Families, Systems, & Health
2010, Vol. 28, No. 1, 1–18
Personal Social Networks and Health: Conceptual and Clinical
Implications of Their Reciprocal Impact
Social networks affect positively or nega-
tively a person’s health, and a person’s
health affects, in turn, the network’s avail-
ability. This article discusses this double
dynamic, recommends the routine explora-
tion of patients’ social networks, and offers
a mapping tool that allows detection of
strengths and weaknesses of those processes
so as to facilitate interventions that improve
the social support’s health-enhancing effect.
Keywords: social networks, mapping net-
works, social support, social networks and
health
No man is an island, entire of itself; every
man is a piece of the continent, a part of the
main.
—John Donne (1572–1631), Devotions
Upon Emergent Occasions, Meditation XVII
he field of social networks and health,
T which focuses on the correlation be-
tween variables of our stable cocoon of
relationships and health, has been expand-
ing exponentially. A plethora of recent re-
search provides evidence about the impact
of those microsocial variables on health,
Carlos E. Sluzki, MD, Department of Global and
Community Health, College of Health and Human
Services, and Institute for Conflict Analysis and Res-
olution, George Mason University.
Correspondence concerning this article should be
addressed to Carlos E. Sluzki, MD, College of Health
and Human Services, George Mason University, 4400
University Drive, MS 5B7, Fairfax, VA 22030. E-mail:
csluzki@gmu.edu
1
© 2010 American Psychological Association
1091-7527/10/$12.00 DOI: 10.1037/a0019061
CARLOS E. SLUZKI, MD
healing, and overall well-being. However,
that field of inquiry, while conceptually a
neighbor of ours, has been scarcely visited
by those inhabiting the world of family sys-
tems and health. As a consequence, we may
be missing the opportunity to enrich our
field with many theoretical as well as prac-
tical corollaries derived from that litera-
ture. This article aims to develop a bridge
between these fields.
To begin, it may be useful to challenge
again, as the field of family systems has
done since its birth, a dominant notion in
the professional literature of North Ameri-
can–European origin, namely, that our self
is skin-bound, that our identity is a rock-
solid personal possession.
Indeed, some experiences tend to rein-
force that belief: We spend a week alone in
a cabin in the mountains, or in a solo sail-
ing experience, or we can even end up ma-
rooned, as Robinson Crusoe did for years,
on a deserted island, and there we are, still
recognizing ourselves as a unit until the
eyes of the other make their blessed recon-
firming appearance in the person of an-
other human being, the Friday of Crusoe,
or, in the case of the main character of the
film Castaway, by Wilson, a basketball
turned imaginary friend. And when we are
wounded, it is us who are in pain until the
caress of another being soothes us.
Our life is social from the moment we
are born. In fact, newborns and young ba-
bies are extremely sensitive to the quality
2 SLUZKI
of their social context: They thrive with the
reasonable quotient of stimulation, contin-
gent responses, variety, acceptance, and
tender affection by their parents and par-
ents’ helpers (grandparents, older siblings,
etc.) or parent substitutes (caretakers in
orphanages, babysitters, and the like;
Bowlby, 1969; Clarke-Stewart, 1977), or, if
insufficient, their development can be de-
layed (Korner, 1974) and may regress, or
even end in terminal marasmus (Bowlby,
1969). Regardless of age, the “others” are a
central feature of our life: Our identity, our
self, our history, our memories live in a
social milieu, embedded in a complex spiral
of reciprocal perspectives (Laing, Phillip-
son, & Lee, 1966). Those who surround us
are, ultimately, part of our selves. This ar-
ticle is devoted to this collective component
of our identity.
OUR PERSONAL SOCIAL NETWORK
Our personal social network is a stable
but evolving relational fabric comprising our
family members, friends, and friendly ac-
quaintances; work and study connections;
and relations resulting from our participa-
tion in formal and informal communal orga-
nizations, including religious, social, recre-
ational, political, vocational, health-related,
and the like. Our social network includes, in
fact, all those with whom we interact and
who distinguish us (and, reciprocally, we dis-
tinguish) from the faceless, anonymous
crowd. This social cocoon accompanies us, in
an evolving form, from cradle to tomb, and
constitutes a key repository of our identity
and our history; it is a key ingredient of our
sense of satisfaction and fulfillment with life.
Kahn and Antonucci (1980) have coined the
rich metaphor of a “social convoy” to refer to
that interpersonal collective with reciprocal
ties that travels with us through our (and
their own) life span, morphing as time passes
and circumstances intervene in terms of
membership, types of interaction, composi-
tion, and rules of reciprocity, adding ships
while others sink over time, as ultimately we
ourselves do in the Sargasso Sea of death.
The term social network has been ap-
plied to a variety of interactive social
forms, from the connectedness that takes
place as part of an Internet system to the
one that ties together sports or hobbies afi-
cionados, from religious organizations that
tie members through common rites and
praying practices to the web that connected
the 9/11 terrorists before their coordinated
attack. A social network can be drawn as a
bird’s eye view collection of nodes (dots)
representing each member of an organiza-
tion, or a neighborhood, or any specific pop-
ulation, plus ties (lines) that connect those
nodes indicating a link or relationship, con-
figuring a graph of one shape or another. In
those cases, the centrality of one given
node is circumstantial in the sense that
nodes/people that are very popular or pow-
erful will have more ties connecting them
with others than people who are new to
system or less powerful or more misogy-
nous, although they can be visually located
at any given area in the surface of the map.
That is not the case with the informant
in the personal social network, as dis-
cussed in this article. Rather than being
designed as an ad hoc graph, it can be
visualized as a constellation surrounding
an individual, as it is an informant-based
social network or egocentric network
(Fisher, 2005) that specifies the universe of
social connections of a given person. Map-
ping such a network assumes that the in-
dividual whose personal social network is
being elicited is at its center (mapping is-
sues are discussed in detail in a later sec-
tion).
