Connectedness: The Updated and Expanded Pillar of Lifestyle Psychiatry and Lifestyle Medicine

Abstract

The field of Lifestyle Psychiatry aims to prevent, treat, and sometimes reverse chronic physical and mental health conditions through evidence-based interventions. The foundational pillars of this field are physical activity & exercise, nutrition, restorative sleep, stress management, toxic exposure reduction, and connectedness. Connection has been defined as “feeling part of something larger than yourself, feeling close to another person or group, feeling welcomed, and understood.” Within Lifestyle Psychiatry, however, we emphasize that connectedness encompasses not only our relationships with other individuals but also our connection to ourselves and with the world at large. We have identified these three relationships as three core or pivotal needs. Similarly, we have expanded our previous model of connectedness to include six domains: (1) Happiness, (2) Purpose in Life & Meaning-Making, (3) Empathy & Compassion, (4) Social Connection & Community, (5) Nature, and (6) Spirituality & Religion. In this paper, we present psychological and scientific data supporting the necessity of the six domains of connectedness. By combining the six domains with the three core needs, practitioners of lifestyle psychiatry can develop impactful and sustainable interventions that promote connectedness, decrease negative health outcomes, and promote psychological growth through increasing resilience, emotional development, and the ability to be alone without loneliness.

“Empathy and compassion are important for personal relationships and impact how we relate to ourselves through self-compassion and self-empathy.”

Introduction

Lifestyle Psychiatry is an emerging field that aims to prevent, treat, and sometimes reverse chronic physical and mental health conditions through evidence-based interventions. The foundational pillars of this field are physical activity & exercise, nutrition, restorative sleep, stress management, toxic exposure reduction (substance use and environment), and connectedness. ¹

Connection has been defined as “feeling part of something larger than yourself, feeling close to another person or group, feeling welcomed, and understood.” ² Within Lifestyle Psychiatry, however, we emphasize that connectedness encompasses not only our relationships with other individuals but also our connection to ourselves and with the world at large. We have identified these three relationships, as three core or pivotal needs: self, others, and the world. Similarly, we have expanded our previous model of connectedness ³ to include six domains: (1) Happiness, (2) Purpose in Life & Meaning-Making, (3) Empathy & Compassion, (4) Social Connection and Community, (5) Nature, and (6) Spirituality and Religion. This model is the Merlo Model of Connectedness depicted in Figure 1 and discussed further next.

Figure 1.

Merlo Model of Connectedness: Six domains of connectedness addressing the three core psychological needs. The six domains include (1) Happiness (2) Purpose in Life & Meaning-Making (3) Empathy & Compassion (4) Social Connection & Community (5) Connection to Nature (6) Spirituality and Religion. These domains address the three core psychological needs: connectedness to self, others & community, and the world at large. Used with permission, Gia Merlo, Restack, Three Degree Publishing, Oct 2024.

Each of these aspects of connectedness should be viewed not as discrete entities, but rather as intertwined threads of a larger web of connection, which is integral to human flourishing.^4,5 Additionally, the domains enhance our connections with our core needs, improving our ability to flourish. ⁶ Specifically, Happiness and Purpose in Life & Meaning-Making help us connect to ourselves; Empathy & Compassion and Social Connectedness help us connect to others; Nature and Spirituality & Religion help us connect to the world.

In this paper, we present psychological and scientific data supporting the necessity of each core need (to self, to others, and to the world) and the six domains of connectedness. The discussion will first center on a core need, followed by the two corresponding domains of connectedness. First, the need to connect to self will be followed by introducing the domains of happiness and purpose in life & meaning-making. Next, the need to connect with others will be introducing the domains of empathy & compassion and social connection. Finally, the need to connect to the world will be followed by introducing the domains of nature and spirituality & religion (see Figure 1). However, it bears repeating that there is overlap between the domains and the needs that they serve. For example, though we list compassion with the psychological need to connect to others, there is compelling data that self-compassion is a necessary need that helps connect to ourselves. Therefore, though there is significant overlap with the domains and the needs they serve, we list them here discreetly for ease of presentation as we introduce these concepts.

By combining the six domains with the three core needs, practitioners of lifestyle psychiatry can develop impactful and sustainable interventions that promote connectedness, decrease negative health outcomes, and promote psychological growth through increasing resilience, emotional development, and the ability to be alone without loneliness.

First Need: Connectedness to Self

Connectedness to self has far-reaching implications for an individual’s way of relating to themselves, to others, and the world. For example, if we do not have a strong, healthy relationship and identity of ourselves, our perceptions of others may be clouded or distorted. ⁷ Overall, the need to connect with oneself improves one’s self-worth. Typically, for example, those with narcissistic personality disorder perceive themselves with grandiose self-importance, yet, psychologically, they critically lack the capacity to feel self-worth. They struggle with their identity and a real, loving relationship to themselves. ⁸

As such, the absence of self-worth can have profound and far-reaching consequences on one’s mental, emotional, and social health. This lack of self-worth often leads to a negative self-perception, causing individuals to internalize failures or criticisms and view themselves unfavorably. This distorted view of oneself may foster feelings of inadequacy and unworthiness ⁹ and is often linked to higher levels of sadness, hopelessness, and anxiety. ¹⁰ Individuals may experience negative emotions that are disproportionate to their current stressor, ¹¹ which may impair their ability to maintain and sustain healthy relationships. ¹² Finally, individuals lacking self-worth may avoid setting or pursuing goals due to a fear of failure or a belief that they are incapable of success. ¹³ The two domains pivotal to our relationship to ourselves are domain one, Happiness, and domain two, Purpose in Life and Meaning Making.

Domain One: Happiness

Developing a greater sense of internal happiness strengthens our connection with ourselves and is thus an important aspect of overall connectedness. Happiness may vary based on individual values and cultural context, but altruism, prosocial behavior, and self-care are all important factors. In this section, we will explore what determines individual happiness, the neuroscience of happiness, and behavioral interventions that increase happiness.

