The sample was 67% male, 33% female, ranging in age from 23 to 62 (mean age 48). The racial/ethnic distribution was 41% African American, 41% Caucasian, 15% Hispanic, and 3% Arab. Slightly more than half (56%) were living in supportive housing, while 23% were living in long-term transitional housing, 8% in residential substance abuse treatment facilities, 5% in apartments with Section 8 vouchers (United States government subsidies for low income housing), 5% in adult care facilities, and 2% in homeless shelters. Eighty-five percent reported long-term substance abuse. The primary psychiatric diagnoses were schizophrenia (56%), bipolar disorder (22%), and major depression (22%).
We identified several themes related to the nature of the social networks, how these networks function, and what effect they had on study participants. Study participants identified an average of two ties each, although the closeness of these ties was not always clear. Nine participants had no ties at all. The research team identified three patterns in the data that address why many of the participants' networks are limited: 1) former members of the network died; 2) study participants pushed away network members or removed themselves from their networks; and 3) network members had problems of their own and were unable to engage with the study participants.
Deaths within the Social Network
Almost all participants lost social network members through death. Often, participants' parents died while the participants were young. Siblings, children, and close friends died too, leaving a social support void that was not refilled. Participants described several types of deaths: accidents, drug use, violence, and poor health.
Some deaths left an immediate void, especially when there were multiple deaths in a brief span of time and when they occurred while the participants were young. One participant, age 59, lost a brother, an aunt, and both parents by age 19.
- Every now and again, I would take a trip back to Pittsburgh to see my family. And, uh… my brother… He had passed away…My aunt. I had one aunt…She committed suicide…what really had an impact on me, was when my father passed away, because I thought he was rather young and he had high blood pressure and a bad heart.
Some participants witnessed the deaths at young ages. At age five, Mario (now 57) saw his older brother decapitated in a motorcycle accident. During childhood, Patrice saw her mother die and was then raised by her older sister. By the time Patrice was 23, her older sister and two of her sister's children died as well.
Maria, whose mother had thrown her out of her house at age 12, returned home at 21 to reconcile with her mother, only to learn that her mother had passed away. A few years earlier, Maria lost her fiancé in a shootout at a strip club where she worked. Her fiancé's death left her alone to raise a baby. She explains,
- So, I opened the door to his jeep. He dropped in my arms out of the car seat and fell in the street. He was shot up. He was shot. I'm screaming, and somebody called the ambulance. By the time the ambulance came he was already dead. The last words he said to me was, “Take care of our baby.”
Even when the deaths were not violent, many were sudden. Karla, for example, experienced the early death of her husband.
- In ‘72 I was married. And my husband passed away in 1976. That was traumatic for me as well…I came home from work and I found him … dead. I didn't know that he was dead. I thought he was still alive because his vital organs were still functioning. But he had had a massive brain hemorrhage.
Perhaps the combination of homelessness, mental illness, and addiction involves more individuals living in environments of high stress, risk of disease, poor health care, and poverty, all of which can lead to early death. Such environmental factors appear to be even more likely culprits when we consider how members of the network passed away: through violence, substance overdose, suicide, and health problems.
The fact that deaths figured so prominently in life narratives has several implications. First, when people died, the support void was usually not filled by other people, either personal or professional (such as service providers). The absences remained pivotal even many years later. Second, the continuing traumatic impact of long-ago deaths may suggest a particular vulnerability to loss. This is perhaps a symptom of mental illness for some, and it may make it more difficult to want to become close with others again.
Pushing and Pulling Away
Study participants described behavior motivated by addiction, mental illness, or both, that they believed damaged their relationships. At times, they were demanding, violent, or wore out their welcome, and at other times they withdrew in order to avoid difficult situations or negative influence from substance users.
Richard, 44, for example, alienated his family by physically assaulting both his parents and stealing from his aunt to pay for drugs. While his aunt may have been forgiving, Richard never felt the same closeness.
- Yeah. I stole a ring from one of my aunts…I was in the bathroom and I saw on the side of the sink a ring. I didn't know it was gold…So I picked it up and I put it in my pocket…I sold it for crack, but got a half ounce of grass…And my aunt said…Remember when you went to the bathroom.” I said, “Yes.” “That ring that you took. That was one of my favorite rings. You should not have taken that ring.” I was like, “Uh, Uh, Uh…” I was gonna lie, but then I said no. I said, “I'm sorry I took your ring.” She goes, “It's OK. I understand”… But ever since then I felt that I was never invited back to her house again.
Other participants similarly felt that their behavior distanced people. One participant, a woman in her early 40s, pointed to substance abuse as a problem in her relationship with her family. “I had started building up my drug use. I had family problems…I got caught up in the drug use and started crime and my family problems really escalated.”
Pete also encountered family problems with his former wife and family members. He described finding reasons to leave the house to escape the tension and conflict that he felt his presence generated, and pushing his family to the point of rejection:
- I used to walk out. And I'd go over to the corner store…and we used to sit there and drink beer and stuff…So I'd get back home and hear it again, and again, and again … It was just the same thing everyday. Or I'd get into a fight with (my wife)…The whole family. I'm fightin’ the whole family. I mean, fightin’-not just arguments. It was fightin’. They're like, “…you gotta get out. You have to leave.”
Pushes and pulls are often hard to disentangle, but in most cases the participants viewed them in more of an agentic way, acknowledging their own role in the separation. For example, one participant described feeling pushed away by peer group members because of his mental illness, but his description also includes his own pulling back.
- And my peers they made me do that cause they were saying things about my original self, that made me want to change into something I'm not…‘I don't like you, cause you this way or that way. Or your opinion just sounds stupid.’ Or ‘you're weird.’ Or ‘you, you, you sound like you have low-low self-esteem about yourself, self-confidence, so, we don't want you with our crowd. We don't want you to fit in with us. We don't like your kind around here.’