Needless to say, the nuclear family con-
stitutes the central component of that net-
work during the first years of life. It ex-
pands, however, quite substantially the
moment the child establishes relationships
with other members of the community
(children in playgrounds or in the neigh-
borhood, students and teachers from kin-
dergarten on), and further expands when
the youngster becomes autonomous and es-
tablishes his or her own sphere of activity,
 NETWORKS AND HEALTH
be it a job or an advanced education, orga-
nizes his or her own family, and so on. That
does not necessarily vanish the role or im-
pact of the family, but generates a much
more complex and diversified network of
resources, which is the focus of this article.
The characteristics of a given individu-
al’s personal social network vary from per-
son to person given individual relational
style as well as many contextual variables.
Extroverted people, that is, people with
propensity to connect with others (Totter-
dell, Holman, & Hukin, 2008), have, not
surprisingly, a richer social network than
their counterparts, introverted people.1
But people who have just moved into a new
area will unavoidably have a skimpier and
less varied social network than people well
established in their community (Sluzki,
1992). And people suffering a chronic, lim-
iting disease will experience a progressive
decline of their social network, as discussed
more in detail later in this article.
Personal social networks, both in their
configuration and in their differentiation
from a larger collective, vary from culture
to culture, as cultures strongly influence
the architecture of intimacy and responsi-
bilities, the boundaries defining who is a
member of a family and who is not, who to
be loyal to and who to mistrust, as well as
prescriptions and proscriptions of gender
relations and rules of access to alternative
support networks. Within each given cul-
tural and socioeconomic niche there will be
a normative profile of individuals’ social
networks, with its own predictable life cy-
cle, in harmony with the life cycle of others
members and vicissitudes of members of
the nuclear family and its context. Need-
less to say, for each sociocultural collective,
the “norm” is but an average of what in real
life is a Gaussian curve that ranges from
an extremely rich, varied, and engaged net-
work to an extremely meager, scarce, and
distant one.2 The latter is highlighted here
because it tends to affect negatively the
health and well-being of the individual.
3
The transition from a family-centered
life to a predominantly socially centered
reliance that followed the Industrial Revo-
lution has been slow and extremely uneven
worldwide. It has required relinquishing
many old practices and learning new ones,
some of which are at odds with what has
been the long-lasting cultural norm of a
given family, clan, culture, or region (Fali-
cov, 2000; McGoldrick, Giordano, & Garcia
Preto, 2005), shifting many social functions
that were central for the development of
people’s identity, sense of agency, and well-
being from the family to community re-
sources—school, day care center, the
neighborhood, for instance.
Solid evidence of the impact of socioeco-
nomic and working variables on health has
been drawn since that period, which has
constituted the basis for the development
of much progressive labor and sanitary leg-
islation over time. However, the first hard
evidence singling out social relations as an
independent variable affecting health can
be credited to a study that opened the doors
of empirical sociology, namely, Durkheim’s
(1897/1951) research that established a
positive correlation between social isola-
tion (anomy) and the probability of suicide.
1
In the realm of psychopathology, people with a
diagnosis of narcissistic and histrionic personality dis-
orders show a richer social network, and frequently
occupy a more central position in the personal social
networks of others, than people with a diagnosis of
avoidant, schizoid, and schizotypal personality disor-
ders (Clifton, Turkheimer, & Oltmanns, 2009).
2
Although not specifically pertinent to the scope of
this article, it cannot be ignored that dramatic circum-
stances such as major uprooting and displacement
both within countries—as is the case of the so-called
internally displaced persons— or between coun-
tries—as is the case of refugees—the frequent result
of natural or human-made catastrophes, drastically
dislocate whatever social network people may have,
compounding the ordeals that this large segment of
the civil population may have to endure. Collective as
well as small-group measures may be envisioned for
that population but, again, alas, that theme reaches
beyond the confines of this article.
4 SLUZKI
RESEARCH IN THE PAST 40 YEARS
During the past 40 years, scores of epi-
demiological studies as well as more focal
investigations have highlighted the impact
of the personal social network, social inte-
gration, social support, social conflict, or
social capital on individuals’ health.3
During the early period of research on
the subject, the question about the direc-
tionality of the process (Does a meager so-
cial network reduce psychological or phys-
ical resilience in individuals, or is it that a
supportive social network functions as a
buffer against disease or death, or is it
perhaps that the presence of an illness af-
fects negatively the social network, reduc-
ing its availability?) was difficult to answer
because of the retrospective design of that
research. Namely, the research evidence
had as a point of departure a sample of
problem subjects (such as people recover-
ing from a heart attack, or a registry of
recent suicides, and a control sample of
healthy subjects) and therefore evaluated
their social network at that point in time.
Although it allows for the establishment of
differences between network traits of both
samples, this approach did not inform
whether the characteristics of the social
network preceded (and eventually contrib-
uted to) the disease, or vice versa, or
whether possible correlations between the
social network and health or disease were
both dependent on a third, still unspecified,
variable.
This situation changed when a new gen-
eration of prospective research contributed
robust evidence of the effect of social net-
works on health. This trend was preluded
by Stanley Cobb (1976) and launched by
the pioneering work of Lisa Berkman and
her team (Berkman, 1984; Berkman &
Syme, 1979), who carried out a 9-year fol-
low-up study of survival within a stratified
random sample of 7,000 adults. Once age,
gender, and prior health status were con-
trolled, variables related to social connect-
edness emerged as a salient trait that dif-
ferentiated those who had died during that
interval and a matched sample of survi-
vors.4
To be precise, the adjusted relative risk
of mortality of those in the lower end of
their social network index was 2.3 for men
and 1.8 for women, that is, men with a
meager social network were more than
twice as likely to die and women almost
twice as likely to die within those 9 years
when compared with subjects with a more
robust social network (Berkman, 1984;
Berkman & Syme, 1979). This correlation
between social network and health was
maintained when those samples were rean-
alyzed controlling baseline health status
(as informed by the subjects), socioeco-
nomic status (based on income and educa-
tion), cigarette smoking, excessive weight,
alcohol abuse, and level of physical activi-
ties.5
A confounding factor that the design of
this project could not tackle was that their
health data were obtained on the basis of a
survey and a questionnaire rather than
clinically; critics argued that people could
have underreported ill health or that per-
haps a lingering disease had negative ef-
fects on those individuals’ social networks
before they themselves detected their ill-
ness.6 However, a series of subsequent re-
search projects launched at community
health centers where a full health evalua-
tion was conducted at the beginning of the
3
For a detail of those instruments, see http://
trans.nih.gov/CEHP/HBPdemo-socialconnectmeasures
.htm.
