Support-receiving networks and the isolation in schizophrenia: A preliminary study toward recovery-oriented occupational therapy

Abstract

Introduction:

Social isolation is a major barrier to recovery for individuals with schizophrenia. Although prior studies examined social networks in relation to symptom severity and quality of life, few have integrated structural and relational dimensions of connectedness within a framework relevant to occupational therapy. This study investigated factors associated with social networks among individuals with schizophrenia in Japan, using Wang et al.’s conceptual framework and social network analysis.

Method:

A cross-sectional study was conducted with 31 individuals attending a psychiatric day-service center. Social isolation was assessed across four domains: network quantity, network quality, emotional appraisal (mattering and loneliness), and resource appraisal (helping and being helped). Multiple regression analysis identified factors related to network size, with significance set at p < 0.05.

Results:

Participants had extremely small networks, averaging fewer than one close contact. Regression analysis showed that only being helped by others was significantly associated with larger network size (β = 0.214, p < 0.01). Loneliness, helping others, and mattering were not significant predictors.

Conclusion:

Individuals with schizophrenia may experience profound social isolation, with networks limited to relationships where they are recipients of help. Occupational therapy should promote opportunities for reciprocal, empowering connections to support recovery and community integration.

Keywords

Schizophrenia isolation recovery social network empowerment

Introduction

Recovery is a core concept for both individuals living with mental health challenges and the occupational therapists who support them. Anthony (1993) defined recovery as “a deeply personal, unique process of changing one’s attitudes, values, feelings, goals, skills, and/or roles. It is a way of living a satisfying, hopeful, and contributing life even with the limitations caused by illness.” Recovery involves developing meaning and purpose beyond mental illness.

Recovery-oriented interventions have been implemented in diverse settings and through various approaches, including occupational therapy (Badu et al., 2021). These interventions have been shown to facilitate not only symptom reduction and functional improvement, but also positive outcomes such as enhanced self-esteem and increased social inclusion. Kelly et al. (2010), within the field of mental health, highlighted the conceptual parallels between recovery and occupation, emphasizing the importance of recovery-oriented frameworks in occupational therapy practice. This perspective resonates with the World Federation of Occupational Therapists’ position that enabling social participation is a core dimension of occupational engagement, reinforcing the international relevance of recovery-oriented approaches.

The CHIME framework: Components of personal recovery

Leamy et al. (2011) proposed the CHIME framework in their systematic review of personal recovery in mental health. This framework synthesizes key components of the recovery process identified across previous literature, with its acronym representing five core themes: Connectedness, Hope and optimism about the future, Identity, Meaning in life, and empowerment. These elements were present in approximately 60% of the 87 studies reviewed, suggesting their central role in personal recovery.

Connectedness encompasses multiple stages, including seeking and receiving support in the early phases, gradually developing autonomy, and actively engaging with the broader community. Community belonging is vital to recovery. Occupational therapists play a central role in supporting individuals within their communities by facilitating meaningful activities that help build social connections and a sense of belonging. Recent occupational therapy research has further highlighted how structured, recovery-oriented interventions can strengthen community integration and enhance social network quality (Bejerholm et al., 2022; Hitch and Pepin, 2021), underscoring the profession’s role in addressing both the structural and experiential dimensions of connectedness.

Social isolation as a barrier to recovery

Despite the emphasis on social connectedness in recovery, individuals with serious mental illness (SMI), including schizophrenia, experience significantly higher levels of social isolation than the general population (Caple et al., 2023).

Social isolation has been defined as “inadequate quality and quantity of social relations with other people at the individual, group, community, and larger social environment levels where human interaction takes place” (Zavaleta et al., 2016). Unlike loneliness, which is a subjective emotional experience, social isolation is an objective condition referring to the actual absence or insufficiency of social connections. Loneliness is a painful subjective state arising when desired and actual social interaction differ (Hawkley and Cacioppo, 2010).

Social isolation has been identified as a predictor of poor well-being (Steptoe et al., 2013), highlighting the fundamental importance of human connection. Mental health services, therefore, must prioritize addressing this issue (Linz and Sturm, 2013).