Determinants of Happiness

What is happiness? After surveying over 2700 individuals across multiple countries, Lyubomirsky and Lepper defined a happy person as one who can “experience frequent positive emotions, such as joy, interest, and pride, and infrequent (though not completely absent) negative emotions, such as sadness, anxiety and anger.” ¹⁴ Subsequent surveys support this definition and help build the theory that the frequency of happiness, rather than the intensity, predicts long-term well-being. ¹⁵ We describe happiness as a subjective state of well-being closely related to our internal sense of satisfaction with ourselves and others. ¹⁶ Well-being is a measurable state of happiness and contentment, with low levels of distress, with an overall subjective positive quality of physical and mental health and life satisfaction.^17,18 Additionally, happiness is often conceptualized as consisting of both hedonia, meaning pleasure, and eudaimonia, meaning a life well-lived, a theory first proposed by Aristotle. Between the two, eudaimonia is especially important in establishing lasting happiness. ¹⁹

Genetics also contributes to happiness. Research from David Lykken involving 4000 twin pairs shows that about 50% of our life satisfaction comes from our genes. He determined that only 8% of happiness came from income, marital status, religion, and education. ²⁰ Lyubomirsky et al. similarly suggest that 50% of our happiness is determined by genetics, 10% by our circumstances, and 40% by intentional actions. ²¹ While our genes significantly influence happiness, we will focus on the role of chosen mindsets and behaviors.

Hedonia, Eudaimonia, and Neuroscience

Our understanding of the relationship between neurological pathways and happiness has evolved over the past few decades. ²² Early research exploring happiness in a neuroscience context focused on the brain circuits involved in responding to simple rewards. ²³ These rewards provide immediate pleasure and are thus hedonistic. Such experiences of hedonistic happiness were shown to activate several areas of the brain, including the dopaminergic ventral striatal circuitry, which includes the nucleus accumbens and ventral pallidum. ²³ Later studies would reveal that eudaimonic happiness involves many of the same structures, but has different long-term results. ²²

Telzer et al. conducted a 2-year study of teenagers using functional magnetic resonance imaging (fMRI) to examine how the brain responded to two different tasks linked to different types of happiness. One task was a form of hedonistic happiness, focused on personal pleasure, and the other was a form of eudaimonic happiness, involving a personal sacrifice for the benefit of the family. Both tasks activated the ventral striatum, a brain area related to reward. However, the task associated with eudaimonic happiness was linked to a long-term reduction in depressive symptoms. In contrast, the task associated with hedonic happiness showed the opposite effect—a long-term increase in depressive symptoms. This suggests that the impact of ventral striatal activation depends on the context of the activity, and that not all types of happiness are created equal. ²⁴

Managing Expectations

The relationship between one’s ability to manage expectations in the light of challenges and one’s level of happiness was introduced by the Roman Stoic philosopher Marcus Aurelius. ²⁵ During our youth, we are frequently encouraged to “chase our dreams” and aim high, which can lead to lower satisfaction with objectively positive achievements. This has been described as the “hedonic treadmill” effect, ²⁶ and it is the basis of the self-centeredness branch of the self-centeredness/selflessness happiness model (SSHM). ²⁷ The hedonic pleasure is unstable and fleeting, and it soon becomes normalized. ²⁸

By intentionally examining our goals and reframing them in ways that feel meaningful and realistic, we develop insight. This becomes an effective way to increase both short and long-term happiness. ²⁹ A longitudinal cohort study of American adults between 1972 and 2004 found increased odds of happiness by 5% for every 10 years of increase in age. ³⁰ The impact of age is significant, showing a trend of increasing happiness throughout the life course as we develop realistic expectations about sources of happiness.

Happiness and Social Connection

Happiness and social connection have a bidirectional relationship. The Harvard Grant Study, an 80-year longitudinal study of happiness conducted at Harvard University, has followed over 1700 participants. Its initial hypothesis was that happiness would result from one’s career or social position. Yet, it found that the quality of one’s relationships is the most important factor in lifelong happiness. ³¹ A similar study examined over 4700 Taiwanese and noted that happiness was related to the quality of social relationships vs the quantity. ³² Social rejection which may lead to social isolation can decrease happiness through impacting the same parts of the brain as physical pain, namely the dorsal anterior cingulate cortex and anterior insula ³³ and by activating neuroinflamatory pathways ³⁴ The link between happiness and social connection is an example of the interdependence of the domains of connectedness.

Happiness and Altruism

Engaging in altruism, meaning actions intended to help others not motivated by self-interest, enhances eudaimonic happiness. ³⁵ Altruism activates some of the same neural circuits as reward-seeking behavior, demonstrating the neurological overlap between happiness and altruism. ³⁶ Practicing altruism has been associated with improved health across the lifespan, with benefits ranging from decreased anxiety and depression symptoms in adolescents to increased longevity in older adults. ³⁷ With advances in neuroimaging, researchers have begun to explain how altruism may lead to changes in brain health.

A 2022 study by Liu et al. compiled voxel-based morphometry data from over 8600 adults to investigate the association between altruism and structural neurologic changes. They found that those who practiced altruistic social behavior had higher gray matter volume in the posterior insula, middle cingulate gyrus, hippocampus, thalamus, superior temporal gyrus, anterior orbital gyrus, and middle occipital gyrus compared to individuals who did not practice altruistic behaviors. ³⁸ Furthermore, increased gray matter volume is protective against depression, cognitive decline, and dementia. ³⁹ While Liu et al.’s results do not prove a causal relationship between altruism and increased brain volume, they provide evidence that altruism is associated with neurological changes known to improve the brain health of older adults. ³⁸ This moves us closer to understanding the exact mechanisms by which altruism improves human health and well-being.

Happiness and Self-Care

Engaging in self-care is one of the most effective things that can be done at the individual level to ensure our internal sense of happiness is resilient to the constant stressors of being human. Self-care begins with the “recognition that people have multiple personal dimensions to attend to live a ‘good’ life, including inner lives, families, work, community, and spirituality.” ⁴⁰ Self-care involves taking steps on both personal and professional levels. On a personal level, activities like meditation, mindfulness, and gratitude can help enhance happiness. This is because our brain’s happiness can be shaped by our thoughts and actions, a concept known as neuroplasticity. ⁴¹ Additionally, meditation and mindfulness have increased gray matter in brain areas involved in learning, memory, emotion regulation, and self-awareness, which may help reduce worry, anxiety, and depression. ⁴²

Happiness and Gratitude

The practice of gratitude often leads to an experience of a boost in mood and well-being, contributing to overall happiness. ⁴³ Gratitude also encourages individuals to focus on the positive aspects of their lives, promoting a more optimistic outlook. This cognitive reframing helps mitigate negative thoughts while enhancing overall happiness. ⁴⁴ As such, the practice of gratitude is one of the top recommended strategies for achieving and maintaining happiness. ⁴⁵

Why is Happiness a Domain in Connectedness?

