carol. 1982. In a Different Voice: Psychological Theory and Women’s Development. Cambridge, MA: Harvard University Press.

Gilligan, Carol. 1990. Making Connections: The Relational Worlds of Adolescent Girls at Emma Willard School. Cambridge, MA: Harvard University Press.

Haney, Phil. 2011. “Genderless Preschool in Sweden.” Baby & Kids, June 28. Retrieved January 12, 2012 (http://www.neatorama.com/2011/06/28/genderless-preschool-in-sweden).

Kohlberg, Lawrence. 1981. The Psychology of Moral Development: The Nature and Validity of Moral Stages. New York: Harper and Row.

Lasch, Christopher. 1979. The Culture of Narcissism: American Life in an Age of Diminishing Expectations. New York: W. Norton and Co.

Social connection is a concept relating to belonging and feeling close to others. Pavey et al (2011) suggest this is a core psychological need that is necessary for life satisfaction. This striving for connection begins at birth and continues throughout our life. Our ability to effectively communicate through voice, and non-verbal signs, such as touch and facial expression, register in our brains so we are able to parent and care for others in our social groups to help us adapt and propagate survival of the species.

Bowlby (1979) wrote on social connectedness and the quality of family dynamics in regards to attachment, bonding and care giving in pairs and in parenting. He was influenced by Freudian thought and the power of deep personal attachments in shaping how the mind looks at the social world, with its assumptions about trust and intimacy formed from early experiences within the family. He identified these as: a secure attachment style that is loving and warm and trusting; an anxious attachment style, where the person is worried and feels like people are going to abandon them; and the avoidant attachment style, which is shown by people who remain distant and possibly dismissive.

Shaver and Mikulincer (2002) have analysed different cultures and observed that secure attachment is essential for happiness so people can trust, are comfortable with intimacy and more likely to remain in stable relationships as they are more likely to be optimistic, forgive their partners, and offer social support. People who struggle are more likely to have an anxious attachment pattern and be more prone to depression, anxiety, drug abuse and eating disorders, for example (Mikulincer and Shaver, 2005).

Attachment status and resulting happiness helps shape the circuitry and systems related to nurturing in the brain when positive interpersonal interaction is delivered and received. Rifkin-Graboi (2008) discovered from the three identified attachment styles that if people received either good or bad feedback, there was a difference in response depending on their attachment status. When participants with anxious attachment style received negative feedback, there was an increased alarm response; however, avoidant attachment respondents elicited an aloof and disinterested reaction, coupled with a corresponding reduced boost of dopamine when any positive feedback was received, lowering joy and pleasure.

Developing Connections

Science indicates that one of the most effective ways to positively improve our happiness is to develop new connections with the people around us, as well as reaffirming those with people we already know (Huppert, 2008; Seligman, 2011) (Box 1). Humans live in groups, pair bond and through connections socialise, share ideas and resources – in fact our survival depends on it. Though interpersonal connection and its interpretation of non-verbal communication may manifest itself differently throughout various cultures, research has suggested our moods are contagious as we are wired to connect with those around us to help understand their feelings and intentions though mirrored neurons (Enticottetal, 2008). Pavey et al (2011) points out that reflecting on feelings of connection increases motivation to help others and therefore increases happiness and improves relationships.

Box 1. Activity: social connections

1. Create a mind-map with the names of people who make up your healthy network of social connections. They are the ones who support, energise, enrich and enable you. They may be:
   • Family and friends
   • Colleagues or managers
   • Professional contacts
   • Online contacts
2. Make a point to keep in contact with your healthy relationships
3. Consider ways in which to stop or reduce contact with those who criticise or are unsupportive.

Adapted from Breines (2014)
Interpersonal interaction

Penner et al (2005) focused on how factors such as ethnicity and gender affected prosocial response. Adding to that body of evidence are further interaction studies that demonstrate how positive cues are given. These can enable us to make the most of face-to-face opportunities when required, such as being supportive to a distressed client, collaborating with colleagues and, delivering person-centred physical care or reacting empathetically in a traumatic situation (Box 2).

Box 2. Activity: interactions

It usually takes five positive interactions to balance up one single negative one.

1. Now focus on one of the positive people from your above network
2. List five positive specific things you could say to them through text, telephone or even better face to face (eg ‘You are so good at…’, ‘Seeing you reminds me of the fabulous time we had at…’
3. Ask them to return the compliment – help to build your own self-compassion.
4. Plan a kind action to show they are not taken for granted (eg plan a small surprise, help them relax, give them an evening off) and be mindful of using positive body language.
5. Show interest in their life – what is a day like in their shoes?

Loneliness

Diener and Seligman (2002) interviewed people about their levels of happiness and other aspects of their life and properties of their personality. They concluded that very happy people tended to have rich and satisfying relationships and they spent little time alone, relative to people with average levels of happiness. Social relationships form a necessary condition for high happiness. Csikszentmihalyi (2013) validated this claim by commenting when people are asked how they are doing on a day-to-day basis that contributes to their happiness, the things that are most strongly related to feeling happy is talking with friends.

There have been studies (Newall et al, 2013; Courtin and Knapp, 2017; Leigh-Hunt et al, 2017) that conclude loneliness shows itself through an increase of symptoms of poor physical health, such as reduced immune response and erratic sleep patterns. Scans have shown activated brain activity is the same area of the brain regardless of whether the person is in social or physical pain (Lieberman and Eisenberger, 2008). Conversely, studies on the effect of touch show an increase in recovery rates, immunity and wellbeing, with a 47% increase in weight gain in premature babies and reduced symptomatology in people with Alzheimer’s disease. These are thought to be due to an increase in release of oxytocin (Wardell and Weymouth, 2004).

Oxytocin in relationships

Oxytocin (the ‘cuddle’ hormone) is a sequence of nine amino acids that are produced in the brain and also move through the blood stream, affecting target organs in the body. Graustella and MacLeod (2012) reviewed the delivery of oxytocin via nasal sprays and concluded it impressively impacted on social cognition by improving the early detection of affect from social cues, particularly positive social cues.

In relation to the benefits of social connection in reducing stress and the cost of stress, Taylor (2006) showed that high levels of oxytocin tended to reduce stress hormones in the bodies such as cortisol, by quietening the cardiovascular response. Feldman et al (2013) found that affectionate touch between parents and offspring increases oxytocin release. This may be extend to society at large to improve trust, generosity, solve conflict more constructively and sharpen emotional intelligence. Kogan et al (2011) investigated genes relating to oxytocin and how they help in emotional intelligence as part of the continuing physical development within the human race that help with connectedness and forming attachments. Furthermore, Wagner et al (2015) note that humans have a strong tendency to affiliate with others, especially in emotional situations. They suggest the perception of sharing emotional experiences is positive and regulates individual emotion as a result of activity in the brain’s reward circuitry.

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