Particularly in schizophrenia, broader social connections following discharge from psychiatric care have been associated with improved quality of life (Andrzej Cechnicki et al., 2007). In contrast, restricted social networks are linked to reduced empowerment, greater stigma, and increased depressive symptoms, ultimately lowering quality of life (Sibitz et al., 2011). Furthermore, Seeman (2016), acknowledging the pathological background of schizophrenia, notes that individuals with the condition may seek solitude as a means of avoiding sensory overload. However, she emphasizes the importance of ensuring safety, alleviating social anxiety, and fostering opportunities for social connection, so that individuals can engage in positive solitude as a voluntary and enriching experience. Such solitude, when chosen within the context of a supportive environment, can contribute meaningfully to personal recovery by promoting autonomy, emotional regulation, and a sense of self.

Conceptualizing social isolation and loneliness

To capture the complexity of isolation and loneliness, Wang et al. (2017) organized social disconnection into four domains:

Network (Quantity)—the size and frequency of interactions in one’s social network;

Network (Quality)—the perceived quality of these relationships;

Appraisal of relationships (Emotional)—subjective evaluation of emotional adequacy, including loneliness; and

Appraisal of relationships (Resources)—perceived availability of tangible support.

Given this multidimensional conceptualization, social network analysis (SNA) provides a complementary lens to examine both structural and transactional aspects of social connections, central to Wang’s framework. Beyond conceptual models, research on social isolation has often used SNA to investigate the structure and function of ties among people with SMI. SNA distinguishes structural features—such as size, composition, density, role diversity, frequency and intensity of contact, and duration—from transactional exchanges of support (Wong et al., 2011). Prior studies consistently report that individuals with SMI have smaller networks (Hamilton et al., 1989), with many focusing on links between network characteristics and clinical outcomes such as relapse or symptom severity (Leff et al., 1990). Others have explored engagement in activities or community settings, such as clubhouse participation, neighborhood ties (Meyer et al., 2022), or health-risk behaviors like smoking (Meza et al., 2024). More recent work highlights the role of network quality in outcomes such as stigma reduction or recovery attitudes (Pullen et al., 2022), and incorporating activities and places as analytical factors has advanced understanding of network diversity and subtypes (Sweet et al., 2018). These findings underscore the value of SNA in capturing social ties across contexts. In occupational therapy, SNA has been applied to evaluate the impact of community-based interventions on participation and role diversity, bridging network metrics with therapeutic outcomes (Josephsson et al., 2020).

Aim of this study

This study aimed to examine social isolation, a critical barrier to recovery, in individuals with schizophrenia in Japan by integrating Wang et al.’s multidimensional framework with an SNA approach. Given Japan’s unique history of prolonged psychiatric hospitalization and slow development of community-based services, the study sought to identify the structural and transactional features of networks in this context. The findings are intended to inform recovery-oriented occupational therapy in Japan and offer insights applicable to other countries facing delayed deinstitutionalization.

Method

Design

A cross-sectional survey was conducted using a self-administered questionnaire. Participants answered online via a tablet. A research assistant who was not acquainted with the participants accompanied them as a tester during the assessment. The assistant provided minimal support, such as offering brief explanations when participants had difficulty reading or understanding the questions.

Participants

Participants were recruited from a day-service center attached to a psychiatric hospital in Aichi Prefecture, Japan, where one of the co-authors worked. The center offered approximately five rehabilitation programs per week, supported by various professionals, including occupational therapists, making it representative of typical centers in Japan. In Japan, most individuals with schizophrenia attend day-service centers for a period after hospital discharge to help reintegrate into community life. However, reintegration into community life is often slow, and many individuals struggle to establish meaningful roles or places within the community. Consequently, the duration in which they depend primarily on day-service centers for daytime engagement is frequently prolonged, posing a persistent challenge in the Japanese healthcare system.

The inclusion criteria were as follows: (a) age 18 years or older (considered an adult in Japan), (b) diagnosed with schizophrenia by the attending psychiatrist according to the Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (DSM-5), (c) user of a day-service center attached to a psychiatric hospital, (d) able to understand and respond independently or with assistance from medical staff, and (e) provided informed consent after receiving an explanation of the research. The exclusion criterion was the presence of any other psychiatric diagnosis besides schizophrenia.

For recruitment, flyers were posted in the day-service center, and medical staff introduced the research during daily morning meetings. Participation was voluntary; individuals who wished to take part approached the clinical staff on their own initiative. Detailed information was then provided to individuals who expressed interest, and their informed consent was obtained.