4
In that study, “social connectedness” included
marital status, contacts with close friends and rela-
tives, church membership, and membership in infor-
mal and formal group associations, analyzed sepa-
rately as well as aggregated in a social network index.
5
As in any multivariate analysis, there were sev-
eral trade-off substitutions that derive from this anal-
ysis, for instance, subjects who are not married but
with many friends had similar mortality rates than
married subjects with fewer friends.
6
It was later shown that global self-rated health was
by itself a solid independent predictor of mortality in
longitudinal studies (cf. Idler & Benyamini, 1997).
 NETWORKS AND HEALTH
study (House, Robbins, & Mekner, 1982;
Shoenbach et al., 1986) and subjects were
followed for no less than 9 years confirmed
the results of the original study: Individu-
als with an insufficient social network
showed a statistically meaningful higher
chance of dying earlier that people with a
more robust social network.
Since then, demographic and social net-
work variables have been correlated with
health and well-being not only in the pop-
ulation at large but also in different specific
sectors, including, in a necessarily incom-
plete list, a focus on children (e.g., Hark-
ness & Super, 1994; Super & Small, 2002)7;
old age (e.g., Adams & Blieszner, 1995;
Bowling & Farquhar, 1991; Choi & Wodar-
ski, 1996; Glass, Mendes de Leon, Seeman,
& Berkman, 1997; Oman & Reed, 1998;
Pilsuk & Minkler, 1980; Sluzki, 2000); so-
cioeconomic sectors, from the poor to the
wealthy (Rosengren, Orth-Gomer, & Wil-
hemsen, 1998; Weyers et al., 2008); social
network, social integration, or social con-
nectedness and morbidity and mortality
(Berkman, 1984; Berkman et al., 2004;
Berkman & Syme, 1979; Bosworth & Schaie,
1997; Hanson, Isaacson, Janzon, & Lindell,
1989; House et al., 1982; House, Landis, &
Umberson, 1988; Orth-Gomer & Johnson,
1987; Ringback Weitoft, Haglund, & Rosen,
2000; Schoenbach, Kaplan, Friedman, &
Kleinbaum, 1986); quality of life in different
contexts (e.g., Adams & Blieszner, 1995;
Kouzis & Eaton, 1998; Michael, Berkman,
Colditz, Holmes, & Kawachi, 2002; Michael,
Berkman, Colditz, & Kawachi, 2001); and
incidence of dementia (Fratiglioni, Wang,
Ericsson, Maytan, & Winblad, 2000), acci-
dents (Tillmann & Hobbs, 1949), relapses
from schizophrenia (Dozier, Harris, & Berg-
man, 1987), stroke (Glass et al., 2000), coro-
nary heart disease (Orth-Gomer, Rosen-
green, & Wilhemsen, 1993; Reed, McGee,
Yano, & Feinleib, 1983; Sundquist, Malm-
ström, & Johansson, 2004), problematic re-
covery from a heart attack (Medalie et al.,
1973), physical and emotional symptoms fol-
lowing stressful events such as losing a job
5
(Gore, 1978), and even the common cold
(Cohen, Brissette, Skoner, & Doyle, 2000;
Pressman et al., 2005).8
In fact, this massive evidence has con-
tributed to the development of a new disci-
pline, named by two key researchers in
that field “social epidemiology” (Berkman
& Kawachi, 2000). This literature in turn
enriches the new impetus in the field of
public health that developed under the
heading of “social determinants of health”
(Commission on Social Determinants of
Health, 2008; Healthy People 2010, 2009;
(Willkinson & Marmot, 2003; Social and
Economic Determinants of Health, 2007).
It should be noted that, while those
studies were taking place—led mainly by
epidemiologists, sociologists, social psychi-
atrists, and psychologists—the field of fam-
ily therapy generated some interesting con-
tribution of its own, focused on therapeutic
perspectives targeting social networks of
people in crisis. Among them can be men-
tioned Speck and Attneave (1973), Rueveni
(1979), Trimble,9 Landau (cf., e.g., Landau,
Mittal, & Wieling, 2008), and myself
(Sluzki, 1985, 1992, 1993, 1995b, 1996,
1998, 2000), as well as several books that
highlighted a contextualized view of fam-
ilies, such as Schwartzman (1985) and
Imber-Black (1988). The more recent lit-
erature on narrative, in turn, asserts that
stories that organize realities “live” in the
interpersonal space, that is, they are
built and sustained (or changed) in con-
7
These authors followed a more anthropological
vein in their research, operationalizing in their stud-
ies the “developmental niche” as composed by three
operational subsystems: “(1) the physical and social
setting of the child’s everyday life; (2) the culturally
regulated customs of child care and child rearing; and
(3) the psychology of the caretakers” (Harkness &
Super, 1994, p. 217).
8
For a broad-strokes superb summary of the con-
nection between social network and health variables,
compare also Capra (1997).
9
David Trimble edited between 1986 and 1995 the
“Netletter,” a low-budget, information-rich, clinically
oriented publication focused on social network inter-
ventions.
6 SLUZKI
versation (of which White & Epston, 1990,
were pioneers). Family therapy can be de-
scribed, from this perspective, as the prac-
tice through which stories that sustain prob-
lems, conflicts, or symptoms by patients and
families are collectively transformed into lib-
erating stories that do not contain the con-
flict or symptom. Many practitioners include
in their sessions not only families but differ-
ent “meaningful others,” such as a patient’s
friends and colleagues. That is also the case
when “interventions” are developed for ad-
dicted or alcoholic individuals.
