Groups 4 Health: Evidence that a social-identity intervention that builds and strengthens social group membership improves mental health

Highlights

• Groups 4 Health targets psychological distress caused by social disconnection.

• The program improved mental health, well-being and social connectedness.

• Social identification was the mechanism underlying improvement in health outcomes.

Abstract

Background

Social isolation and disconnection have profound negative effects on mental health, but there are few, if any, theoretically-derived interventions that directly target this problem. We evaluate a new intervention, Groups 4 Health (G4H), a manualized 5-module psychological intervention that targets the development and maintenance of social group relationships to treat psychological distress arising from social isolation.

Methods

G4H was tested using a non-randomized control design. The program was delivered to young adults presenting with social isolation and affective disturbance. Primary outcome measures assessed mental health (depression, general anxiety, social anxiety, and stress), well-being (life satisfaction, self-esteem) and social connectedness (loneliness, social functioning). Our secondary goal was to assess whether mechanisms of social identification were responsible for changes in outcomes.

Results

G4H was found to significantly improve mental health, well-being, and social connectedness on all measures, both on program completion and 6-month follow-up. In line with social identity theorizing, analysis also showed that improvements in depression, anxiety, stress, loneliness, and life satisfaction were underpinned by participants’ increased identification both with their G4H group and with multiple groups.

Limitations

This study provides preliminary evidence of the potential value of G4H and its underlying mechanisms, but further examination is required in other populations to address issues of generalizability, and in randomized controlled trials to address its wider efficacy.

Conclusions

Results of this pilot study confirm that G4H has the potential to reduce the negative health-related consequences of social disconnection. Future research will determine its utility in wider community contexts.

Introduction

People who are more socially connected live longer and experience better mental and physical health (e.g., Holt-Lunstad et al., 2010). Research relevant to this question has focused almost exclusively on establishing the benefits of social resources and the mechanisms through which they might emerge. These data are clearly important, but we need to act on them and move towards articulation and rigorous testing of a coherent approach to social intervention. In this paper, we introduce a novel psychological intervention, Groups 4 Health, to address this gap, and report findings from the program's initial evaluation in a study of people presenting with affective disturbance arising from social isolation.

Social disconnection refers to the lack or loss of social bonds and social separation that ranges in its emotional impact based on the closeness of those relationships. Disconnection arises for many reasons – in response to longstanding social disadvantage, mental health problems, negative experiences of social exclusion and rejection (e.g., ostracism), and even in response to common life transitions (e.g., changing jobs, moving house, retiring). Threats to social connectedness have been shown to be detrimental to survival, and, as highlighted in the social capital literature, has a major impact on mental health and well-being irrespective of age (Berkman and Syme, 1979, Marmot, 2005).

A number of reviews have examined the effectiveness of strategies that target social isolation and loneliness. Several focus specifically on older adults given their heightened risk of social isolation. The majority found support for the benefits of social intervention (McWhirter, 1990, Cattan et al., 2005, Perese and Wolf, 2005), with the findings of Cattan et al. (2005) particularly relevant. Of the 30 studies meeting their review criteria, nine of the ten effective interventions were group-based which led the authors to conclude that social group activity was a vital component in managing loneliness and isolation. However, the specific advantage of group-based over individually-based interventions for isolation has been questioned (Masi et al., 2011) and thus has yet to be directly tested.

Managing maladaptive cognitions has been identified as a key intervention strategy (Masi et al., 2011) and this draws largely on cognitive behavior therapy (CBT) approaches, which are recognized as evidence-based treatments for psychological and psychiatric disturbance. Nonetheless, in the social isolation domain, the message that may be communicated by prioritizing a person’s faulty thinking is that the cause of, and thus the solution to, problems of social disconnection reside primarily within the individual. There are also important implications for longer-term prognosis, with several studies now demonstrating greater pessimism in recovery potential among those patients who attribute their psychological disturbance to biological (and hence individually-determined) causes (Lebowitz, 2014).