Happiness is important for our connectedness with ourselves and others. When happiness centers on eudaimonia, it helps us reconnect to our first need, ourselves. Happiness improves our self-worth and self-connectedness, and overlaps with our second need: connections with others. ⁴⁶ Happiness can enhance motivation and promote meaningful interactions with others. ⁴⁷ Whereas being in a state of unhappiness can lead to feelings of being “defective, inadequate, diseased, or deprived” ⁴⁸ and subsequently, unhappy individuals have a poorer connection to themselves and less engagement with others. ⁴⁹ By engaging in activities and practices that bring happiness, individuals can establish a positive feedback loop that reinforces their ability to connect with themselves and with others. ⁷

Domain Two: Purpose in Life and Meaning-Making

What is the purpose of life? How do we find meaning in life? These questions have been highly debated by scholars, religious figures, and philosophers. Researchers at the Claremont Adolescent Moral Development Lab identified three dimensions of purpose that can help guide us in the search for meaning. These include goal orientation, personal meaningfulness, and a focus on aims beyond the self. ⁵⁰ Purpose is a type of long-term goal that also provides a motivational framework for achieving smaller goals relating to one’s overarching purpose. Personal meaningfulness inspires us to find and commit to purposes. ⁵⁰ Although there is no unified standard for what makes something personally meaningful, Emmons identified the following realms: work and achievement, relationships and intimacy, religion and spirituality, and self-transcendence and generativity, which many have found to be sources of personal meaning. ⁵¹

This reflective process can help ground ourselves and connect us to our first need, as it helps define our core identity and solidify personal values. Because purposes can orient towards aims beyond the self, developing a sense of purpose also builds connectedness to our second need, others, and our third need, the world. Overall, the pursuit of purpose plays a vital role in mental health, serving as a powerful catalyst for emotional resilience, improved well-being, and meaningful social connections. By promoting purpose-driven engagement, The Model underscores the importance of the pursuit of facilitating connections that enhance overall life satisfaction and emotional health.^52,53

Additionally, finding a sense of purpose can significantly influence mental health, as individuals with strong, clear personal goals often report higher levels of well-being. ⁵⁴ Activities that foster a sense of accomplishment and belonging provide a motivational framework that helps individuals create meaning in their lives, thus cultivating a stronger connection to both themselves, their communities, and their world.^55,56

Purpose Improves Mental Health

Existential psychiatrist Viktor Frankl theorized that seeking meaning and a self-transcendent purpose is essential for human flourishing. ⁵⁷ Subsequent studies have affirmed that a sense of purpose likely positively impacts brain health. A recent meta-analysis including 99 studies and over 60,000 subjects found that purpose in life is associated with decreased depression and anxiety. ⁵⁸ In adolescent populations, purpose has been associated with decreased depressive symptoms and increased self-esteem. ⁵⁹ Among older adults, purpose in life has been associated with higher cognitive function and a reduced risk of dementia.^60,61 Sutin et al. found that purpose is also protective against the development of loneliness, a known risk factor for physical and mental health pathologies across age groups.^61,62

Science of Purpose and Resilience

Purpose plays a significant role in promoting resilience in the context of stressful and traumatic circumstances. A study investigating the mental health of survivors of the 2005 Pakistan earthquake found that a sense of purpose was associated with decreased post-traumatic stress disorder (PTSD) symptoms and increased positive emotions. ⁶³ Likewise, among individuals with brain tumors and an expected survival of less than 5 years, having existentially meaningful goals has been associated with improved quality of life and psychological well-being. ⁶⁴

While the impact of purpose on physiology and brain health remains largely unknown, preliminary research suggests that purpose may foster resilience through enhancing emotional regulation. Schafer et al. found that people who expressed greater purpose in life had improved emotional recovery (as indicated by measurements of the eyeblink startle reflex) after exposure to distressing images. ⁶⁵ Similarly, Fogelman & Canli found that while baseline cortisol levels (a stress hormone) were not associated with purpose, those with a higher sense of purpose experienced a faster rate of cortisol recovery after experiencing acute stress. ⁶⁶

Enhancing Purpose Within Psychiatry

Logotherapy and meaning-centered therapy are well-established therapies that enhance an individual’s sense of purpose.^67,68 While this paper will not delve into the details, both employ unique behavioral and cognitive strategies to help patients reflect on past and current life circumstances to identify personally meaningful life purposes. ⁶⁹ In addition to these therapy options, other evidence-based strategies may be more accessible for patients and clinicians. ⁷⁰ First, engaging patients in conversations about what matters most to them effectively encourages a greater sense of purpose. A study by Bundick found that college students who received a 45-minute guided discussion about their values, aspirations, and purpose experienced greater life satisfaction and goal-directedness for months after the initial intervention. Interventions to increase gratitude may also enhance purpose.^70,71 Practices of gratitude, such as gratitude journaling and writing letters of gratitude, allow people to reflect on the value of doing things for others and may help spark purpose-driven goals. ⁷² Finally, guiding patients through setting and working towards personally meaningful goals is another effective method for cultivating purpose.^73,74

Second Need: Connectedness to Others

In 1960, social scientist Elaine Cummings and colleagues first postulated the disengagement theory, which states that as individuals age, they disengage from their social life. ⁷⁵ At that time, they could not have predicted that with each subsequent generation, there would be more community disengagement. ⁷⁶ Furthermore, with each generation (Silent Generation, Baby Boomers, Generation X, Millennials, and Generation Z), there is more distrust towards people within the community or first encounters, and they report having fewer lifetime friends. ⁷⁷ This distrust may be driven by the growing impacts of the consumption society in which we all live, where we attempt to purchase friendship instead of developing and nurturing it.^50,78

Additionally, there is a growing frustration that our communities are no longer considered competent. Historically, competent communities promote the “local population’s well-being and health, which included health education, the promotion of healthy environments, decent housing conditions, employment and access to a sufficient level of income, safety and protection, access to transportation, spiritual support, and citizen engagement.” ⁷⁹ Yet, by focusing on what individuals and communities are not doing, individuals may struggle to develop a sense of belonging, create a more substantial social fabric where individuals can access resources and contribute to their surroundings, and enhance the quality of life for everyone involved. ⁷⁷ Subsequently, the lack of connectedness to others and communities impacts mental and physical health. ⁸⁰

Within the Merlo Model of Connectedness, the two domains pivotal to our relationship to others are domain three, Empathy and Compassion, and domain four, Social Connection and Community.