SOCIAL NETWORKS AND HEALTH
As this review highlights, there is ample
evidence that a stable, sensitive, active,
and reliable personal social network has a
salutogenic effect: Individuals who count
on a “good enough” personal social network
show enhanced emotional resilience, and
also display enhanced immunodefenses,
getting sick less and recovering more
readily from disease, surgery, or accidents
than those with a meager social network. A
reliable social network provides emotional
support, sense of worth, reasons to remain
alive when other reasons fail, and at the
same time, provides practical aid, acts as
referral agents, increases the appropriate-
ness and timely use of health services, and
nurses members into recovery. At the other
end of the continuum, individuals with an
inaccessible or meager social network show
higher morbidity and mortality from a va-
riety of diseases, as well as poorer recovery
from them.
There is ample evidence to indicate that
that correlation is both cause and conse-
quence. Healthy people tend to give emo-
tional and practical support to other mem-
bers of their network, and those actions in
turn strengthen their network’s cohesion
and potential responses to them when
needed. But, while social networks tend to
actively mobilize around members during
crises or prolonged diseases (e.g., cancer,
schizophrenia, Alzheimer’s disease, pro-
gressive neurological conditions, etc.), the
social offerings and availability of those
networks deteriorate in the long run.
In sum, the exploration of this evidence
allows us to catch a glimpse at two anti-
thetical recursive processes relating social
networks and health:
• Virtuous (“salutogenic”) cycles, where
the presence of a substantive social net-
work protects and promotes the health of
individuals and, reciprocally, the health of
the individual contributes to maintain and
enhance the network’s availability and re-
sponsiveness. It should be understood that
“substantive” is not a mere reference to
quantity, to the number of people constitut-
ing the person’s network, but to the quality of
the relationship, evaluated on the basis of
intimacy, loyalty, availability, and equiva-
lent attributes, which are discussed more
in detail in subsequent sections of this ar-
ticle.
• Vicious (“pathogenic”) cycles, where a
meager social network negatively affects
the health of individuals, and diseases
(specially lingering ones) in turn nega-
tively affect the resources and resilience of
their social network, a decline that in turn
negatively affects the health of the individ-
uals, which in turn increases network at-
trition, in a spiral of reciprocal progressive
deterioration or decay, not to mention the
progressive overload for those who may re-
main involved.
SOCIAL NETWORK AND HEALTH:
THEIR RECIPROCAL EFFECT
As clearly demonstrated by the contri-
butions discussed above, the premise of a
direct correlation between quality of the
personal social network and health has
been supported by ample evidence derived
from empirical research, not to mention
from clinical experience. This correlation
opens several questions that merit being
explored and, if possible, answered.
1. Through which processes do solid, re-
liable, and efficient personal social net-
works positively affect the health of indi-
viduals? Stating it otherwise, how does
 NETWORKS AND HEALTH
participation in your social network gives
you the best chances of maintaining and
improving health? What constitutes a
high-quality social network or social com-
munity may be deconstructed in several
overlapping processes:
(a) Social relations contribute to provide
life meaning and role satisfaction to the
participants, both as providers and as re-
cipients of care (“We love you; we need
you!” and “They need me; I am meaning-
ful”) and motivate them to take care of
themselves (Achat et al., 1998; Adams &
Blieszner, 1995; Tobin & Neugarten, 1961).
(b) A reliable personal social network
provides emotional support, which in turn
mitigates alarm reactions, causally associ-
ated in the long run to disease (Achat et al.,
1998; Blazer, 1982), and facilitates coping
and adaptation.10 This “stress-buffering
hypothesis,” originally proposed by Cassel
(1976) and Cobb (1976), tends to cover both
emotional and instrumental resources.
Several mechanisms have been proposed
about the buffering effect. Among them is
that the assumption that others will be avail-
able when needed increases the individual’s
ability to cope, as it leads the individual to
perceive a health crisis as less demanding
(Adams & Blieszner, 1995; Cohen & Press-
man, 2004; Thoits, 1986). Also, the possibil-
ity (or at least the assumption of the possi-
bility) to talk with others about stressful
situations reduces the emotional and physi-
cal reactivity to those events and the result-
ing potentially maladaptive behaviors
(Lepore, Silver, Wortman, & Wayment,
1996). It should be also taken into consid-
eration that the psychophysiological reac-
tivity to stressful events, although ex-
tremely varied among individuals, tends to
be quite stable within individuals. Those
who have a predictably stormy psycho-
physiological reaction to stressful events,
be it emotional or physical, are more sus-
ceptible to disease (Cohen & Hamrick,
2003). It merits proposing that hyperreac-
tive individuals are more likely to exhaust
their network with demands and expecta-
7
tions. But, alternatively, it could be sug-
gested that those individuals broadcast
their needs more openly and therefore
elicit more responses within their sur-
roundings, and they are responsive to the
ministrations of their support network,
thus generating a rewarding environment.
(c) Reliable personal social networks
provide practical/logistical support (“Go to
hospital XX, they provide good care and
speak our language. Bus N37 takes you
there”), dampening the experience of over-
load, resolving some problems, and activat-
ing and facilitating the access to health
care resources (Cohen, Gottlieb, & Undre-
wood, 2000; Mattlin, Weithington, &
Kessler, 1990). For instance, Mexican
American immigrants who live in areas with
a high proportion of Hispanics have better
access to care than those who live in a cul-
turally dissonant neighborhood (Derose,
2000; Roan Gresenz, Rogowski, & Escarce,
2007), a finding that may be attributed to
thicker social networking facilitated by
shared language and customs among mem-
bers of their barrio.
(d) Social relations provide feedback
about signs of dis-ease and deviations from
healthy practices (“You look too pale. Go
see a doctor”), triggering self- or other
health-caring behaviors (Cohen & Willis,
1985; Hajema, Knibbe, & Drop, 1999).
