Title: "If I Stay By Myself, I feel Safer"
Description: Despite advances in mental health and housing interventions, social isolation among persons with severe mental illness (SMI), particularly among those who have experienced homelessness, continues to be high (Perese & Wolf, 2005; Hawkins & Abrams, 2007). Given that social attachment can be considered a fundamental need and that social connectedness is key to health, well-being, and recovery, it is imperative to understand why high levels of social isolation persist among persons with SMI. Whereas prior research has typically focused on how individual pathology undermines the ability of individuals to develop social connections, and how stigma leads to social exclusion, this study investigates the possibility that social isolation may also be addressed as a by-product of agency; that is, that it may result in part from a calculated decision-making process in response to the social conditions in which formerly homeless individuals with SMI live their lives. Using grounded theory methodology, the study analyzes in-depth qualitative interviews at baseline and eight-year follow-up with participants who have SMI and are receiving housing and support services through a Housing First program.

Interviews elicited individuals' experiences with their social networks and social interactions, while also capturing the perceived context in which these patterns of relating are embedded. The study sought to address the following research questions: 1: How do formerly homeless individuals with SMI describe their social connectedness and how does overall social connectedness change over time? 2: What are the factors that hinder social connectedness as reported by persons with severe mental illness? 3: What are the factors that facilitate social connectedness as reported by persons with severe mental illness? In line with previous research (Hawkins & Abrams, 2007; Padgett et al., 2008; Tsai et al., 2012; Yanos et al. 2012), participants' social connectedness was generally low. Further, individuals appeared to make limited progress in the domain of social connectedness over the course of eight years. This was generally attributable to their underlying ambivalence regarding social connectedness.

On the one hand, individuals valued the privacy and solitude of being at home and were content with spending their time alone; on the other, individuals also expressed concerns regarding loneliness and when discussing what was missing in their lives, the subject was overwhelmingly in the domain of social connectedness. Individuals' actions regarding social connectedness were generally characterized by social distancing - a purposeful limiting of social interaction - yet their desires still reflected a longing for close others. Engaging in social distancing appeared to have developed in reaction to individuals' history of exposure to relationships that involved negative interactions, stress, and threats to personal freedom, resources, and recovery. Social distancing thus emerged as a strategy for minimizing exposure to risky situations and often occurred for practical reasons of self-preservation. Individuals described much of their social environments as characterized by poverty, prejudice, discrimination, and illicit activity, which set the stage for problematic relationships and sustained social distancing.

Many themes reflected upstream factors that influence people's opportunities to develop social relationships and likelihood of experiencing negative consequences, including residential segregation, racial discrimination, stigma, disability policies that yield inadequate incomes, poverty in general, and concentrated poverty in particular. Despite depicting a fairly consistent picture of strained relationships, disadvantaged social conditions, and social distancing, the data also suggested several factors that prevented complete isolation for persons with SMI. These included connecting with aspects of their past, taking care of others, pursuing artistic activities, accessing distal neighborhood supports and resources, and having employment or volunteering. Further, maintaining or rebuilding relationships with past network members posed one of the few viable alternatives to social isolation. Overall, this study suggests that social isolation among formerly homeless persons with SMI often reflected a lack of perceived opportunities for safe, stress-free, and supportive social affiliations, an issue that may be more a consequence of cumulative and concentrated disadvantage than a direct effect of mental illness (Draine, Salzer, Culhane, & Hadley, 2002).

Given the benefits to quality of life that persons with mental illness derive from having their own homes through Housing First programs (Padgett, 2007; Yanos et al., 2004), addressing the broad factors that contribute to social isolation could increase connectedness and further enhance the effectiveness of this program model.