Domain Three: Empathy and Compassion

Empathy and compassion are closely connected. Without empathy, it is challenging to respond compassionately to the needs of others. Empathy and compassion are important for personal relationships and impact how we relate to ourselves through self-compassion and self-empathy. Here, we emphasize that both empathy and compassion are teachable qualities. Our ability to practice empathy and compassion, which can be developed through behavioral interventions, directly influences our overall sense of connectedness, especially with others. ⁸¹

Empathy

Empathy is the ability to understand and share another’s feelings. ⁸¹ Empathy develops in early childhood, with some primitive forms evident within hours of birth. For example, newborns exhibit a stronger reaction to the sound of other babies crying compared to other noises. ⁸² The ability to empathize with others has multiple adaptive advantages, including facilitating prosocial behavior. Understanding the emotions of others is important for building lasting relationships. ⁸³ There are three well-studied subcategories of empathy: (1) affective empathy, meaning feeling another’s feelings, (2) mirror empathy, meaning replicating another’s behavior, and (3) cognitive empathy, meaning understanding another’s feelings. ⁸⁴ These different forms of empathy are interdependent, and all contribute to connectedness.

Neural Pathways of Empathy

Imaging studies have looked for neurological correlates of the psychological roles of empathy. Thompson et al. propose that empathy is not an emotional state, like happiness or sadness, but rather a process through which emotions are understood. As such, emotions are first perceived, then embodied or mimicked, and lastly cognitively processed. Reactions to these emotions vary depending on the individual’s motivation. fMRI evidence suggests that emotions are perceived within the visual and temporal cortices and screened through the amygdala, which provides emotional recognition. Mimicry is believed to occur with the putative mirror network systems. Finally, the cognitive process of empathy is more deliberate and occurs within the medial prefrontal cortex, the superior temporal sulcus, the temporoparietal junction, and the anterior temporal pole. ⁸⁵ Because of neural plasticity, the strength of neural pathways contributing to empathetic processing could be strengthened by targeted behavioral interventions. This model of understanding empathy supports the idea that empathy is a dynamic and modifiable phenomenon.

Developing Empathy

While empathy may come more naturally to some, it should be viewed as a teachable skill. Teding van Berkhout and Mallouff’s meta-analysis of eighteen randomized control trials concluded that empathy training effectively increases individuals’ empathy scores. ⁸⁶ Some studies in their meta-analysis showed heightened empathy even six months after training. ⁸⁷ Research by Long et al. identifies six trainable factors that facilitate empathy in relationships: “empathic sensitivity, suspension of one’s thoughts and feelings, empathic listening, empathic communication, the communication of an understanding through paraphrasing, and empathic checking with a partner.” ⁸⁸ Behavioral interventions that have been shown to increase empathy include engaging in theater and the arts, reflecting on negative interactions with others, practicing interpreting facial expressions and body language, and moderate to high intensity physical exercise. ³

Compassion

Compassion describes an emotional response to distress, both in ourselves and others, and the subsequent desire to alleviate suffering. In this section, we will focus on self-compassion because of its potential to improve our relationship with ourselves, and thus our ability to form connections with others. Researchers have associated self-compassion with improved quality of life, interpersonal functioning, and health-seeking behaviors.^89-91 Further, self-compassion is associated with decreased shame, loneliness, and burnout.^92-94 By increasing our capacity for positivity, joy, and love, self-compassion makes us more comfortable with our own identities and more confident in forming new relationships.

Components of Self-Compassion

Dr Kristin Neff describes self-compassion as consisting of three components: (1 self-kindness vs self-judgment, (2 common humanity vs isolation, and (3 mindfulness vs over-identification. ⁹⁵ As an example of what these components of self-compassion look like in practice, let us consider an individual in the stressful situation of failing a course. Practicing self-kindness would mean reacting to the bad news with sympathy, and reminding oneself that setbacks are a natural, even expected, part of trying to achieve difficult goals. Practicing common humanity would mean realizing that other people have experienced the same struggles, and trying to be open about one’s experience rather than self-isolating. Finally, engaging in mindfulness would mean acknowledging one’s negative emotions, but also considering the bigger picture and the futility of over-indulging in self-pity. Like empathy, self-compassion is a dynamic quality that can be improved over time. ⁹⁶

Science of Compassion

Preliminary research suggests that some of the psychological benefits of self-compassion are linked to its effects on the parasympathetic nervous system. ⁹⁷ The parasympathetic nervous system is activated in states of rest, and has the opposite physiological effects as the “fight or flight” sympathetic nervous system. ⁹⁸ Studies have correlated self-compassion with increased heart rate variability, a feature of the parasympathetic nervous system that is associated with improved emotional regulation.^97,99 Based on this research, it is reasonable to theorize that self-compassion improves one’s ability to deal with stress and trauma through decreasing emotional reactivity. Research has also found connections between self-compassion and oxytocin signaling. ⁹⁶ Oxytocin is a hormone and neurotransmitter involved in neural pathways of social bonding and feelings of safety. ¹⁰⁰ While this is still an emerging area of research, perhaps future work will elucidate oxytocin-mediated mechanisms explaining the psychological impacts of self-compassion.

Strategies to Increase Self-Compassion

Loving-kindness meditation is an effective behavioral intervention to increase self-compassion. ¹⁰¹ In loving-kindness meditation, one practices sending positive affirmations about oneself and others outwards, as well as receiving affirmations directed inwards. ¹⁰² Practitioners of lifestyle psychiatry can “prescribe” exercises that increase self-compassion, such as loving-kindness meditation and mindful self-talk. Another way that mental health practitioners can promote self-compassion in their patients is through practicing compassion-focused therapy (CFT). CFT was developed in the early 2000s by Professor Paul Gilbert, who was inspired by seeing patients struggle to progress in other types of therapy due to internalized shame and negative self-perception. ¹⁰³ The cornerstone of CFT is guiding patients towards developing a kinder inner voice and teaching them to identify and soothe negative emotions. ¹⁰⁴ CFT has been shown to improve symptoms in multiple psychiatric disorders, including depression, anxiety, eating disorders, and psychosis.^105-107 Engaging in practices such as loving-kindness meditation and compassion-focused therapy enhances self-compassion. It can therefore indirectly improve the quality of our connection to ourselves and our ability to strengthen connections with others.