(e) Life within a close-enough social net-
work, such as family or other cooperative
life arrangements, facilitates the mainte-
nance of daily routines (such as regular
nourishing meals, medication reminders)
and provides normative (preventive) incen-
tives (such as regular sleeping, hygiene)
10
For instance, for many elders, even with reduced
motility and other foibles of age, this health-
enhancing influence may be stronger with the contin-
ued involvement with friends and neighbors than
with a well-intentioned move to an offspring’s house-
hold distant from their original dwelling, as the
former comprises continuity, shared history, and life-
style, whereas the latter may increase dependency
and a stressful adjustment to a new environment
(Arling, 1976).
8 SLUZKI
that are associated with good health and
appropriate self-care (Baxter et al., 1998;
Franssen & Knipscheer, 1990).
2. Through which processes does a
scarce, unreliable, or inefficient personal
social network have a deleterious effect on
the health of individuals? This is, of course,
a question that complements— or mir-
rors—the previous one.
(a) Social isolation forces an increase in
overall alertness, a heightening of the “gen-
eral adaptation syndrome” known to de-
press in the long run the psychoneuroim-
munological system and, through that
mechanism, increases susceptibility to dis-
ease;
(b) the scarcity of practical and logistic
support reduces accessibility to health re-
sources;
(c) the lack of a social “echo”— of being of
value to others in one way or another—
conspires against arguments that justify
the effort to keep on living (Kouzis &
Eaton, 1998);
(d) through reduction of social monitor-
ing and feedback (intrinsic to any situation
of living in a collective), and even more
with the added gray tinting of the world
that characterizes depression, isolation
generates carelessness, reducing the aver-
sion for risk-taking behavior or at least
muffling the appraisal process;
(e) solitude reduces the incentives and
social reinforcement for the maintenance of
habits and routines associated with good
health—from regular meals and sleep pat-
terns to hygiene habits (Berkman & Syme,
1979); and
(f) an unreliable or deteriorated social
environment, such as that of an elderly
person lacking family and friends and liv-
ing in a poorly managed nursing facility or
sequestered by his or her own family in a
back room, and the exposure to predomi-
nantly negative or infantilizing interac-
tions (excessive demands or criticism,
thoughtless or disrespectful behavior)
erode the sense of purpose and meaning of
life, which in turn deteriorates physical
and emotional health, as shown by Cohen
(2004) and, focusing on an elderly popula-
tion, Krause (2004), Parquart (2002), and
Reker (1997).
3. By which process does the presence of
a chronic or a severe illness of an individ-
ual have a negative effect on his or her
social network, reducing the quality and
quantity of the social offering and hence
adding to the potential pathogenicity of
disease?
(a) Any disease, especially if long last-
ing, debilitates or restricts the mobility of
the individual, which in turn has an impact
on behaviors of members of the social net-
work. This happens in two ways: First, the
lack of energy and motivation generated by
a lingering disease, as well as the self-
preoccupation of the diseased person and
some frequent moderate level of depres-
sion, reduces the initiative of the individual
to reach out and activate or maintain the
existing network, which as part of that pro-
cess, reduces the quality if not the quantity
of acts of reciprocity (give and receive) in
social exchanges, one of the motors that
keep links alive (Plickert, Cote, & Well-
man, 2007; Vinokur & Vinokur-Kaplan,
1990). Second, sick people are more home-
bound or have a more restricted motility,
which reduces their opportunity for expo-
sure to contexts in which social contact is
available, thus contributing to their isola-
tion (Feibel & Springer, 1982).
(b) The evidence of an individual’s dis-
ease has a predicable negative effect on
others. This can be attributed to two rea-
sons. One is that diseases have an aversive
interpersonal effect in the nonimmediate
circle of relations. People instinctively tend
to distance themselves from diseased indi-
viduals, reducing their availability, unless
they belong to very intimate, close group,
for whom the opposite is the case. There is
some evidence also that the aversive effect
is stronger when the sick person is male
than female, probably because in our soci-
ety “the expression of distress is less role-
appropriate for men, and therefore more
 NETWORKS AND HEALTH
likely to invite sanctions” (Johnson, 1991,
p. 408). The other reason is that the care of
chronically ill individuals tends not to be
rewarding (it is repetitive and with little
perceived healing), and its lack of gratifi-
cation reduces motivation for reiterated
contact (Hamlett, Pellegrini, & Katz, 1992;
Pagel, Erdly, & Becker, 1987), except in
cultures with a strong family-oriented or
duty bias, such as the Latino population
(John, Resendiz, & de Vargas, 1997).
(c) Chronic disease has an attrition ef-
fect on caretakers. The care of chronically
ill individuals tends to be resource-inten-
sive, that is, it requires time and effort, and
hence debilitates the caretakers’ ability to
care for themselves, socialize, and other-
wise nourish their own needs.11 Hence,
caretakers end up also socially isolated,
and their efficacy diminishes. Not surpris-
ingly, the spouses of people with Alzhei-
mer’s disease have been frequently labeled
“the hidden victim” of that disorder.
However, chronic diseases may generate
new networks for isolated individuals, as
they may provide opportunity for contact
with other patients also institutionalized
or with caretakers in the community. As an
example, elderly people who live in their
own dwelling but lack family and friends in
their vicinity tend to maintain a thicker set
of caretakers, be they physician, nurse
practitioner, or rehabilitation specialists,
as these professionals become an impor-
tant source of self-affirming social contact
and, in some cases, constitute the central
characters in the patient’s meager social
entourage.
MAPPING A PERSONAL SOCIAL
NETWORK12
In a research endeavor, as well as in a
practice, in the emergency room, in the re-
habilitation hospital, in the nursing home,
in the hospice, and in the office, the per-
sonal social network of a given patient can
be evaluated and mapped in a short period
of time, providing a useful summary of so-
9
cial network strength and shortfalls that
merits being discussed in detail.