Problems of Their Own
Because many of the individuals had a family history of poverty, they had relatives and friends who faced challenges of their own. Some participants' family members and friends faced mental illness as well as physical illnesses, had served time in jail or were currently incarcerated, or were limited by their own substance abuse. Others felt burdened by stresses of managing families and low income jobs.
One Latino male, age 28, discussed how his parents served as a role model for his own drug use as a child.
- My mother was doing weed and my father was shooting up dope, he's in the gang, my mother's in the gang, a bunch of drug war stuff. That's why I started using drugs…
It was not uncommon for social network members, especially family members, to have mental illness or substance addiction as well, sometimes diagnosed and sometimes not.
- I was living in Bronx when I met my husband…He was a drug addict. He was doing it to escape from having to have to live (with a mental illness). And…he was constantly going in and out of mental, men-, mental…he was constantly going out of drug, drug, drug rehabilitation testing.
Another participant visited her boyfriend and family members who were substance abusers while she was in treatment.
- I had just started sniffing cocaine with my family on the weekends…I'd get a pass to stay out for the weekend and come back.
Dealing with these problems was often very stressful for participants, as this participant explains his father's mental illness.
- It got to a point where it became overbearing for me…I took my dad for shock treatments; when they come out they don't know where they are. And one time I had to go to the store and I was walking with him and he… was like a little drunk. And I was going to the store to get some cigarettes…And he started to run away from me. I said, “No, dad!” And here I'm running after him on street. And it took everything out of me. And I cried to my brother, cried to my mom. I felt like a rubber band that's being expanded and…and ready to break.
Often, when participants turned to their social network for help, they sought emotional or financial support. While some individuals were helpful, others had their own intense struggles and simply could not spare any extra resources. Jimmy, for example, had a brother who was also mentally ill, and was barely scraping by providing for his two sons.
Bonding, Rebonding, and Social Isolation
If the pre-treatment characteristics of the social networks are described as “bonding,” where the members of the social network shared socio-economic, demographic, and psychological characteristics (Szreter & Woolcock, 2004
), then perhaps participants engaged in “rebonding” during and following treatment. Study participants wanted to interact and rebuild a social network, often with people much like themselves: they had a mental illness, were former or current substance abusers, lived in poverty, and were dealing with multiple problems.
One man in his 50s met a woman he helps out from time to time.
- I got acquaintances that [need] help…Like this girl in Philly…I take to the AA meetings…She has grandchildren. Lives in a single room, and I feel for her…And we both have a friendship. She's there building on me, you know, building up…she's working now like a babysitter. And she's great at it, you know. But I told her, I said, “You just got out of the [psychiatric] hospital, but I hope you told the people that you're working for that you, you know, what's going on.” You understand?
Other study participants found relationships within a treatment program as well. This bonding, however, continues relationships that are similar to the former bonding relationships: they provide emotional support, and are limited in their ability to provide other types of reliable support. One male participant said that he was close friends with one person already in his program and another who was trying to get into the program.
- He's another person that I would, would talk to. But that's about it, one, two people, because you know, you don't know who you can share this information.
Other participants believed that peer pressure played too large a role in their lives and wanted to break away from that pressure. A 59-year-old woman described the pressure she felt from a group of friends she met at a psychiatric hospital.
- They [my friends] were drinking…everybody was drinking. They said, “Come on…the guy's buying beer for everybody.” I said, “No, no, no, no. ‘Cause I knew if I started drinking I'd act like a fool. And then, what kind of housing are they gonna get me? I'm there for housing. I'm not there for drink. I'm sorry. “Oh you want to be one of them stuck in the mud kinds of bitches….” So you get a bad name with your peers. But fuck them, you know. You're not there for them.
Many study participants had had their trust betrayed, and spoke of how they no longer trusted very many people. Some wanted to make new friends and build relationships; others, however, preferred to isolate themselves. Although several men isolated themselves, women appeared more likely to do so.
When asked about her friends one female participant said:
- I don't have no friends…I had one friend. She stabbed me in my back…Not literally stabbed me in my back, no. She said she was my friend, she wasn't my friend.
In contrast, a male participant recalled that after he received treatment, he made significant changes to his social environment.
- I had to make all new friends. When I came into this fellowship I had to let go of all my friends. I had to stop going to all the old places I used to go. And now I replaced them with new places and new friends that I know now. So I don't go to any of those places any more.
Although it was rare, a few participants created bridging or linking social capital through their service providers. These connections developed beyond the typical case management or counseling relationship into one that seemed more personal. One participant describes such a relationship:
- I know his (telephone) number, and his address…He became like my adopted father when my mother passed away, he was there through thick and thin. He helped Betty, my mother…He was that kind-hearted. And more respect…he gave more respect for me and my mother than any in my family.
Another participant describes her ongoing friendship with a former provider. She developed a bond with him as he helped her through various life situations, first within a professional setting, but later outside of the institution.
- He kept up with me…he always had time for me. You know even if I wasn't even affiliated at the hospital…He was my social worker when I was younger. When I was going to day treatment. ‥I'd just go there, hey, talk, you know, whatever. Sometimes I needed some money he would lend me some money. It was like a friendship thing. Not a friendship, but I don't know how to explain it. More like a person I know. A good person I know. Confidant. Yeah. Not a friend, yeah, maybe a confidant, yeah. A friend confidant.
These two examples notwithstanding, bridging and linking relationships were rare. In other research with low-income, non-mentally ill, and non-substance abusing samples, service providers are often viewed by their clients as part of their social/friend network (Dominguez & Watkins, 2003
), creating the possibility of generating positive bridging or linking social capital. But, if these relationships existed, they were fleeting among our sample.