Domain Four: Social Connection and Community

From an evolutionary perspective, social connectedness is essential to human survival through encouraging collaboration, mutual aid, and altruism. ¹⁰⁸ Social connectedness is a basic need. Whereas loneliness, while inherently unpleasant, has an aversive purpose much like that of hunger. Loneliness should encourage us to seek out the social connections we are missing. Arguably, some aspect of the modern world appears to have clouded our ability to recognize loneliness as a warning signal. A 2024 poll by the American Psychiatric Association found that 30% of American adults experience loneliness at least weekly, ¹⁰⁹ and the rates of loneliness are highest in those under 30 and over 70 years of age. ¹¹⁰ Certain subpopulations, including Black Americans and those with mental health disorders, also experience elevated rates of loneliness.^111,112 However, only a fifth of people reporting frequent loneliness view it as a major problem. ¹¹³ Decades of research on the health impacts of loneliness suggest they may be misguided. A meta-analysis by Holt-Lunstad et al. found that low levels of social connection have similar health impacts to obesity and living a sedentary lifestyle. ⁶²

In this section, we will delve into the meaning of social connection, how and why social connectedness affects well-being, and proposed initiatives to increase social connection on both individual and societal levels, which ties into our first two core needs.

Components of Connectedness

The Surgeon General’s “Epidemic of Loneliness” Health Advisory breaks social connection into three key components—structure, function, and quality. Structure describes our number, frequency, and variety of interactions with others. This includes household size, number of friends, and relationship status. Function expresses how social relationships improve our lives. This can look like emotional support, mentorship, and help in times of crisis. Finally, quality encompasses one’s degree of satisfaction within their relationships, as well as perceptions of social inclusion and exclusion. ¹¹⁴ Understanding the importance of each dimension of social connection helps us to understand how different types of social interaction affect our overall sense of social connectedness.

Applying the three components of social connection to the relationship between social media and social connectedness is an example of the utility of this model. On a surface level, humans would feel more socially connected than ever with globalization and technological advances allowing for around-the-clock communication. In actuality, research exploring the relationship between social media usage and social connection has had varied results. For example, while social media use has decreased perceptions of loneliness in older adults, increased time spent on social media is associated with greater feelings of isolation in young adults.^115,116 Considering the three components of social connectedness helps explain these seemingly contradictory results.

Depending on how they are used, the same social networking sites may have drastically different impacts on the structure, function, and quality of individuals’ social connections. Some social media users may only increase their connections (structure) while others may engage with others in a way that provides emotional support and advice (function). Some may find benefits in more frequent positive contact with their friends and community, while others may experience feelings of jealousy and exclusion (quality). The structure, function, and quality model of social connection helps us to avoid labeling social media as inherently good or evil, and provides a framework for individuals to assess how social media use affects their overall social connectedness and adjust their habits if necessary. Applying the three components of social connection to social media use is just one example of how this framework is productive and accounts for the nuances of social connection.

Psychological Benefits of Social Connectedness

High levels of social connection have been associated with improved well-being in the context of stressful life circumstances. This phenomenon was well-studied during the COVID-19 pandemic. A study by Nitschke et al. conducted during the lockdown period of the pandemic demonstrated that greater social connectedness was associated with decreased levels of perceived stress and worry and fewer fatigue symptoms. ¹¹⁷ Similarly, during the initial months of the pandemic, Matos et al. surveyed over 4000 participants from 21 countries and found that those with increased social connections experienced more post-traumatic growth and overall wellness compared to those with less social connections. ¹¹⁸

Expanding beyond the pandemic, social support has been identified as a protective factor against developing PTSD. A meta-analysis by Wang et al. found a bidirectional relationship between PTSD and social support. Social support negatively predicted the development of PTSD symptoms, and PTSD symptoms negatively predicted future social support. ¹¹⁹ These findings highlight how trauma-related symptoms can erode social resources over time, as well as the importance of implementing interventions that increase social connectedness among trauma survivors. ¹²⁰

Social Connection with Pets

Our connection to pets plays a significant role in mental health and well-being. According to data from the Pew Research Center, over 60% of American households have pets, making this topic broadly relevant. ¹²¹ Service animals make up a small subset of companion animals and are specifically trained to perform tasks that help people with disabilities. Some brain-based conditions qualify for service animal companionship, including PTSD and autism.^122,123 A meta-analysis by Hediger et al. found that service animals are effective in decreasing PTSD symptoms in both adults and children (n = 1111). Non-service animals also have the potential to improve human well-being. ¹²³ A study in Malaysia during the COVID-19 pandemic found that pet ownership was associated with improved coping, self-efficacy, and psychological well-being. ¹²⁴ Pets also provide meaningful social and emotional connections to another living being, which many people lack, especially given the current “loneliness epidemic.” ¹²⁵ The attachments formed between humans and dogs seem to mirror infant-caregiver relationships. ¹²⁶ It is important to note that the choice to have a pet is personal and may not be the right one for everyone—there are stressors involved in pet ownership, such as financial costs and the emotional challenge of pet illness and death. ¹²⁷ Pet ownership can be a complicated decision, but it provides connection and emotional support to many.

Social Connection with Music

Before written language, our ancestors relied on music to enhance social functions, evoke emotions, stimulate cognitive or self-related functions, and enhance physiological or arousal-related functions. ¹²⁸ Schäfer et al. surveyed 834 respondents about their relationship to music and noted that people use music “to feel close to their friends, to express their identity and values to others, and to gather information about their social environment.” ¹²⁹ Tarr et al. note that rhythm of “music provides external, predictable scaffolding that can facilitate synchrony with the music and, by extension, aid synchrony between individuals engaging in the same musical experience.” ¹³⁰ Whether through rhythm or neurotransmitters, music achieves social cohesion, communication, coordination of action, empathy, and social cognition. ¹³¹

Social Connection Throughout the Lifespan

Social connection influences mental health at all points of the human lifespan. In children and adolescents, who are still developing their self-image and self-esteem, the effects of loneliness may be long-lasting. A 2020 meta-analysis by Loades et al. found that loneliness experienced in childhood, especially feeling isolated amongst peers, can lead to symptoms of anxiety and depression for up to 9 years after the period of loneliness resolves. ¹³² During pregnancy and the postpartum period, another phase of life where people experience increased susceptibility to mental health challenges, perceived low or moderate social support is associated with increased odds of developing postpartum depression. ¹³³ Lastly, it is well known that older Americans experience some of the highest rates of social isolation. This has significant mental health consequences. A study by Troya et al. found that loneliness in elderly adults is associated with increased risk of self-harm and suicidal behaviors. ¹³⁴ Conversely, a cross-sectional study using data from the Washington Heights-Inwood Columbia Aging Project found that social connectedness may be protective for cognitive function as individuals age. ¹³⁵ Understanding how social connectedness influences brain health at different phases of life is important for developing targeted interventions for people of different ages.