To start, health professionals and care-
givers will find it revealing to explore the
composition and accessibility of the pa-
tient’s social network in the course of a
consultation and make a note of areas of
potential deficit. Information about a per-
son’s social network tends to be easily ac-
cessible: People usually talk about their
social world comfortably and without a
sense of being exposed. A patient or pro-
vider can easily transcribe this information
onto a map, as it does not require more
equipment than pencil and paper or ex-
tended training by the interviewer. Figure
1 provides a blueprint for such a personal
social network map.13
The personal social network map differ-
entiates three layers of intimacy, designed
as concentric circles around a central point,
the informant: (a) A central circle encom-
passes an area corresponding to the inti-
mate connections, people “close to our
heart” with whom we can share intimacy or
rely on without question; this territory is
generally occupied by close parents or sib-
lings, a mate, close friends, and a few other
special individuals, perhaps a trusted ther-
apist or member of the clergy, sometimes a
coworker or a school friend with whom we
have total trust and confidence even while
maintaining the relationship confined to
11
It should be noted that all these considerations
may apply also to the plight of the elderly, even when
reasonably healthy, especially if socially isolated—
while there is strong evidence that the availability of
the informal support provided by the extended net-
work of the elderly is more bound by the size of the
network that by the specific demands for care (Choi &
Wodarski, 1996).
12
An early incursion into this theme by the author
of this article may be found in Sluzki (1995a).
13
To trace the genealogy of this specific model and
map is a rather difficult task, as, like so many other
models, it contains traits of multiple progeny, includ-
ing but not limited to contributions by Pilsuk and
Hiller Parks (1986) and so many others.
10 SLUZKI
Figure 1. Diagram for mapping a per-
sonal social network: The four quadrants
and three circles.
the work space.14 (b) An intermediate circle
encompasses an area of relations charac-
terized by social connectedness without a
high degree of intimacy, including social
friends (with whom we may share social
activities such as dinners, sports, comfort-
able work or study exchanges, etc.). (c) An
external circle delimits an area of acquain-
tances, that is, people with whom we have
occasional contact, such as family members
who we meet at weddings and funerals,
friends of friends with whom we interact
circumstantially, the clerk of the corner
store or our regular hairdresser with whom
we exchange greetings and occasional cour-
tesies, coworkers who we greet in corridors,
fellow students who we know and who
know us from shared classes and occa-
sional exchanges, cult brethrens, our inter-
nist’s stable receptionist, and so on. It es-
tablishes the boundary with the vast area
of “the unknown other,” the millions of peo-
ple we do not know and who do not know
us. The test of membership in this terri-
tory, as opposed to that of “the others,” may
lie in the answer to the question, “If you
cross path with that person in a vacation
spot, would you stop and greet and chat
with them briefly?”15
The mapping of the personal social net-
work is further systemized by dividing it in
four quadrants, namely (a) family, that is,
those related to the informant by blood or
by other family ties; (b) friends and ac-
quaintances, that is, links that are based
on personal empathy, those connected only
by social ties; (c) work or study relations,
that is, links established and maintained
fundamentally within the confines of trade,
profession, or school joint activities; and (d)
community-based relations, including peo-
ple who we know and know us on the basis
of sharing membership in organizations,
such as religious groups,16 clubs, affinity
groups, and other outlets, including health
and mental health, social, or legal services,
and the like.17
This schematic design for a mapping
should be understood as a toolbox to por-
tray the composition, distribution, and spe-
cific traits of a constellation of relations
that constitutes an individual’s personal
14
Reciprocity, although a dimension of a relation-
ship, is not a necessary condition for inclusion. Hence,
for instance, a trusted therapist or a specific wise
clergyperson of our congregation may be experienced
by us as important potential resources and merit be-
ing included as part of the inner circle within our
social network. In turn, while they may perceive
themselves as a resource for us, they would not in-
clude us in their map at all. An extreme example of
this is the attachment developed by many people to
public figures, including politicians, actors, and enter-
tainers, who may occupy an important place in the
public’s life even though no personal relation has been
established with them, beyond the one fostered by a
sector of the press solely dedicated to sustain that
interest through photos and gossip about these char-
acters’ lives and tribulations, which affects those in-
volved as if this information would be one related to
family or close friends.
15
Throughout the text, some sample questions are
included as suggestions to explore specific issues.
They appear in italics.
16
A more subjective, self-reported measure, namely
“religiosity,” has shown an interesting age-related dif-
ference: In a 12-year follow-up study (Kraut, Melamed,
Gofer, & Froom, 2004), religiosity was associated with
lower adjusted mortality for younger respondents and
with higher adjusted mortality for a 55-year or older
cohort, as compared with nonreligious respondents. In
regard to religious collectives and health, see also Oman
and Reed (1998).
17
These distant relations play, however, a crucial
role: As their own personal social network generally
does not overlap much with that of the informant,
these relations open doors to other networks, allowing
for contacts that otherwise would be accessible.
Hence, the felicitous description of Granovetter (1983)
about “the strength of weak ties.”
 NETWORKS AND HEALTH
social network. It has the merit of simplic-
ity and practicality, which are perhaps its
main claim when compared with other
valuable social network tools and question-
naires, such as the Family Environment
Scale (Moos & Moos, 1976), the Social Net-
work Inventory (Berkman & Syme, 1979),
or the Social Network Index (Cohen & Wil-
lis, 1985).18 In fact, most of the parameters
discussed here have been used, isolated or
in combination, as independent variables
in many of those tools.
The “inhabitants” of the social network
can be elicited by a variation of the follow-
ing question: “With whom have you had
any interaction whatsoever in this past
week who is not a total stranger, people who
you know as well as they know you? They
may even be persons who do not know your
name or you theirs, but they know you.”
From that first set of questions, addi-
tional ones may flow, among which are the
following: “With whom do you maintain
contact who is really important for you, and
how frequently?” “Who initiates the con-
tact?” “Who do you trust implicitly?” “Who
is reliable and responsive to requests for
help?” “With whom do you go out occasion-
ally, in social activities?” “Give me a list of
all the persons in your current life that are
close to your heart,” and so on.
