Friendship and social connection

Domain XV · Nature, philosophy, social & rites of passage

What it is

Friendship and social connection is not a psychotherapy. It is a health determinant that public-health bodies now ask clinicians to assess and address. The Surgeon General's Advisory describes social connection as having three components: structure (how many relationships, how varied, how often…

Format

• No source gives a manualised protocol, session count or format for clinical work on social connection; the stages below organise what the public-health sources ask of clinicians plus standard CBT structure, and the sequencing and transition criteria are.
• Link to community. Goal: connect the client to groups and services outside therapy (social prescribing link workers, community organisations, volunteering). Move on when contact with at least one non-therapy source of connection is happening without the therapist's prompting.

Who practises it, and how they are trained or regulated

• Intervene across the four types. Goal: match the work to the formulation using Masi et al.'s four categories: improving social skills, enhancing social support, increasing opportunities for social contact, and addressing maladaptive social cognition. Individual-level options WHO lists for older people are social skills training, peer-support and social activity groups, befriending and CBT, face to face or digital.…

Evidence status, as the guide reports it

• Version followed: the public-health framing of the US Surgeon General's Advisory Our Epidemic of Loneliness and Isolation (2023) and the WHO Commission on Social Connection report From loneliness to social connection (launched 30 June 2025), with the four-type classification of loneliness…

Questions to explore with your client

• What drew you to it, and what are you hoping it will change?
• Is there physical contact? Was it explained beforehand, and do you feel free to say no or stop at any point?
• Does it involve fasting, a special diet or 'detox'? Have you discussed this with your doctor?
• Is it a group, retreat or community? How do they respond if someone wants to leave or raises a concern?
• Does it use a device, heat, cold, water or a physical procedure? Has a medical professional checked that it is safe for you?
• Who runs it, and what training or registration do they hold?
• What actually happens in a session or meeting, and how often?
• What does it cost, and is there pressure to commit to more?
• How do you feel afterwards, in the hours and days that follow?
• Does it fit with, or clash with, the work we do here?

What practitioners of it watch for

• a crisis or new withdrawal timed with ending. Working: the client can describe their plan without prompts.
• pressure from family to reconcile with someone harmful; grief if repair fails. Working: the client acts in line with their values whatever the outcome.
• the client hearing "it's your fault"; stress that the cycle is common and understandable. Working: the client starts noticing the cycle between sessions.
• over-commitment, people-pleasing and helper burnout, especially in clients with caring roles. Working: the client reports contact and a sense of contribution.
• the strategy states social prescribing does not replace medical care; keep treating any mental-health condition. Working: the client attends a linked activity.

Problems the guide addresses

• Stuck client: "there's no one and nothing out there"
• Resistance and "I prefer being alone"
• Overwhelm and social anxiety
• Non-adherence to between-session tasks
• Rupture and over-reliance on the therapist
• Skills differences, neurodivergence and communication barriers
• Harmful relationships and exploitation
• Suicide risk
• Grief, migration and losses behind the loneliness
• Limited local options or access

When to involve someone else

• New or worsening physical symptoms, or advice to stop or change prescribed medication: involve the client's doctor or prescriber.
• Signs of coercion, isolation from family and friends, escalating costs or secrecy: discuss openly and consider safeguarding.
• A crisis or thoughts of suicide: follow your crisis protocol. In the US, call or text 988; in the UK and Ireland, Samaritans on 116 123.

Drawn automatically from the guide's own sections. Stay curious: neither endorse nor dismiss what the client values, and check anything that matters against the full guide and its sources. Not medical advice.