Science of Social Connection

The mechanisms through which social connection affects health are still being uncovered, but the hypothalamic-pituitary-adrenal cortex (HPA) axis appears to play a significant role. ¹³⁶ The HPA axis is part of humans’ “fight, flight, or freeze” system and is activated by acute and chronic stress. Sustained overactivation of the HPA axis has been associated with increased pro-inflammatory cytokines that cause direct tissue damage and changes in gene transcription that accelerate the development of chronic health conditions. ¹³⁷ The connection between the HPA axis and social isolation has been supported through studies showing higher levels of cortisol, a key hormone of the HPA axis, in people experiencing both acute and chronic loneliness. ¹³⁸ The relationship between inflammation and social isolation is bidirectional. Physical symptoms of increased inflammation may cause individuals to socially withdraw from society. It is a relentless cycle that is often difficult to escape. Conversely, high levels of social connectedness have been shown to decrease HPA axis hypersensitivity, decreasing systemic inflammation. ¹³⁹

Social connection has also been associated with structural neurological changes. In older adults, high levels of social support are associated with increased overall brain volume and a slower rate of brain volume shrinkage over time. ¹⁴⁰ In adolescence, low connectedness is associated with lower axonal density and coherence. ¹⁴¹ While much is still to be discovered about the connection between social connectedness and brain health, these initial discoveries help explain why connectedness plays such a large role in human health.

Third Need: Connectedness to the World

We are trending toward an ever-growing culturally eroded world that is not taking its cues from traditional cultural values, but rather from social influencers, political leaders, and a perceived sense of scarcity. ¹⁴² The growing noise has been further amplified through urbanization, migrations, and globalization. ¹⁴³ As individuals feel disconnected from their world or cultural roots, it can lead to an identity crisis, or disconnection with self, ¹⁴⁴ a sense of loss, grief, ¹⁴⁵ emptiness or worsening mental health symptoms. Additionally, individuals may feel isolated and marginalized if their culture is no longer valued or practiced by the wider society, which further compounds their challenges. ¹⁴⁶

Similarly, cultural erosion leads to disconnection from others. The erosion of shared values and practices can weaken community bonds and social structures. ¹⁴³ Loss of cultural practices can lead to the disappearance of traditional knowledge, skills, and languages, impacting the community’s ability to adapt and thrive. ¹⁴⁷ Cultural erosion can also contribute to social problems such as crime, substance abuse, and domestic violence, particularly when it leads to a breakdown of traditional social controls. ¹⁴⁸

Reconnecting to nature and cultural or spiritual beliefs can improve resilience, decrease loneliness, improve overall health, and rebuild the effects of cultural erosion. ¹⁴⁵ As such, the two domains pivotal to our relationship to the world are domain five, Nature, and domain six, Spirituality and Religion.

Domain Five: Connection to Nature

People often express feeling most at peace when they are engaging with nature, whether that means hiking through a forest, gardening, or spending time with animals. Scholar Edward Wilson coined “biophilia” to describe the inherent connection between humans and the natural world. ¹⁴⁹ Developing a sense of biophilia has tangible benefits for human well-being.^150,151 In addition to strengthening connectedness to the greater world, there is evidence that biophilia may enhance self-connection and decrease social loneliness.^152,153 A more personal aspect of biophilia is our relationship to animals, including pets; these connections are also known to protect psychological health. ¹⁵⁴

Unfortunately, in the modern world, our sense of biophilia is dwindling. Large-scale surveys have found that Americans spend less than 10% of their time outdoors. ¹⁵⁵ For many, spending time in nature is challenging because of structural barriers, such as a lack of local parks and green spaces. ¹⁵⁶ In this section, we will present the psychological benefits of connection to nature (including animals), the physiologic impacts of nature contact, and accessible strategies for increasing connectedness to nature, even in urban environments, and how nature helps connect us to our third need.

Mental Health Impact of Nature Exposure

Many of our insights into the mental health benefits of connecting to nature arise from studying the impact of human proximity to green and blue spaces. Green spaces are defined as areas with vegetation, such as parks, forests, prairies, and lawns. Blue spaces refer to bodies of water, including rivers, ponds, lakes, and oceans. ¹⁵⁷ Data from the Survey of Health of Wisconsin showed higher levels of green space within neighborhoods were associated with decreased depressive symptoms, even after controlling for many potential confounding factors. ¹⁵⁸ There is less evidence supporting the benefits of blue spaces, but in older adults exposure to blue spaces has been associated with lower depression scores in both Irish and Chinese populations.^159,160

Going beyond the concepts of green and blue spaces, a scoping review across 18 countries (n = 16,307) found that nature-connectedness, defined as the degree of feeling interconnected with nature, was positively associated with well-being and negatively associated with mental distress. ¹⁵⁷ A meta-analysis by Capaldi et al. further shows that connectedness to nature significantly correlated to improved vitality (r = 0.24), followed by positive affect (r = 0.22) and life satisfaction (r = 0.17) (NF-Capaldi). ¹⁶¹

Forest Bathing - A Practical Intervention

Forest bathing—shinrin-yoku—is a Japanese tradition of bringing a sense of calmness to ourselves and connecting with nature through our senses. Forest therapy is similar to meditation and involves individuals breathing in phytoncides, chemicals emitted by plants that are beneficial to our immune system. A meta-analysis by Antonelli et al. showed that groups who practiced forest bathing showed a significant decrease in cortisol concentration (MD = - 0.05 μg/dl [95% CI: 0.06 to - 0.04 μg/dl]; P < 0.01; I2 = 88%). ¹⁶²