All procedures were approved by the Research Ethics Committee of the Graduate School of Medicine, Nagoya University, Japan (authorization number:2023-0406).

Measures

Demographic information and measurements

The following information was collected: age, sex, including the number of hospitalizations, medication dosage (chlorpromazine equivalent), the most recent Global Assessment of Functioning (GAF) score, and the most recent Brief Psychiatric Rating Scale (BPRS) score. GAF is an objective assessment tool used to evaluate the overall social, occupational, and psychological functioning of individuals with mental disorders, generating a score from 0 to 100 (Ministry of Health, Labour and Welfare, 2003). It is administered by staff members who are familiar with the subject. BPRS, a commonly used psychiatric assessment tool, evaluates symptoms of individuals with mental disorders across 18 items (Kolakowska, 1976). The reliability and validity of the Japanese versions of both scales have been established (Kitamura et al., 1985). In this study, the most recent scores from regular medical examinations conducted by the attending physician were used as data.

Network: Quantity and quality

Network quantity and quality were assessed using the Name Generator technique, a method widely used in egocentric network analysis to identify members of an individual’s personal social network (Perry, 2018). Whereas previous studies have often relied on social media or digital communication data to assess network characteristics, such approaches were not suitable for the current study. Many individuals with schizophrenia in the target population lacked the digital skills or access to such platforms, which limited the applicability of conventional network analysis tools. Therefore, the Name Generator method was adopted to capture meaningful, real-life, social interactions.

Participants were prompted to recall people within their community with whom they regularly interacted, such as individuals they talk with, consult, or collaborate with. These individuals were referred to as “alters,” following Perry’s (2018) framework. Participants were first asked the question:

“Imagine the individuals you encounter in daily community life—people you talk with, report to, consult with, or collaborate with. Is there anyone like this?” If they answered “Yes,” they listed up to three alters and indicated the frequency of interaction on a five-point scale (daily, every 2–3 days, weekly, every two weeks, or monthly/less). Although SNA usually permits an unlimited number of alters, preliminary discussions with clinical staff suggested that too many options might overwhelm participants or imply that few connections were undesirable, increasing the intrusiveness of the assessment. As no similar studies had been conducted in Japanese day-service centers, the research team adopted a cautious approach and limited alters to three. If most participants identified three, the validity of findings was to be interpreted with caution.

Although the primary aim was to measure the quantity of social contacts, the interaction frequency also reflects aspects of relationship quality, such as regularity and closeness. As such, this method allowed for an integrated assessment of both the structural (quantity) and relational (quality) aspects of participants’ social networks.

Appraisal of relationships (Resources)

Using the Name Generator method, participants were asked to evaluate the extent to which they receive help from each identified person (“alter”), as well as the extent to which they provide help to that person in return, using a five-point Likert scale: never, rarely, sometimes, often, and always.

Appraisal of relationships (Emotional)

This domain was assessed using two validated scales.

Mattering: The construction of mattering was measured using the General Mattering Scale (GMS), a five-item instrument designed to assess the extent to which individuals feel valued and significant to others. Sample items include: “How significant are you to others?”, “How interested are others in hearing what you have to say?”, and “To what extent do others rely on you?” Previous studies have demonstrated good internal consistency for the GMS (α = 0.84) (Flett et al., 2021).

In this study, the scale was used in Japanese for the first time. The translation followed Brislin’s (1970) back-translation method: (1) a bilingual researcher in the study team translated the original English items into Japanese, (2) another bilingual researcher with expertise in the field back-translated the Japanese version into English, and (3) a native English-speaking researcher familiar with the domain compared the two versions to identify discrepancies in meaning. This process was repeated until semantic and conceptual equivalence was achieved. Though this procedure ensured linguistic and conceptual accuracy, no psychometric testing of the Japanese version has yet been conducted in a Japanese population, which represents a limitation of the present study.

Loneliness: To assess feelings of loneliness, the Japanese version of the Three-Item Loneliness Scale was used (Igarashi, 2019). This scale includes the following items: “How often do you feel that you lack companionship?”, “How often do you feel left out?”, and “How often do you feel isolated from others?” Prior research has reported a high level of internal consistency for this measure (α = 0.81), and the reliability and validity of the Japanese version have been established by Igarashi (2019) through psychometric testing in a Japanese population, including assessments of internal consistency, test–retest reliability, and construct validity.