In a first stage of mapping, each person
is marked in the map as a dot. Names or
numbers from a prior list of people gener-
ated by the informant are written by each
dot for identification purposes (even pets, if
mentioned by the informant, may be in-
cluded in the “friends” sector). To estimate
centrality as well as density, in a second
stage, lines are drawn between people/
points in the map who know each other
independent of the informant, such as
friends of the informant who are friends
between themselves. In a third stage, peo-
ple who share the household (family mem-
bers, friends, or acquaintances that may
live with the informant, if any) and other
specific clusters may be circled together. If
the informant has migrated, marks about
11
people living in different regions may be
drawn with different colors or circled.
As mentioned above, the portrait elic-
ited by this inquiry is, in principle, static
rather than dynamic, that is, at one point
in time rather than over time. However,
additional variations may include (a) ex-
ploring the evolution of the network at dif-
ferent points in time, such as eliciting a
map responding to the question, “If you
would have drawn this map 3 years ago,
what would have been different?” and com-
paring it with the one centered in the
present (this becomes particularly rele-
vant in sequential maps from the same
informant 3 years before and after an
event such as a marriage or a divorce or
the onset of a chronic disease); (b) includ-
ing meaningful deceased people in it; and
(c) comparing dominant maps in samples
of individuals belonging to specific co-
horts, such as different social class, edu-
cation, and sociocultural backgrounds;
specific affinities, sexual orientations,
and disorders; and so on.
It is possible, and in some case advis-
able, to conjointly map the shared and not
shared social networks of couples, families,
or other small groups. However, a joint
map risks missing unevenness or major dif-
ferences in terms of the individual contri-
bution to the joint map. For instance, the
information provided by the joint mapping
of a couple’s network might contrast, some-
times dramatically, from the individual
map of each member of the couple. Such is
the case when one of them moved away
from his or her prior neighborhood, town,
or country to live with the other, or one of
them is working in a socially rich environ-
ment and the other is at home, or, as men-
tioned above, one may be simply more so-
ciable than the other and therefore have a
substantive different individual personal
network. These differences may become a
18
This tool, used by Cohen and his collaborators in
many of their projects, can be found at http://
www.psy.cmu.edu/⬃scohen/SNI.html
12 SLUZKI
major source of conflict for some couples,
whereas for others, they may operate as
complementary traits that balance their
social life for their mutual benefit.
For purposes of expanding the analytic
capacity of this tool, a personal social net-
work may be further evaluated according
to structural, functional, and trait vari-
ables.19
A personal social network’s structural
characteristics include
• size: number of members or “inhabit-
ants,” total and by social quadrant;
• composition: distribution within and
between the four social quadrants and the
three circles or layers of intimacy;
• density: connectedness between
members, independent of the informant,
within and across quadrants (“Who among
these knows whom, independently of you?”);
• dispersion: geographic or practical
distance from the informant;
• degrees of homogeneity and heteroge-
neity: similarity or dissimilarity among
members according to variables such as
age, gender, cultural background, social
class, ideology, perceived status, and so
forth20; and
• overall dominance of specific emo-
tional and social functions and of link traits
provided by the network (see next items).
A personal social network also includes
dominant emotional/social functions that
each given relationship or social link ac-
complishes for the informant (these func-
tions may overlap), including the following:
• emotional support: “being there” for
the other when needed, providing or receiv-
ing reliable empathic support and succor-
ing (“Who is there for you in case you need
somebody to hold your hand, or for you to
hold their hand when they need it?”);
• social companionship: sharing plea-
surable social activities such as going to
the movies together, dancing, having din-
ner, shopping, hunting, or praying together
(overlapping with the prior one should not
be assumed); “Whom of these would do
choose when you want to have a light social
outing, dinner, the movies, or things like
that?”;
• cognitive guidance and advice: pro-
viding or receiving practical advice, coun-
seling, or guidance at different junctures;
• social regulation: enforcing social do’s
and don’ts by counsel, action, or mere pres-
ence;
• material support and services: actual
physical help as well as doing things for the
other when needed; and
• connection with other links/nets, not
infrequently the role of more peripheral
members, who may be more central in
other networks (Granovetter, 1983); (“Who
has been a good ‘bridge‘ to open new con-
nections when needed?”).
Last but not the least, the specific char-
acteristics of the relationship between the
informant and any given person in his or
her network, that is, specific link traits, can
be analyzed according to
• intensity: commitment to the rela-
tionship;
• duration: how long have they known
each other;
• shared history: how many memories
do they share, and of what nature;
• emotional/social functions (already
discussed above) that predominate in the
relationship;
• (multi)dimensionality: how many so-
cial functions characterize the relation-
ship; and
19
Far from defining these variables as original, I
should make it clear that this listing borrows heavily
from many authors, chiefly Berkman and Cohen (see
several references for these authors), reserving for
myself only some systematization of them as well as
any errors.
20
This variable is affected by two opposite social
tendencies: homophily, that is, the tendency of indi-
viduals to associate with similar others (a notion in-
troduced by Lazarsfeld & Merton, 1954, and exten-
sively reviewed by McPherson, Smith-Lovin, & Cook,
2001); and heterophily, that is, the tendency to con-
nect with diverse groups (Roger, 2003). The former
facilitates reconfirmation of views and the latter fos-
ters innovative ideas.
 NETWORKS AND HEALTH
• reciprocity: ratio of “give and receive”
transactions.21
These structural, functional, and trait
variables probably exceed the needs of a
practicing clinician, and may risk over-
whelming what may otherwise be a useful
optic. They are specified here to highlight
the richness of this perspective and open
avenues for the research-oriented reader.