Lifestyle medicine practitioners can prescribe forest bathing, or similar ways of immersing oneself in nature, to those who may benefit from a greater sense of biophilia. ¹⁶³ Another practical intervention for fostering a greater connection with nature is gardening, which can be practiced in urban environments through community gardens. A review by Clatworthy et al. found that gardening not only decreased anxiety and depression symptoms but had health benefits across “emotional, social, vocational, physical, and spiritual domains.” Both forest bathing and gardening are accessible and potentially powerful ways to help patients improve their mental health and connectedness from a biophilia perspective. ¹⁶⁴

Domain Six: Spirituality and Religion

Understanding Spirituality

Spirituality encompasses how humans seek and express personal meaning and connection to something larger than themselves. ¹⁶⁵ Religiosity refers to an organized belief system with rituals related to a higher power, which is only one of many ways people cultivate a sense of spirituality. ¹⁶⁶ Spiritual practices take on a wide range of forms, including meditation, prayer, breathing exercises, chanting, singing, pastoral care, art therapy, yoga, journaling, reading sacred texts, and reflective walks. While very different on the surface, each practice promotes a sense of connectedness to the greater world, and sometimes to the divine. Spiritual practices also often involve community, which enhances connectedness to other individuals. ¹⁶⁷

Many people consider spirituality to be a key aspect of their identity. In 2023, surveys by the Pew Research Center found that around 70% of Americans consider themselves spiritual, with an even higher percentage (83%) endorsing the belief that “people have a soul or spirit in addition to their physical body.” Further, 40% stated that spirituality is very important in their lives. ¹⁶⁸ Given the vast number of people who engage in spiritual practices, engaging with spiritual or religious practices can foster a profound sense of community, belonging, and support. It can inform individual coping strategies, sense of hope, and resilience, which can provide a counterbalance to cultural erosion. ¹⁶⁹ In this section, we will explore the impact of spirituality on mental health, the neuroscience of spirituality, and strategies for incorporating spirituality into mental health care.

Spirituality and Mental Health

Researchers have found associations between spirituality and improved mental health, especially regarding anxiety, depression, and substance use disorder. ¹⁷⁰ A meta-analysis by Goncalves et al. found that spiritual interventions have tangible psychological benefits, most notably decreased anxiety. The relationship between spirituality and mental health persists throughout the lifespan. ¹⁷¹ Aggarwal et al. found that spiritual well-being is protective against adolescent depression. ¹⁷² In older adults, spirituality has been linked to decreased loneliness and an improved overall quality of life. ¹⁷³ Engaging in spirituality has also been suggested to ameliorate trauma symptoms in a diverse range of groups, ranging from those affected by natural disasters to U.S. military veterans.^174,175

However, it is also necessary to recognize that some forms of spirituality can be detrimental to psychological well-being. Specifically, “negative religious coping,” which describes feeling abandoned or punished by God, is associated with increased depressive symptoms. ¹⁷⁶ It is important to reflect on one’s spiritual practices to ensure they are protective, rather than harmful, for mental health.

Spirituality and Neuroscience

Several mechanisms through which spiritual practices may influence physiology have been proposed. A 2017 study by Cahn et al. found that after participating in a 3-month yoga and meditation retreat, participants had increased serum brain-derived neurotrophic factor (BDNF), a regulatory protein that promotes neuronal growth and plasticity. ¹⁷⁷ Low levels of BDNF have been linked to multiple psychopathologies, including depression, PTSD, and schizophrenia. ¹⁷⁸ Additionally, studies exploring neurobiological changes occurring during meditation have found altered neurotransmitter signaling, including in pathways involved in stress responses. ¹⁷⁹ These findings explain the observed mental health benefits of spirituality. Because children and adolescents experience rapid brain growth and development, engaging them in spiritual practices may be especially impactful in fostering long-term connectedness and mental well-being. ¹⁸⁰

Spirituality in Psychiatry

Spirituality is an essential aspect of person-centered care, which is defined as valuing a patient’s preferences, needs, and values throughout all clinical decisions. ¹⁸¹ Medical institutions are starting to see the importance of meeting patients’ spiritual needs. Balboni et al. highlight a significant gap in the provision of spiritual care within hospitals, revealing that many institutions fail to address the spiritual needs of their patients. Their work also found that patients receiving spiritual care experienced notable improvements in physical and psychological well-being. ¹⁸²

Incorporating a patient’s spiritual views and practices into psychiatry may be unfamiliar to some practitioners. The FICA tool (faith, importance and influence, community, assessment), which originates in nursing, is a helpful strategy in navigating conversations about spirituality. ⁵⁸ First, the “faith” component of FICA is addressed by asking patients about their spiritual views. Some may express that they do not want to discuss the topic, which is acceptable. For those who do describe some spiritual beliefs or practices, one can proceed to the “importance and influence” stage. These questions help practitioners understand how a person’s spirituality affects their day-to-day life, including their physical and mental health.

Next, “community” encompasses asking about spirituality-related organizations or congregations. These social networks are protective of mental health, and patients may want to involve members of their spiritual community in their treatment. Finally, “assessments” involves engaging in open dialogue with patients about how their spirituality and spiritual practices can be incorporated into their mental health treatment plan. This conversation has the potential not only to identify previously unknown sources of support and resilience but also to strengthen the therapeutic alliance. ¹⁸³ Encouraging interested patients to incorporate healthy spiritual practices into their therapeutic plan is likely to improve both their mental health symptoms and sense of overall connectedness.

Practical Applications of Connectedness

The impact of connectedness on various psychiatric conditions can be profound. The most data exists for patients struggling with depression, anxiety, bipolar disorder, adhd, psychotic disorders, substance use disorders, PTSD, and trauma-related disorders. In patients with diagnostically severe psychiatric disorder symptomatology, recommending connectedness should necessarily wait until symptoms have stabilized. Multiple studies in each of the six domains point to the efficacy of these interventions in those struggling with psychiatric symptoms. For this paper, we will focus on interventions for patients across the lifespan.