Arguably, to target social dysfunction effectively, we need a social intervention grounded in theories of social process, in the same way that we draw on cognitive theory to understand and manage distortions in thinking. At the same time, though, as Masi et al. (2011) meta-analysis makes clear, we need one that is more powerful than the social skills and support strategies currently offered. In this regard, Interpersonal therapy (IPT) is an alternative approach that recognizes the influence of social processes. Like CBT, IPT was originally developed as a treatment for depressive disorders (Elkin et al., 1995), but it targets disturbing life events and relationships that either trigger, or are a response to, mood disturbance (Markowitz and Weissman, 2004). IPT clearly places a greater emphasis on the link between social relationships and depression than CBT. However, its analysis is rather narrow – prioritizing a person's current dysfunctional roles, interpersonal relationships or individual skills deficit, over the wider influence of social group relationships (e.g., with family, work, and friendship groups) that affect a person's emotional state. Moreover, IPT is typically delivered individually rather than in a group context, and, as we discuss further below, the latter may be an important foundation for building social capital.

While neither CBT nor IPT are established treatments for social disconnection, elements of these approaches are evident in previously trialed strategies to manage symptoms of loneliness and isolation. But such diagnosis-led approaches may be suboptimal when social disconnection is the primary source of dysfunction. What is needed is an intervention derived from the science of social relationships. Groups for Health (G4H) addresses this gap. Here we provide initial results of its effects on the mental health of socially isolated young adults, and underlying mechanisms.

G4H specifically targets social connectedness with the aim of improving general health and life satisfaction. It is a five-module, manualized program that seeks to increase connectedness by building group-based social identifications in the context of an in-vivo group experience. In prioritizing social disconnection, G4H was not developed for any specific diagnostic group, though we recognize that where such disconnection is longstanding, it is most commonly expressed in affective disturbance. The program draws on two lines of evidence. The first is the well-established epidemiological literature that recognizes the social determinants of physical health (Holt-Lunstad et al., 2010), mental health (Cruwys et al., 2013), cognitive health (Ertel et al., 2009), and well-being (Helliwell et al., 2013). The second is recent work that applies social psychological theory to account for the conditions in which social relationships are either curative or harmful for health (Jetten et al., 2012), and which explains why social group (as opposed to individual) engagement is especially beneficial in this regard (see Haslam et al. (2014), Cruwys et al. (2014b) and Haslam et al. (2015c)). While there is growing interest in group-based therapies more generally, there is limited recognition of the therapeutic role that the group per se plays in the success of such interventions—in particular, arising from the distinctive properties of group identification (Cruwys et al., 2014a, Gleibs et al., 2011, Haslam et al., 2010) and normative influence (Cruwys et al., 2015). Nor is there a theory-informed understanding of the dynamics of social connectedness that structure health outcomes.

A major problem with the literature on interventions for social isolation is the lack of a theory of social process that accounts for the effect that social group ties have on our cognitions, emotions, and behavior. One approach that can fill this gap is provided by social identity theory (Tajfel and Turner, 1979) and self-categorization theory (Turner et al., 1987; a.k.a., the social identity approach; Haslam, 2004). Fundamental to these theories is the idea that social group memberships furnish people with a distinctive sense of self arising from internalized social identities that entail ties to other ingroup members (e.g., as ‘us University students’, ‘us Catholics’, ‘us Australians’). Indeed, these social identities are often more central to our self-concept – and hence to our behavior (Turner, 1982) – than our idiosyncratic traits or personal identities. The importance of social identity for psychological functioning derives from the fact that when groups are internalized into our sense of self, they exert a profound influence on the way we think, feel and act, and a critical basis for access to health enhancing social support. Social identities also provide people with grounding and anchoring – what Durkheim (1951) referred to as a sense of ‘existential security’ – that has the capacity to make them stronger, more fulfilled, and more resilient as individuals, particularly when vulnerable or challenged (Postmes and Jetten, 2006).