Analyses

To examine factors associated with social networks, multiple regression analysis using the ordinary least squares method was performed. The dependent variable was the total number of alters, representing the size of each participant’s social network. This variable was found to be highly correlated with another network-related indicator, the interaction amount, and was therefore selected as the primary outcome.

Four independent variables were entered into the model, reflecting two dimensions of relationship appraisal: Appraisal of Relationships—Resources, with the total score for experiences of helping alters and the total score for experiences of being helped by alters; and Appraisal of Relationships—Emotional, with the GMS/Three-Item Loneliness Scale

In addition, several background variables, age, sex, sum dosage of antipsychotics (chlorpromazine-equivalent), GAF, and BPRS total score, were initially considered as potential covariates. However, partial correlation analyses showed that none of these variables was significantly associated with the total number of alters. Consequently, they were excluded from the regression model and were not used as covariates. All statistical analyses were performed using JMP Pro (SAS Institute), USA with the level of significance set at p < 0.05. For multiple regression analysis, a commonly cited guideline recommends at least 10–15 observations per independent variable to obtain stable estimates, with alternative recommendations suggesting N ⩾ 50 + 8 when testing the overall multiple correlation. When the available sample is smaller than these guidelines, analyses should be framed as preliminary, and findings interpreted with appropriate caution (Babyak, 2004). In the present study, regression analysis was used not only to examine the size of participants’ social networks, which were expected to be relatively small in this population, but also to identify factors associated with network size based on Wang’s framework. This approach was considered essential to achieve the study’s aim of capturing the situation of social isolation of people with mental illness in Japan.

Results

Demographic information

A total of 31 participants took part in the study. Table 1 presents demographic information and scores. The total score on the BPRS (18 items) was 34.7, indicating mild psychiatric symptoms. In addition, the GAF scores ranged from 40 to 50, suggesting significant impairments that make social activities, such as work or education, difficult. This finding aligns with the clinical characteristics of individuals attending daycare services.

Table 1.

Demographic information and results of measurements.

Demographic information (mean ± SD)
Age (year)	52.8 ± 8.59
Sex
Male	21
Female	9
Other	1
Household composition (duplicate)
Lived with others
With family	15
With non-family (ex: friends/partner)	1
With group home member	8
Alone	9
Sum dosage of antipsychotics (chlorpromazine equivalent (mg))	873 ± 2150
Number of hospitalizations	2.65 ± 2.46
GAF	46.3 ± 13.0
BPRS	34.7 ± 40.5
Network (mean ± SD)
The total number of alters	0.96 ± 0.92
The interaction frequency (sum of frequency score)	4.60 ± 4.60
Appraisal of relationships (Resources) (mean ± SD)
The total score for experiences of helping alters	2.56 ± 2.81
The total score for experiences of being helped by alters	3.03 ± 3.04
Appraisal of relationships (Emotional) (mean ± SD)
GMS	14.1 ± 5.65
Three-Item Loneliness Scale	5.16 ± 1.80

SD: Standard deviation; GAF: Global assessment of functioning; BPRS: Brief Psychiatric Rating Scale; GMS: General Mattering Scale.

Factors associated with the size of social networks

Multiple regression analysis was performed to examine the associations between relationship-related factors and the total number of alters. The model was significant (F(4,25) = 33.28, p < 0.0001) and demonstrated a high level of explanatory power (R^² = 0.84, adjusted R^² = 0.82). The residual standard error was 0.397. Given the relatively small sample size and the number of predictors in the model, this high R^² should be interpreted with caution, as it may reflect overfitting (Table 2).

Table 2.

Multiple regression analysis predicting the total number of alters.

Predictor	Standardized coefficient (β)	Standard error	t-Value	p-Value
Intercept	0.023	0.297	0.79	0.4350
Total score for experiences of being helped by alters	0.214	0.061	3.54	0.0016
Total score for experiences of helping alters	0.102	0.066	1.52	0.1407
General Mattering Scale (GMS)	−0.022	0.016	−1.45	0.1591
Three-Item Loneliness Scale	0.028	0.041	0.69	0.4960

Dependent variable: Total number of alters.

GMS: General Mattering Scale.

