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Passport to Whole Health: Chapter 10

Chapter 10.  Family, Friends, & Co-Workers: Relationships

An icon with ME above a reflected image that reads WE.
It is in the shelter of each other that people live.
―Irish Proverb

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The Importance of Healthy Relationships

If you put an animal under stress and it is alone, its plasma cortisol, a stress hormone, will increase by 50%.  If you stress the same animal when it is surrounded by familiar companions, its cortisol does not change.[561]  The same holds true for people; social support matters.  The Alameda County study followed over 7,000 people for nine years and found that the best predictor of mortality in people over 60 was how much social support they had.[562]  We know that better social support correlates with better surgical outcomes,[563] as well as with decreased frequency of colds.[564]  Cancer recurrences, development of dementia, and depression also decrease for those with positive social relationships.[565]  A 2016 review of 35 studies found benefit for connection in diabetes care as well (when done in person or using various communication technologies), including for self-care behavior, physical activity, weight management, and hemoglobin A1C levels.[566]  Loss of social connectedness is also a major contributor to burnout.[567]

When all is said and done, connection is life.  We are social beings, and we thrive on interaction.  As you co-create a Personal Health Plan (PHP) with someone, keep in mind that the “Me” at the center of the Circle of Health is best served when there is a “We” offering support.  In this chapter, the focus is more on relationships with other individuals.  In Chapter 19, we will focus on broader relationships related to Community.

It is clear (and not surprising) that loneliness and lack of connection decrease health.  A 2014 summary of 23 interviews with Veterans who had attempted suicide reported that some of the main conditions contributing to their decision were loneliness and isolation.[568]  A 2019 review went so far as to say that loneliness and social isolation should be included into suicide risk assessments.[569]  Isolation has a significant health impact.  A 2015 analysis of 70 different studies found that social isolation is linked to a 29% higher likelihood of dying.[570]  These findings were consistent across gender, world region, and length of follow up.  Loneliness and poor social connection lead to inflammation and chronic disease.[571]  There is a reason why solitary confinement is considered a terrible punishment.  It has been proposed that social disconnectedness be discussed to screen for heart disease risk,[572] and social connection is associated with a decrease in suicide risk and reduced mortality.[573]

In addition to asking a person What really matters, it is also important to ask:

Who really matters?

The diagram shown in Figure 10-1 is used in skill-building courses to give Veterans a framework for thinking about Family, Friends, and Co-Workers, or “who really matters.”  The “subtopics” can offer ideas for how to bring one’s relationships more fully into focus and assist in incorporating that aspect of self-care into their PHPs.  Each of these areas is discussed in this chapter.

Six subtopics surround the Self-Care header of Family, Friends and Coworkers (Relationships). Those subtopics include: Connect with Loved Ones, Connect with Other Veterans and Community, Improve Communication, Practice Compassion, Work with an Expert, and Make One Small Change.

Figure 10-1.  Subtopics within the Family, Friends, and Co-Workers Circle of Self-Care

Questions to Ask About Relationships

Social support has three dimensions, and all of them are important.  Consider asking about all three[574]:

  1. Who provides you with support? 
  2. How satisfied are you with the support you receive?  A negative relationship may be worse than no relationship at all.
  3. What types of support do you receive?  Social support can be emotional or instrumental (i.e., involves receiving labor, time, or funding from others).  It may also involve receiving mentoring (feedback) or information. 

To pursue this further, you can ask the following14:

  • Who are the 10 people in your life who matter the most to you?  Who are you closest to in your family?  Who is your best friend?  Who is your most trusted colleague?
  • Who provides you with emotional support?
  • Who gives you instrumental support in the form of time, money, and other types of help?
  • What about your sources of appraisal support?  Who gives you affirmation, evaluation, and feedback?
  • Finally, where do you get informational support?  Who offers you advice, guidance, and helpful suggestions?

And here are some other key questions you can consider:

  • Which relationships fulfill and/or strengthen you?
  • Do you get the support you need from your loved ones?
  • Are you lonely?
  • How often do you share your feelings and thoughts with others?
  • Who or what drains your energy?  Can you change this?
  • Do you have friends or family members you can talk to about your health?
  • What do your partner and family think are the causes of your health conditions?
  • Has an illness of a loved one ever affected you?  Are you taking care of anyone with chronic illness?
  • Is there someone you would like to have come with you to your health care appointments?
  • Are you close to your blood relatives (parents, siblings, extended family, children)?
  • Who do you consider to be your “family of choice?”  Is it your blood relatives?  Who else is important to you in your life? 
  • How deeply are your family members involved in each other’s lives?
  • Do you have a significant other?
  • Do you feel supported by your partner? 
  • Are you sexually active?  Are you satisfied with this aspect of your health, and why or why not?
  • Do you have any children?  What ages?
  • What activities do you and your partner do together? 
  • Is anyone hurting you?  Have you been hit, kicked, punched, choked, or otherwise hurt by an intimate partner? (Never forget to ask about safety at home, as noted in Chapter 6, “Surroundings.”)
  • If single: Are you satisfied with being single, and do you have the support you need in your life?
  • Tell me about your closest friend.  What do friendships mean to you?
  • In terms of COVID, how are you doing with balancing physical distancing and social connectedness?[575]
  • Are you able to connect with the people you care about using different types of technology?
  • If you are working, how are your relationships with your coworkers?
  • Do you feel that the work you do is appreciated?

Ten Tips for Enhancing Social Connection and Relationships

The following tips can help as you explore enhancing social connection.

1.  Consider social capital, and ways to increase it

The term “social capital” was first introduced by Robert Putnam in Bowling Alone: The Collapse and Revival of American Community.[576]  The act of bowling alone was used as a reference to the disintegration of U.S. after-work bowling leagues.  It serves as a metaphor for the decline of social, political, civic, religious, and workplace connections in the United States. 

Social capital refers to the value of belonging to one’s social networks.  It is all the benefits that arise from reciprocal exchanges with others, be they family, friends, co-workers, or social, political, or religious organizations.  These networks have value for health.  You contribute in relationships, and just as other people or groups can count on you if they are in need, you can count on them.  Your contributions to relationships increase your chances of receiving support in the future.  An example of social capital would be the shared connection between two people who are both alumni of the same college; they are more likely to connect and share various resources with each other.  There is a strong positive relationship between social capital and both mental and physical health, and it seems to be protective of mortality, noting that is still unclear how social capital influences specific health outcomes.[577],[578]  A study of 944 pairs of identical twins found that if they had higher degrees of social capital, they had better mental and physical health.[579]  In some studies, social capital seems to be linked to some potential negative health effects as well, depending on the nature of a person’s relationships.[580]

2.  Join a healthy group of some kind

This recommendation can be a helpful part of practically every PHP that is written.  Strategize with Veterans about which groups they might like to join, respecting that some people are introverted and need to strike a healthy balance between social time and “alone time.”  Encourage Veterans to explore their options and have a list of options handy.  These may include the following:

  • Volunteer programs.  Volunteering and its benefits are discussed in Chapter 7, “Personal Development.”
  • Support groups.  Many of these are available in the VA.  Some are even offered remotely, via Telehealth.  Find out what is offered in your area.  Many of them center on a specific diagnosis, such as chronic pain, mental health, or substance use disorders (e.g., Alcoholics Anonymous can be quite beneficial).  A study of the benefits of support groups for patients with malignant melanoma found that participants in a six-week support group had half the recurrence rate and a third of the mortality rate when compared to the control group at five years follow-up.[581] More studies are needed, however, as was shown by a 2016 review of the benefits of support groups which only found 1 of 9757 studies that met inclusion criteria.[582]
  • Social media.  For Veterans comfortable with technology, sites like Facebook can be useful resources.[583]
  • Help with a community garden.  Many VA facilities are now sponsoring these, as well as farmer’s markets where Veterans sell what they grow.
  • Join a gym.  This provides a combination of physical activity and social connection.
3.  Become more active in the local community

This ties into the other suggestions listed above.  Examples include the following:

  • Attend community events like civic celebrations, stage productions, and fundraisers.
  • Attend local sporting events.
  • Help with directing or organizing community events. 
  • Join a religious or spiritual community.
  • Participate in the arts. 
  • Take (or teach) a course of some kind.

See Chapter 19 for more about “Whole Health and Community.” 

4.  Have confidants in your life, if possible

We know that health is influenced by the number of close confidants a person has.  Number of confidants is more of a health indicator than how many friends one has or how many people one knows.[584]  That is, quality of relationships matters more than quantity.  Ask people if they have someone in their lives they can confide in, someone they are comfortable telling their secrets, or with whom they can share what is going on with them in terms of their health.  In one study of older women, lack of a confidant was associated with lower reported physical function and vitality.  The negative effect of not having confidants was as strong as being a heavy smoker or overweight.[585] 

