Bringing friendship into practice to tackle loneliness

Bryan Lynch, director of social work at the Sussex Partnership NHS Trust, says he is thinking of creating a line of T-shirts with the slogan, ‘Putting the social back into social work’.

It’s a joke, but one that aptly sums up a key area of practice he and colleague Caroline Field are currently focusing on – the importance of friendships and social connections in practice.

“Someone in our focus group said friendship is a dirty word within professional language because we are told we are not there to be friends with people,” says Caroline, a senior mental health practitioner in one of the trust’s Early Intervention in Psychosis Service teams.

“But in the team I work in, we work with people for up to three years. We have a small caseload, so we really get to know them. I see most of the people on my caseload more than I see members of my own family.

“When you are seeing people every week you do almost become friends with people. Part of our role is to mirror to them what friendship is and how to connect with people.”

The importance of friendship to wellbeing may seem a given. But when Caroline and Bryan looked into this, they struggled to find any social work models promoting it. Nor, to their knowledge, is friendship something that’s emphasised on social work courses. The language is more often of ‘peers’ rather than ‘friends’.

The shift in focus at the trust came after Caroline read an article in the British Journal of Social Work about promoting friendship among care experienced people.

Caroline presented the article to a ‘Social Work Journal Club’ set up by Bryan for colleagues to share interesting papers for discussion and reflection. The paper, by Autumn Roesch-Marsh and Ruth Emond, argued that friendship is an essential human need and should be centrally placed in social work assessments and interventions.

In wake of the enforced social isolation of the Covid pandemic, it’s not difficult to understand why the paper struck a chord within the team.

Social isolation is regularly described as a pandemic in its own right. Earlier this year, research by Ipsos and Sky News showed more than one in three Britons feel lonely, rising to more than half of 18 to 24-year-olds.

The Government’s Community Life Survey of adults aged over 16 in England found six per cent of the population feel lonely always, 19 per cent some of the time and 22 per cent occasionally.

The survey also highlighted that people with long-term illness or disability are more likely to feel lonely, as are people living in deprived areas.

Johann Hari, in his bestselling book Lost Connections, cites social disconnect as largely to blame for increased depression and anxiety. And researchers claim being regularly lonely is as bad as smoking 15 cigarettes a day. To tackle this, loneliness strategies have been launched in England, Scotland and Wales over the last five years.

Such is the extent of the problem that the World Health Organisation has launched a social connection commission to address loneliness as a "pressing health threat".

“Everyone talks about prevention but how do you do that?” asks Bryan. “For me, if we are serious about prevention, it’s about creating the right environment and culture for people to make connections.

“You can’t be too prescriptive about it, you just have to try to create the conditions to help people find their own way to make connections.

“That is a fundamental part of what we should do rather than just prescribe. I have a [government] white paper from 1971 which recognises that mental illness is not just a major health problem but also a major social problem. It’s 50 years later and we’re still not thinking enough about the social aspects of it.”

As social workers in a health setting, Bryan and Caroline believe they have a key role to play emphasising social models of recovery.

Caroline says: “One of the themes that came up in our focus groups was around the NICE guidelines for psychosis. While the evidence base for biological and psychological interventions is strong, there are fewer evidence based social interventions.

“What came across to me in our discussions is that people sometimes don’t consider the barriers people with mental illness face in terms of the economic things, the stigma, the discrimination. People usually make friends by joining a club or a gym but that will cost money. And if you’ve lost your job and you’re unable to work because you’re having a psychosis episode it can be really, really difficult.”

Caroline talks about the friendship “stages” that some people miss out on.

“Friendships mean different things at different stages. For younger people it’s like your world, how many friends you have got. As you get older, you have fewer close friends or your family become more important.

“If you have difficulties with your mental health and you’re not reaching those normal stages society expects of you, you can feel this real disconnect.”

It is, perhaps, ironic that loneliness and poor mental health is on the rise at a time when people have more ways to connect than ever before thanks to the internet.

But social media platforms like Facebook can be alienating to some people, says Caroline.

“You could argue that quite a lot of poor mental health is about comparison, comparing ourselves to others similar to ourselves.”

The team she works in finds ways to get people of all ages, backgrounds and genders together in safe real-world spaces where relationships can grow and flourish.

“A large part of what we do is create groups, so we have a walking group. An offshoot has formed from that and people now meet for coffee without the service, which is amazing. When people come to the end of their three years with us, we don’t want to create a dependency on the service. It gives a lot of hope to see someone transfer the skills they have learned to other areas of life and make more connections and more friendships.”

The team recently launched a research project to capture service users’ experiences of friendship and social connections. The data is being analysed and will be used to create a practice guide.

“The question is how well understood is the importance of friendship with those with lived experience of mental health conditions?” says Caroline. “What is the impact of a lived experience of mental health on friendship and social connections? What are the barriers to finding and keeping friends and social connections? How can social workers or other social care professionals best support those with mental health conditions to make and keep friends?

“There are models on strength-based approaches and being person-centred but I don’t know if there’s anything that names friendship.”

Bryan believes the work the team is doing demonstrates a key strength of social work which should be celebrated and valued.

“What is a mental health social worker in the NHS?” he says. “It’s never been well defined before, but studies like this may help us move closer to describing it. We don’t shout enough about what we do and describe it. You can’t quantify it in [hospital] bed days, but it’s probably more impactful than that. Our job is done when we are no longer needed.”

*This article first appeared in the July/August edition of PSW magazine