Of the independent variables, only the total score for experiences of being helped by alters showed a significant association with the total number of alters (β = 0.214, p = 0.0016). In contrast, the total score for experiences of helping alters (β = 0.102, p = 0.1407), GMS (β = –0.022, p = 0.1591), and the Three-Item Loneliness Scale (β = 0.028, p = 0.4960) were not significant. Thus, these results suggest a significant association between receiving help from others and the size of an individual’s social network.

Discussion

Scarcity of social connections

Participants with schizophrenia demonstrated a notably low number of social connections, with the average number of close contacts reported being fewer than one. Most participants lived with family or in group homes and attended daycare, yet many lacked close relationships and remained isolated.

Although no direct comparison group was included, the extremely low number of connections remains noteworthy.

Similar findings were reported by Koenders et al. (2017) in the Netherlands, where patients with severe mental illness had social networks 2.5 times smaller than those of controls. Fortuna et al. (2019) further identified social isolation and loneliness as major unmet needs for individuals with severe mental illness. Though the present study did not directly assess participants’ needs, it highlights their considerable social challenges.

A survey by the Cabinet Office of Japan showed that 81.2% of individuals with mental disabilities cohabit with family, but only 18.7% of individuals with schizophrenia have a spouse, far less than the 46.0% for those with other disabilities (Cabinet Office, Government of Japan, 2013). The onset of schizophrenia in adolescence or early adulthood often leads to prolonged dependence on family, reducing opportunities for broader community participation. In Japan and East Asia, cultural acceptance of extended family cohabitation and persistent stigma against mental illness (Ran et al., 2021) can exacerbate social isolation. In this context, individuals may remain within the family as their primary, sometimes sole, community, whereas families themselves, under the cultural construct of “home,” may unintentionally perpetuate stigma and refrain from encouraging broader participation. At the same time, this sociocultural structure functions as a high-capacity safety net, ensuring that individuals have a place to belong and receive care. Interventions, therefore, must be designed with sensitivity to these dual aspects, leveraging the protective role of the family while addressing its potential to constrain community engagement. Effective interventions must consider these cultural and societal contexts.

Being helped experience

The results of the multivariate analysis indicated that, of the relationship-related factors, only the total score for experiences of being helped by alters was significantly associated with the size of social networks. This finding suggests that receiving support is closely related to the structure of participants’ networks. Although the cross-sectional design of this study does not allow for causal inferences, it is possible that participants may be building their networks primarily through relationships in which they receive support. Given the relatively small number of alters identified, it is plausible that the participants’ networks are formed within the context of being helped, rather than through reciprocal or diverse social roles. Although this study did not explicitly distinguish the roles of alters, such as whether they were family members, friends, or professional supporters, the results imply that alters may primarily serve as sources of assistance for the participants. In other words, the presence of supportive relationships appears to play a central role in the structure of their social networks.

However, this finding also implies that participants who were able to build networks had at least some supporters within them. Previous social network studies have suggested that, for individuals with the most severe disabilities, a small number of supporters are often closely involved, and that both the size and the strength of these connections should be adapted to the individual’s circumstances (Wyngaerden et al., 2019). It has also been suggested that the size of networks may vary depending on the specific settings and activities in which they are embedded (Sweet et al., 2018). In the present study, the strength and quality of networks and sub-analyses related to clinical symptoms were not examined due to the limited sample size. From this perspective, although these aspects were not directly examined, the presence of a network, even one primarily characterized by receiving support, could be interpreted as a potential strength for participants with moderate levels of disability, as was the case in the present sample. Further research with a larger sample size is warranted to examine in detail, and to empirically validate, the nature and current status of networks that enhance empowerment of individuals with diverse backgrounds, taking into account support-related perspectives.

In contrast, in the present study, loneliness, which has been reported to have a significant association with network size in previous research (Caple et al., 2023), did not emerge as a significant factor. Most studies of loneliness and network size involving people with mental illness have been conducted in Western contexts, and because social networks themselves are shaped by cultural influences, it is possible that such differences in context contributed to the divergence in results. Furthermore, in the present study, the mean loneliness score was below the threshold of six, which is generally considered to indicate high loneliness, whereas the mean number of alters was less than one, suggesting an extremely isolated situation. Therefore, this apparent discrepancy between low self-reported loneliness scores and the extremely small network size observed in the sample may indicate that subjective loneliness does not fully capture the extent of social isolation in this population. Such a pattern may reflect cultural influences on the perception and expression of loneliness, as well as potential underreporting due to stigma or the normalization of limited social contact. This finding underscores the importance of assessing both subjective and objective indicators of social connectedness and considering their potential divergence when planning interventions and support strategies.