Unfortunately, the number of confidants per person has dropped over the years in the U.S.[586]  On the positive side, while people may not know their neighbors, and while people are less engaged than they used to be in civic activities, a 2009 report concluded that mobile phones and online social media may be helping people to connect in other ways.23  With the COVID-19 pandemic, concerns have been raised about the “infodemic”—the effect of a huge amount of negative media exposure—and an increase in mental health problems.[587]

5.  Connect with a significant other, if possible

Having a close relationship with a significant other is also health promoting.  For example, in a study of 10,000 men with heart disease, being able to answer, “Yes, my wife shows me her love” was linked to 50% less angina and 50% fewer ulcers.[588]  In 1,400 men and women who had been through heart catheterization, the five-year mortality rate was over three times higher for those who reported not being happily married or having a confidante.[589]  A study of women who were anticipating receiving an electric shock looked at their functional MRIs.  It was noted that they had fewer anxiety-related MRI findings if they were holding hands with their husbands (versus strangers) and they rated their marriages favorably.[590] Being unhappily married seems to be associated with worse health outcomes than being single, and negative partner interactions are associated with higher rates of depression, anxiety and chronic illness.  Being married and being a parent a linked to well-being and mental health in old age.[591]  Recent research has also indicated that legalization of same-sex marriages has had numerous health-related benefits.[592]  Studies also indicate that involving loved ones in Veteran’s treatment for PTSD can improve outcomes for both the PTSD and the relationship.[593]

A fascinating 2018 study measured EEG tracings on couples.[594]  One person was subjected to pain, and the other would touch his/her hand to offer “social touch analgesia.”  (We know that touch can have a pain-reducing effect.)  Researchers found that both people would show certain alpha waves in the same parts of their brains, which were in the same area where the brain was stimulated by the pain.  How much the coupling there was between the two people’s brains correlated to the degree of pain reduction the touch offered.  A prior study by the same researchers found that coupling of the heart rate and respiration also occurred under similar circumstances.[595]

6.  Connect with animals

Animals can be powerful healers.  Animal-assisted therapy (AAT)has been found to have a number of health benefits.[596]  Having a companion animal reduces depression and loneliness, decreases anxiety, and enhances social skills; it often promotes physical activity as well.[597]  Elderly people with depression may benefit from AAT.[598]  A number of VAs offer equine therapy programs (working with horses), therapy dog visits, or programs that help Veterans find pets.  The “Animal-Assisted Therapies” tool has additional information. 

7.  Heal—or avoid—negative relationships

Conflicted or unfulfilled relationships can have a negative health impact, as you might expect.[599]  Intimate partner violence is experienced by over 1/3 of American women and psychiatric patients; in addition to physical injuries, it may cause depression, anxiety, PTSD, psychosis, self-harm, and many psychosomatic conditions.[600]  Spousal conflict is associated with poor pain tolerance and higher blood pressure and heart rate in addition to significantly worse cardiovascular outcomes, endocrine function, and immunity.[601]  Many VAs offer couples and marriage counseling through their Mental Health and/or Chaplaincy service lines.  Safety of one’s emotional environment is covered in Chapter 6, “Surroundings.”

8.  Cultivate communication skills

Everyone can learn simple communication skills that can foster better connections with others and help them to avoid negative interactions.  Some examples of approaches you can teach Veterans about or try yourself include the following5:

  • Listen wellListen in a way where you are totally present, with full mindful awareness of what the other person is saying.  Listen with your “entire self”—this means not only using your ears, but also listening with your heart (tuning in to emotions) and closely observing body language.  Good listeners are not judgmental; they are able to share about themselves without over-disclosing. 
  • InquiryGood communicating involves actively reflecting what has been said to you, showing the other person through clarifying questions that you are genuinely interested in them.  Inquiry helps the other person to more easily draw their own conclusions; it does not involve the listener trying to impose those conclusions on them. 
  • Nonviolent Communication (NVC).[602]  Created by Marshall Rosenberg, nonviolent communication teaches a series of steps one can follow in communicating with others.  It was designed to steer interactions away from blame and criticism to a place of greater empathy and understanding.  NVC assumes people share certain fundamental needs and are compassionate by nature.  We can unlearn strategies that involve violence and come together through our common humanity to solve interpersonal differences.  The process might include making an observation about an event and sharing the feeling it evokes, rather than making generalizations about the experience.  NVC focuses on considering what you and the other person need.  Then both people outline concrete steps that might be taken to improve a situation.  More information on NVC is available in the Resources section at the end of this chapter.
  • “I Statements.”  This is another commonly used communication tool.[603]  Speaking strictly for yourself gives another person space for the opinions, beliefs, and thoughts they have that might be different from yours.  Sentences begin with “I” rather than “You.”  For example, rather than generalizing by saying, “It is bad for you to do that,” a person could say, “I am opposed to doing that.”  Instead of saying, “That movie was great,” a person could say, “I liked that movie.  What did you think?”  These statements do not attribute feelings to the other person, but they make the speaker’s feelings and thoughts clear.  This supports healthy dialog. 
  • Use the Four Habits Model.  This was created by Kaiser Permanente, to enhance clinician communication.  Its four steps, which can inform any conversation where one person is trying to help another (including Whole Health visits), are as follows[604]:
    1. Invest in the beginning.  Introduce yourself and put the other person at ease.  Ask open-ended questions about concerns.  Plan out the discussion with the other person.  What do they want to accomplish with the conversation?
    2. Get the other person’s perspective.  Ask them what is going on and what is concerning to them.  If you are speaking of illness, explore how it has affected his or her life. 
    3. Show empathy.  Empathy is the ability to mutually experience what is going on with others—thoughts, experiences, and emotions—while maintaining healthy boundaries.[605]  Be open to the other person’s emotions and show it through both verbal and nonverbal communication.  We know that empathy is a powerful contributor to health and well-being.[606] 
    4. Invest in the end of the conversation.  Provide any information and education that is required.  Involve the other person in deciding next steps and summarize what has been discussed.  Verify that the other person has asked all their questions. 
9.  Work with social workers