CLINICAL IMPLICATIONS
The information obtained by exploring
the social network of patients may expose
important therapeutic implications. Some
of them will entail convening whoever is
available in the person’s social network
and conducting a collective session where
problems are made explicit, risks are de-
tailed, and plans are developed for a more
effective management of the crisis or prob-
lem, along the lines of the “interventions”
done with families with alcoholics or the
“network therapy” promoted by Speck and
Attneave (1973). Others will activate a min-
imal component of the network, frequently
family members, by maintaining a focus on
the support of the extended resources. Fi-
nally, some interventions can rely only on
the patient him/herself for the evaluation
and interventions aimed at promoting sup-
porting social connections.22 The latter will
require gently confronting some prejudices
that permeate our culture, such as the as-
sumption that one should not initiate con-
tacts that imply any weakness (i.e., that
relationships should be maintained from a
position of strength or at least reciprocity)
and even less ask for help, or that the only
way to measure others’ allegiance is to ex-
pect for them to initiate the contact (“They
KNOW that I am feeble, or alone, so THEY
should be the ones to contact me, not me to
contact them!”). In those circumstances, I
sometimes recommend that they call “just
to chat,” without making any effort at
transforming it into a visit. In fact, a task
that I have favored is to make one phone
call per day to a person they have not seen
in more than 2 weeks, “just to chat,” which
13
usually has a rather important activating
effect in the network, as “the others” not
infrequently feel either that they do not
want to intrude, or that the contact is not
valued by the individual, or even that they
are not welcome.
Enacted in a psychoeducational mode, a
primer on personal network enhancement
may also include stimulating, seeking, and
providing emotional support, as well as
practical and logistic support with existing
members of their network; developing com-
fort in providing and accepting feedback
about deviations from health-enhancing
practices; an insistence on the retention of
routines—we, providers, are not only part
of the patient’s network, but sometimes
one of the few inhabitants of that social
space; promoting and enhancing opportu-
nities for exposures to contexts where so-
cial contacts are available, as social, cul-
tural, political, and religious activities are
all spaces where social connections can be
established or reactivated, sometimes after
some awkward first moments of self-doubts
and fears of rejection; enhancing reciproc-
ity behaviors—such as calling to express
appreciation for a visit, returning calls, an-
swering letters, e-letters, and text mes-
sages aimed at retaining relations; promot-
ing social activities and recommending
conversations that are not disease-based;
enhancing support for caretakers of chron-
ically ill or elderly infirm individuals; and
21
Reciprocity of contacts, frequent interactions,
proximity, shared history, and shared activities keep
alive a relation (Klein Ikkink & van Tilburg, 1999). Of
course, reciprocity may be embedded in extended led-
gers—such as the case of offspring caring for an ailing
parent on the basis of an emotional need to recipro-
cate for the ministrations received during the first
decades of their life.
22
A caveat: There are toxic relationships (relations
that foster dependency or that consistently negatively
label the patient) that people do better to avoid, unless
couched toward a transformation of that relationship.
Hence, the quality of the relationship is an important
variable to consider. However, a valuable-but-
distanced relationship may be an important target for
attempts at reconnection.
14 SLUZKI
one way or another, facilitating the devel-
opment of new networks for patients as
well as for caretakers. These observations
apply in a very special way to the vicissi-
tudes of recently migrated families (Sluzki,
1979).
Another social dimension may be added
to the above. One of the predictable effects
of major catastrophes, both natural (earth-
quakes, tsunamis, floods, hurricanes, and
the sort) or humanmade (collective violence
and wars in any of its many variations), is
the dismemberment of the social support
network through social dislocation and
forced migration when not due to death or
disappearance of many meaningful members
of the personal net, and the extinction of
collective rituals that maintained people’s
connections. Interventions aimed at recon-
necting the remnants of the social network
have been part of the focus of international
reconstruction agencies as well as nongov-
ernmental organizations, not only for pur-
poses of reestablishing the nuclei of civil so-
ciety but because of its effect on enhancing
resilience and improving survival (Barudy,
1989; de Jong, 2002; Miller & Rasco, 2004;
Landau et al., 2008).
SOCIAL NETWORK ENHANCEMENT: A
PRIMARY PREVENTION VIEW
The evidence of the impact of different
qualities of the personal social networks on
the health of individuals is overwhelming
and conclusive: Insufficient or inefficient
social support associates positively with in-
creased probability of getting sick, remain-
ing sick, recovering more slowly, having
increased complications during recovery,
and, as a result, experiencing a reduced
quality of life and, alas, dying earlier. Stat-
ing it in a reversed fashion, a reliable and
efficient personal social network will not
only have a buffering effect against disease
of every kind, resulting in a longer life, but
will have a positive effect on the quality of
the longer life lived.
However, there has been less empha-
sis on the reciprocal effect between those
variables, namely, that the presence of
disease, especially chronic disease, has a
negative effect on the personal social net-
work’s availability and efficiency, creat-
ing a potentially vicious cycle in which
the insufficient or ineffective personal so-
cial network negatively affects health
and disease negatively affects the social
network. The negative cycle and the com-
plementary positive cycle between good
health and an efficient social network
merit being incorporated into the optics
of health care.
The analysis of these reciprocal pro-
cesses not only enriches our understanding
about the complex reciprocal influence be-
tween social surrounding and health but
allows us to propose additional avenues to-
ward improving health, enhancing recov-
ery, and living a longer, happier life.
More important, social network interven-
tions constitute a powerful tool at service not
only when a disorder is already in place and
integrated in a treatment plan, but for pri-
mary prevention. As the model of “advanced
primary care” is moving front stage, the
“medical home” principles of patient care co-
ordination and sensitivity to the patient’s
context must include in its optic not only the
nuclear family but also the whole microcosm
of the extended personal social network. This
mediating structure between the individual
and the community at large not only reflects
the community, but is, in fact, its immediate
representation.
The exploration of patients’ personal so-
cial networks, including family members,
friends, work or study connections, and
community-based contacts, may lead to in-
terventions that can play a crucial role in
immediate as well as long-range health re-
covery and maintenance and in overall
well-being. These very interventions may
be vital not only for those who consult us,
but for the members of their social net-
work, individually and collectively reaf-
firmed in their social and emotional value
for one another.
 NETWORKS AND HEALTH
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