CHIME framework and empowerment

Within the CHIME framework, a widely recognized recovery-oriented model, empowerment is positioned as a core process alongside connection, hope, identity, and meaning (Leamy et al., 2011). Empowerment refers to the process through which individuals recognize and mobilize their strengths, transitioning from passive recipients of care to active agents capable of influencing their communities and environments. From this perspective, although the present study did not assess recovery outcomes directly, the predominance of “being helped” relationships in participants’ networks may reflect limited opportunities for mutual or generative connections, thereby indicating a lack of empowerment. Conversely, these supportive relationships may also serve as important foundations upon which empowerment can be built. This dual interpretation underscores that the quality and nature of social relationships can, in themselves, be indicators of recovery status. Therefore, fostering opportunities for people with SMIs to engage not only as recipients of support but also as contributors is essential for reinforcing agency, identity, and social inclusion.

Implications for occupational therapy practice

This study applied a multidimensional perspective on social isolation, integrating both structural and relational aspects of connectedness. This approach aligns with recent interdisciplinary views that frame isolation as shaped by structural, cultural, and policy contexts (Holt-Lunstad, 2021). In recovery research, increasing emphasis is placed on integrating recovery-oriented frameworks such as CHIME with social determinants of health, underscoring the need to address systemic barriers alongside individual capacities (Karadzhov, 2023). Occupational therapy has similarly advanced debates on occupational justice and community participation, calling for interventions that foster reciprocal, empowering relationships and inclusive environments beyond clinical or family settings (Whiteford and Hocking, 2021).

In practice, these perspectives highlight the value of community development approaches that support participation and foster belonging. An example is proactive community-based services that enhance social participation among adults with mental illness in diverse contexts (Phadsri et al., 2021). Addressing isolation thus requires efforts at both the individual level, by building meaningful roles and relationships, and the societal level, by transforming environments and systems to expand opportunities for connection.

Limitations

This study has several limitations. First, the sample size was limited to 31 participants, which may reduce the stability of estimates, increase the risk of overfitting, and limit generalizability. A larger sample would be necessary to ensure more robust results. Nevertheless, the aim was not only to capture network size—which was expected to be relatively small in this population—but also to examine its associations with related factors using an established framework. Regression analyses were therefore essential to provide preliminary findings that can inform future research. Importantly, this is the first study in Japan to apply egocentric network analysis to individuals with schizophrenia, demonstrating marked social isolation. In addition, using Wang’s multidimensional framework enabled a more comprehensive understanding of connectedness beyond network size, underscoring the methodological novelty of this work. The findings further suggest that receiving support is a salient structural feature of networks in this population, offering a direction for future investigation. In addition, the cross-sectional design precludes any inference of causal relationships. Future research should consider larger-scale and longitudinal studies to further validate and expand upon these findings. As previous studies have shown (Sweet et al., 2018), social networks can vary greatly depending on individuals’ circumstances and symptoms. Accumulating data that capture multiple factors and causal pathways in a given target population is necessary to generate meaningful implications for concrete interventions. Therefore, future studies should use more comprehensive modeling approaches, such as structural equation modeling, with larger datasets to allow for a more nuanced analysis.

Second, the study sample was restricted to participants residing in Japan, which may limit the applicability of the findings to other cultural or healthcare contexts. The current state of community participation and network building among individuals with mental illness is strongly influenced by national mental health policies, historical background, and cultural context. Although cross-country comparisons remain limited due to scarce comparable data and the need to account for individual diversity, studies in Western countries have reported larger average network sizes than in Japan. Nevertheless, this research provides a valuable initial insight into social isolation of individuals with schizophrenia in Japan and may have relevant implications for other Asian countries with similar socio-cultural backgrounds, such as South Korea.