Informed by social identity theorizing, the social identity approach to health (see Haslam et al. (2009) and Jetten et al. (2012)) extends these concepts into the health domain. For our present purposes, the social identity model of identity change (SIMIC; Iyer et al., 2008) is particularly relevant as it highlights the centrality of social identification to health and well-being outcomes and specifies the social group factors that offer protection in this context. Indeed, while the model focuses on the impact of life transitions (e.g., leaving school, becoming a parent, experiencing illness), the social processes that it highlights (e.g., social identification and social identity continuity) have been shown to have general relevance to the process of managing health and well-being in the world at large (e.g., Haslam et al., 2014).

SIMIC identifies four aspects of group life that serve to buffer well-being in a range of social contexts: (a) multiple group memberships, (b) group compatibility, (c) group maintenance or continuity, and (d) new group acquisition. First, it is apparent that having access to multiple identities increases the likelihood that a person can access useful forms of support when needed (Haslam et al., 2008, Iyer et al., 2009, Sani et al., 2015). Second, greater compatibility of these groups ensures they are easier to manage and not a source of unwanted interference and stress (Iyer et al., 2009). Third, maintenance of group memberships over time provides a sense of social identity-based self-continuity in the face of change and uncertainty (e.g., Haslam et al., 2008). Finally, where it is neither possible or desirable to retain old identities, such loss can be countered by acquiring new group memberships that afford opportunities to develop new social identities (Haslam et al., 2014, Dingle et al., 2015, Tabuteau-Harrison et al., 2015). Importantly, it is these group processes – which target social connectedness, rather than simply social support and social contact – that are beneficial to health. These aspects of group life, highlighted in SIMIC, have all informed the content of G4H, and provide the focus for program modules.

G4H's five modules give people the knowledge and skills they need to manage their social group memberships, and the identities that underpin them, effectively. Each module contains a series of exercises and discussions targeting the different aspects of group life identified within SIMIC.

The first module, Schooling, raises awareness of the beneficial effects that social group memberships have for health. It highlights the costs of ignoring the social dimensions of health and points out that failure to use all the social resources at our disposal generally leads to suboptimal health outcomes. However, the module also makes the point that it is within people’s power to counter these effects by learning how best to develop, maintain and harness group-based social resources.

Module two, Scoping, focuses on the range of group-based resources that people have, or ideally should have at their disposal, to optimize health. This module engages participants in the process of social identity mapping (Cruwys et al., 2015). This tool was developed to explore respondents’ social identities, in order to assess their current social functioning and develop a sense of how they would ideally like to function in the future.

The third module, Sourcing, focuses on identifying and strengthening existing valued social identities with a view to optimizing and sustaining these in the longer term. Module four, Scaffolding, uses the G4H group as a model for establishing and embedding new social group connections whilst at the same time exploring strategies to identify which connections to develop and enact through a social plan of action. The goal is to trial these social plans between this and the final module, which takes place at least one month later.

The final module, Sustaining, is a booster session held one month later that aims to troubleshoot any difficulties that have arisen in the course of implementing these social plans. It also revisits social identity maps, created in Module 2, to see how they have developed in the course of the program. The social foundations that have been identified and developed in the preceding four modules are also reviewed with a view to encouraging their long-term maintenance.

The present paper reports the findings of an initial investigation of G4H in young adults experiencing social isolation and associated depression or anxiety, in a non-randomized controlled pilot study. Our aim was to assess the program for its effectiveness in improving health and well-being, and to test hypothesized mechanisms supporting improvement.

Our primary hypothesis is that G4H will improve health and well-being immediately following the program relative to baseline scores (H1a), and be sustained six months later relative to a control group (H1b). We further predict that G4H will achieve these outcomes through the social identity mechanisms outlined in SIMIC – notably, increased identification with one’s new G4H group and multiple (existing and new) group memberships (H2).