Additionally, although interventions may occur in many settings, we will focus on those that can be delivered in the office or in person, as well as via social prescribing, which links individuals to services and supports in the community and voluntary sectors to address non-medical needs. ¹⁸⁴ In a recent review by Oster et al., the authors identify a six-step process to maximize the use of community resources. First, identify potential participants, a process that would occur within the clinic. Second, refer that participant to a link worker, someone who knows the program or resource that will help the individual connect with the service. Third, screen the participants for non-medical needs (e.g., personal judgment, ability to use digital technology, etc). Fourth, refer to non-medical services and supports. Fifth, assess the participant for additional health coaching needs. Finally, sixth, follow up with participants at scheduled outpatient appointments with the help of office staff. ¹⁸⁵

Adults

During office encounters, healthcare providers can explore the patient’s personal view on meaning by exploring Emmons’ four realms of personal meaning ⁵¹ : Work and achievements, relationships and intimacy, religion and spiritual practice, and self-transcendence (See Section II.A, and for more information see 186-188). Although mindfulness and meditation practices are frequently discussed, providers should encourage activities that promote a state of “flow,” where individuals are fully immersed and enjoying the process. ¹⁸⁹ When considering social prescribing, the following are types of activities:

• • Activity Groups: Encourage participation in book clubs, hobby groups (such as gardening, knitting, or running), nature activities, or fitness classes.

• • Skill-building Groups: Classes enable individuals to learn new skills (e.g., photography, computer) while connecting with others who share similar interests, enhancing both social and personal development.

• • Volunteering: Engaging in community service or charitable work can foster a sense of purpose and connection. Volunteering for meaningful causes, such as animal welfare, environmental conservation, or elder care, allows individuals to contribute positively to their communities while building relationships. Mentorship or coaching opportunities, where individuals share their expertise through teaching, tutoring, or coaching, create rewarding bonds and mutual growth.

• • Peer Support Programs: Encourage participation in programs, such as grief support, parenting, or substance use, that pair individuals with mentors or peers who share similar challenges or goals.

• • Cultural and intergenerational programs: Provide unique opportunities for individuals to connect across diverse groups. Attending cultural events, such as local festivals, museum tours, or performances, fosters a sense of community while celebrating shared heritage. Volunteering in intergenerational programs, such as seniors reading to children, bridges generational gaps and encourages meaningful interactions, promoting mutual learning and understanding.

• • Creative and Expressive Outlets: Engaging in creative and expressive activities offers individuals opportunities to connect with others while promoting self-expression and emotional well-being. Art therapy, including participation in art classes or communal workshops, offers a shared space for creativity that encourages interaction and personal growth. Similarly, joining music groups, such as choirs or dance classes, enhances connection through collaborative artistic expression. These activities not only promote social bonding but also have therapeutic benefits, improving mood and reducing stress.

Pregnancy and the Postpartum Period

Apart from those concepts discussed within the adult section (See Section V I), it is especially important to encourage self-connection practices during pregnancy and the postpartum period. ¹⁹⁰ Uncompassionate self-responding correlates with levels of postpartum depression, which thereby impacts mother-infant bonding. ¹⁹¹ Pregnant women who maintain regular mindfulness practices show a reduction in pregnancy-related anxiety ¹⁹² and a deeper connection with their changing bodies while managing the emotional transitions of pregnancy.^193,194

Older Adults

The impact of loneliness on older adults is profound and multifaceted ¹¹⁴ as it exacerbates mental health issues, contributes to cognitive decline, and accelerates mortality rates. ¹⁹⁵ As such, providers need to screen, assess, and socially prescribe for older adults for connectedness as it is crucial for improving mental health outcomes, quality of life, and preventing cognitive decline. ¹⁹⁶ This is further supported by a review by Ki et al., that identified 15 protective factors for suicide prevention in older adults. The majority center of the domains of connectedness and included purpose in life, religiosity, sense of belonging, mattering, positive relationships, social support, social connectedness, and social participation. ¹⁹⁷ Hence, social connectedness is an important modifiable risk factor for adverse health outcomes. ¹⁹⁵ Additionally, pet ownership among older adults slowed the decline in verbal fluency and memory among individuals living alone. ¹⁹⁸

Pediatric and Adolescent Patients

For multiple reasons, many pediatric and adolescent patients lack connectedness skills. Therapeutic office settings can be an ideal place to assess and socially prescribe activities. For example, social connectedness can be fostered through group activities like team sports or art, which allow children to develop social skills, strong peer relationships, emotional regulation, and resilience. ¹⁹⁹ By focusing on and encouraging positive peer relationships and family connections, children can thrive as they have secure attachments to caregivers. ²⁰⁰ As adolescence is a crucial time for identity development and forming peer groups, they should be supported and encouraged to engage in group activities, creative arts, athletics, learning, volunteering, and spiritual practices. Peer support reduces loneliness, provides a sense of belonging and enhances mental well-being in adolescents. ²⁰¹ Additionally, these practices can later spark and contribute to a mature sense of purpose. ²⁰²

Conclusion

Psychological and scientific evidence support the concept that connectedness is a critical aspect of reaching our human potential. ²⁰³ While this may seem like an intimidating task, our proposed Merlo Model of Connectedness provides a framework for initiating lifestyle changes that foster connections with ourselves, others, and the world around us. One of the key principles of the Lifestyle Psychiatry pillar of connection is that fulfilling relationships with others and the world are impossible without a sense of connectedness to oneself. ²⁰⁴

While the domains in this paper have been assigned a primary need, they fulfill all three needs. For example, psychological knowledge tells us that our relationship with ourselves, in the form of happiness, self-empathy, compassion, purpose, spirituality, and connection with nature, is all foundational to our ability to engage with others. Developing a sense of self-connection and empowering others to do the same is a critical but often neglected aspect of increasing social connectedness.

For clinicians, recognizing and understanding the multiple aspects of connectedness is the first step towards promoting connectedness for patients. From there, beginning to talk about connectedness with patients and including related questions on intake forms conveys that connectedness matters. For patients who are unsatisfied with their current level of connectedness, clinicians can suggest using a “connectedness prescription” to set specific and achievable goals that increase connectedness across the six domains suggested in this paper. Patients and clinicians can work together to set goals, ranging from calling a family member weekly to incorporating time in nature into one’s daily routine. Combining these individual-level interventions with community-based efforts provides clinicians with the opportunity to foster a more connected, healthier, and happier world.

ORCID iDs

Gia Merlo https://orcid.org/0000-0002-7209-5403

Steven G. Sugden https://orcid.org/0000-0002-2255-9804