Third, this study introduced, for the first time in Japan, the use of the Mattering Scale and the Name Generator in this population. The Mattering Scale was newly translated into Japanese following Brislin’s (1970) back-translation method, ensuring high linguistic and conceptual equivalence; however, its reliability and validity have not yet been psychometrically tested in a Japanese sample. This is a limitation, particularly given potential cultural differences in how mattering is perceived. Nevertheless, the study is valuable as the first to measure mattering in Japan with a rigorously translated scale. Similarly, although “helping others” and “mattering” were not significantly associated with network characteristics, these constructs remain theoretically relevant to social connectedness. Future research with larger and more diverse samples is needed to clarify their potential roles in shaping networks.

Finally, the schizophrenia group consisted solely of individuals attending daycare services, which may limit the generalizability of the findings to the broader population of individuals with schizophrenia. However, given that daycare services represent a central component of post-discharge support in Japan, the findings reflect an important aspect of current mental health service utilization. Furthermore, because participation in this study was voluntary, it is possible that individuals with extremely limited social connections, who may have wished to avoid potential regret or discomfort in disclosing such isolation, were not represented in the sample. Nevertheless, even when this potential selection bias is considered, the findings still indicate a markedly severe degree of social isolation, thereby providing substantial implications for the future practice of occupational therapy.

Despite these limitations, the study’s methodological innovations and novel application of network analysis provide valuable contributions to the field and offer a foundation for future research aimed at developing effective interventions to support the recovery of individuals with schizophrenia.

Future research

This study used SNA to examine social isolation among individuals with SMI in Japanese day-service centers, showing the central role of receiving support. However, it did not address in detail the subtypes of networks or the factors influencing their structure. As SNA methods increasingly incorporate places and activities as well as interpersonal ties, future research needs to investigate the contexts and occupations through which supportive relationships are formed, and the barriers that limit the development of more empowering connections. Such work is necessary to capture the diversity of networks and to identify characteristics of relationships that foster meaningful participation. Advancing this knowledge will not only refine the understanding of social isolation in Japan but also inform strategies for building supportive networks for people with SMI globally.

Implications for occupational therapy practice

The findings of this study suggest the following practical implications and insights for occupational therapy practice:

Assess meaningful social connections and the roles within them that empower individuals, and use these findings to inform intervention.

Support the development of high-quality social networks that foster empowerment and sustained participation.

Promote the well-being of all individuals through social approaches using an occupational lens.

Conclusion

This study suggests that individuals with schizophrenia attending day-service centers, a form of secondary mental healthcare in Japan, experience profound social isolation, and that their social networks are characterized primarily by relationships in which they receive support. Only the experience of receiving support from alters was significantly associated with network size, whereas other evaluated domains, such as loneliness, helping others, and mattering, were not. Though receiving assistance may indicate access to appropriate forms of support, it also implies the absence of empowering social connections that facilitate reintegration into the community as active members of society. These findings highlight the need for occupational therapy to go beyond fostering one-way support relationships and to actively create opportunities for reciprocal, empowering connections within community settings. Future research should examine factors shaping network quality to identify supportive relationships. As the first such study in Japan, these findings provide a foundation for targeted interventions and societal efforts to support recovery and inclusion.

Key findings

Participants with schizophrenia experienced severe social isolation, with fewer than one close contact on average.

Being helped by others was significantly linked to larger social networks.

What the study has added

This study suggested that individuals with schizophrenia experience severe social isolation and that their social networks are largely limited to relationships in which they receive support.

Footnotes

Acknowledgements

The authors would like to express their sincere gratitude to all participants who took part in this study, as well as to the staff at the facilities where the data were collected. The authors also wish to extend their thanks to those who assisted with back-translation and contributed to the development and evaluation of the research tools.

Authors’ note

During the development, progress, and reporting of the submitted research, Patient and Public Involvement in the research was: Included in the conduct of the research

Research ethics

All procedures were approved by the Research Ethics Committee of the Graduate School of Medicine, Nagoya University, Japan in 2023 (authorization number: 2023-0406). All participants provided informed consent after receiving both written and verbal explanations of the study.

Declaration of conflicting interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This work was supported by Tokai Pathways to Global Excellence (T-GEx), part of MEXT Strategic Professional Development Program for Young Researchers.

Contributorship

Conceptualization: A.H., S.N.; Methodology: A.H., S.N., T.A., T.H.; Formal analysis: A.H.; Writing – original draft: A.H.; Writing – review & editing: A.H., S.N.,T.H.; Supervision: A.H. All authors read and approved the final manuscript.

ORCID iD

Aiko Hoshino

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