Social workers can be powerful allies when it comes to forging helpful relationships, finding support groups and community resources, or navigating the health care system in general.[607]  While noting that more research is needed, a 2017 review found that having social workers involved in care had positive effects on health outcomes and service utilization and saved costs.[608]  The study concluded, “The economic and health benefits reported in these studies suggest that the broad health perspective taken by the social work profession for patient, personal, and environmental needs may be particularly valuable for achieving goals of cost containment, prevention, and population health.”  Social workers significantly contribute an additional, helpful perspective that honors the power of relationship. 

10.  Practice compassion and loving-kindness

There are many ways to do this.  Loving-kindness meditation is a traditional Buddhist meditation wherein one focuses benevolence and support toward self and others.[609]  Compassion-based interventions focus on tuning into suffering of oneself or others, with a commitment to prevent it.  An example of a loving-kindness meditation is featured as a Whole Health tool on the next page. 

Compassion based interventions and loving-kindness meditation have many benefits, whether a person is struggling with health conditions or not.  These types of meditation lead to progressive and favorable changes in brain function.[610]  They increase mindfulness, positive emotions, compassion, and self-compassion in a systematic review and meta-analysis of 22 studies.[611]  They also enhance pro-social behavior.[612]  Loving-kindness has been found to be effective in treating chronic pain.  Compassion meditation was found to help with psychotic disorders, affective disorders, major depression, eating disorders, and suicide risk.  A combination of the two was helpful with borderline personality disorder.5149 

  Whole Health Tool: Loving-Kindness Meditation

While many meditation exercises have you focus on what is happening with your thinking, this one focuses more on your heart.[613]  Make sure you are in a comfortable position.  Close your eyes or rest them comfortably with a soft gaze on a place a few feet in front of you.  Begin with five deep breaths.  Focus on using your abdomen to breathe first.  As you breathe in, your abdomen should go out.  As you breathe out, your abdomen should pull back in. 

After you have settled into being aware of your breath, focus on the area around your heart.  With each breath, draw love, compassion and acceptance into your heart.  It can help to focus on people who “warm your heart” or memories that “make your heart sing.”

Next, turn your attention to feeling compassion for yourself and for others.  Recognize that compassion is the desire for freedom from suffering.  In this state, visualize radiating how you feel in your heart to everyone mentioned in the statements below.  Without judgment, notice the feelings, thoughts, sensations, or images that arise. 

Pause with each statement—at least for the space of one breath—before moving on to the next one. 

  1. Start by directing the compassion towards yourself.

    May I be safe and protected.  (Breathe)

    May I be balanced and well in body and mind.  (Breathe)

    May I be full of loving-kindness.  (Breathe)

    May I be truly happy and free.  (Breathe)

  2. Next, direct this compassion toward someone you love or for whom you feel great gratitude.  This can be a family member or friend, a teacher, a pet, a role model, or someone else who has supported you sometime in your life.

    May you be safe and protected.  (Breathe)

    May you be balanced and well in body and mind.  (Breathe)

    May you be full of loving-kindness.  (Breathe)

    May you be truly happy and free.  (Breathe)

  3. Now visualize someone you relate to in a neutral way, someone you neither like nor dislike.  Perhaps this is someone you just passed on the street or a person you see on your way to work.

    May you be safe and protected.  (Breathe)

    May you be balanced and well in body and mind.  (Breathe)

    May you be full of loving-kindness.  (Breathe)

    May you be truly happy and free.  (Breathe)

  4. Now, if possible, turn your attention to someone who is challenging, someone who you might be having a hard time relating to.  This need not be the most difficult person in your life—do this in a way that does not cause you distress

    May you be safe and protected.  (Breathe)

    May you be balanced and well in body and mind.  (Breathe)

    May you be full of loving-kindness.  (Breathe)

    May you be truly happy and free.  (Breathe)

  5. Now, direct this compassion toward all the Veterans/patients who you serve and their loved ones. 

    May you all be safe and protected.  (Breathe)

    May you all be balanced and well in body and mind.  (Breathe)

    May you all be full of loving-kindness.  (Breathe)

    May you all be truly happy and free.  (Breathe)

  6. Next direct this compassion toward your colleagues who serve Veterans and their families. 

    May you all be safe and protected.  (Breathe)

    May you all be balanced and well in body and mind.  (Breathe)

    May you all be full of loving-kindness.  (Breathe)

    May you all be truly happy and free.  (Breathe)

  7. Direct this compassion toward all people and all beings everywhere.

    May all living beings be safe and protected.  (Breathe)

    May all living beings be balanced and well in body and mind.  (Breathe)

    May all living beings be full of loving-kindness.  (Breathe)

    May all living beings be truly happy and free.  (Breathe)

  8. And, finally, return to offering this compassion for yourself.

    May I be safe and protected.  (Breathe)

    May I be balanced and well in body and mind.  (Breathe)

    May I be full of loving-kindness.  (Breathe)

    May I be truly happy and free.  (Breathe)

As you conclude, notice how you are feeling in your heart area, and in your body in general.  Note, but try not to judge, any emotions that came up during this exercise. 

  Whole Health Tool: Celebrating Good News

We are often supportive to our friends and family members when they need our support in times of stress. We drop everything to be there when someone is struggling, and certainly that support strengthens your relationship.  And, researchers have found that how you respond to good news may actually be more important for strengthening relationships.54  Celebrating good news provides a boost of positive emotion for both you and the person you are supporting—and those positive conversations lay important groundwork for times when someone needs your support.

We can sometimes respond in ways that can undermine their good news.  For example, we may:

  • Squash the news by pointing out problems or providing negative feedback
  • Shut down the conversation by minimizing the news or being distracted
  • Steal the conversation by shifting focus to ourselves

Instead, think about how you can help celebrate the news using active, constructive responding—a term coined by Shelly Gable and her colleagues.  Using active constructive responding means you ask  questions to learn more about the news, show authentic interest, and be mindful of your reaction and respond intentionally.  You may not be particularly excited or care about the news they are sharing, but that is less important than the care you are showing to the other person.

Think about times that a colleague, friend, or a family member came to you with good news.  How did you respond? Note, but try not to judge, any emotions that come up as you think about your responses.  We may not always be able to use active constructive responding every time someone shares good news, but you may be noticing some  patterns in the way you respond to your friends, family, or colleagues.  If so, the next time someone shares good news with you, take time to pause and celebrate with the person.

Family, Friends, & Co-Workers Resources


VA Whole Health and Related Sites

    • Bowling Alone: The Collapse and Revival of American Community, Robert Putnam (2001)
    • Compassion: Bridging Practice and Science.  Stanford University e-book.
    • <li
Connected: The Surprising Power of Our Social Networks and How They Shape Our Lives
    , Nicholas Christakis (2009)
  • Lifeskills: 8 Simple Ways to Build Stronger Relationships, Communicate More Clearly, and Improve Your Health, Virginia Williams (1999)
  • Nonviolent Communication: A Language of Life, Marshall Rosenberg (2015)
  • The Brain That Changes Itself, Norman Doidge (2007)
  • The Wisdom of Crowds, James Surowiecki (2005)
  • The Zen of Listening: Mindful Communication in an Age of Distraction, Rebecca Shafir (2003)
  • Together: The Healing Power of Human Connection in a Sometimes Lonely World, Vivek Murthy (2020)
  • Platonic: How the Science of Attachment Can Help You Make—And Keep—Friends, Marisa G. Franco (2022).

Special thanks to Christine Milovani LCSW, who co-wrote the original Whole Health Library materials on Family, Friends, and Co-Workers that inspired content for some of this chapter, as well as to Greta Kuphal, MD, who updated those materials in 2018.