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Covid-19 kept families and caregivers out of hospitals. Some doctors think that shouldn’t happen again

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Covid-19 kept families and caregivers out of hospitals. Some doctors think that shouldn’t happen again

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HILADELPHIA - On an early summer morning in North Philadelphia, Marsha El sits on a bench outside Temple University Hospital, scrolling on her phone. Inside, doctors perform a heart procedure on her husband, Timothy. Barred from being by his side due to Covid-19 visitor restrictions, Marsha, a retired insurance company branch manager, anxiously waits for a phone call with any update on his condition.

"I'm just praying that when they take him upstairs, I'm able to go up here and visit him for a while," she says.

Even as most businesses in the U.S. have been removing Covid mask mandates and social distancing policies, one major exception continues to be hospitals, which have been more cautious in lifting restrictions. At the start of the pandemic, in the face of a new virus and the many unknowns that came with it, hospitals rushed to implement rules to keep patients as well as hospital staff safe, including barring visitors from entering altogether. Now, with the nature of the pandemic changing in the U.S. and increasing vaccination rates among the general population, patients and many physicians say the more restrictive ongoing limits, like only allowing one visitor, are no longer justified and may actually be harming patients' mental health and leading to worse outcomes.

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"It's understandable that when fear strikes, like when a new contagious disease comes along, we're going to be very guarded about who can be in the hospital," said Kevin Biese, an emergency medicine physician and geriatrician at the University of North Carolina at Chapel Hill. But with the current state of the pandemic, he believes that "if [visitors] have no identified risk, they should be allowed to go on in and see their loved ones."

Timothy and Marsha El have acutely felt the drawbacks of the restrictions since their first visit to Temple University Hospital more than a month ago. In the beginning of June, Timothy had an eight-hour heart procedure, after which hospital policies at the time kept Marsha from seeing him at all during his four-day stay. Once Timothy was stabilized and taken back to his room, neither Marsha nor her husband could sleep. Worried about how each other was doing, they talked on the phone until 11 p.m., and Marsha's apprehension only worsened when he was moved to the ICU with complications.

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"If I could have been there, it could have been a comfort to him and to myself," she said. "When you don't see [the procedure] firsthand, you start wondering, 'Is he breathing? Is he on a lot of machines?' I asked myself a thousand questions."

Temple University Hospital did not respond to multiple email requests and calls for comment.

During the height of the pandemic in the U.S. last year, 93% of hospitals had implemented Covid-related visitor policies, according to an analysis of about 350 hospital websites conducted between June and September 2020. Many prohibited all visitors except those coming to see children, patients with disabilities, or patients at the end of life.

Hospitals now generally allow one or two visitors per patient, as long as they go through a screening process that asks about symptoms or exposure to Covid-19. But they remain cautious about returning to their pre-pandemic policies. "It was a very fine line to try to meet the priorities of [a patient's well-being], but at the same time we needed to make sure that the safety of the family was maintained," said Sam Torbati, emergency physician and medical director of the emergency department at Cedars-Sinai Medical Center in Los Angeles who was involved in the hospital's Covid policy decisions. Currently, Cedars Sinai allows two healthy visitors in most inpatient areas and one visitor in the emergency room, which was the policy before the pandemic.

Even with widespread vaccination, visitor limits are still in place. Hospital officials said that their mission is to protect patients who are ill, meaning they need to be more careful than other businesses, such as restaurants. "It's important to remember that we are a health care organization and our obligation is to keep patients at the center of all of the decisions that we make," said Aliza Narva, director of ethics at the Hospital of the University of Pennsylvania. "We're not looking to fill tables, so the values that drive our mission are very different."

Lori Handy, medical director of infection prevention and control at Children's Hospital of Philadelphia, also pointed out that there is still ongoing community transmission of SARS-CoV-2 and especially of the more infectious Delta variant. This puts patients, particularly unvaccinated children, at risk. And with cases increasing in many parts of the country, the pandemic continues to be unpredictable, she added. As long as there are unvaccinated visitors, they present a risk to patients.

One way to get around this would be to ask visitors for proof of vaccination. An increasing number of hospitals are requiring proof of vaccination from health care workers, and hospitals may soon start asking proof from visitors as well. But that can get into tricky legal territory, said Torbati. In April, for example, Houston Methodist Hospital became the first hospital system to require all their employees to be vaccinated, which eventually led to the firing or suspension of around 150 employees who refused to get the vaccine. Nearly 120 of those employees sued the hospital system over its vaccine requirements, citing concerns that the vaccine was not yet fully approved by the Food and Drug Administration, but the lawsuit was eventually dismissed.

Torbati said that Cedars-Sinai currently does not require proof of vaccination from its visitors. Other facilities like Temple University Hospital say on their website that visitors should be vaccinated and that they may require proof.

Even with concerns over ongoing viral spread, some doctors who witnessed the negative impact of policies barring or limiting visitors altogether said hospitals need to consider the trade-offs and emphasize that family caregivers are more than simply visitors. It's a point also highlighted in the Centers for Disease Control and Prevention's guidelines, which state that "visitation should continue to be prioritized for those visitors important for the patient's physical or emotional well-being and care."

Limiting caregivers' access to patients may mean doctors miss out on critical information about a patient's medical history, especially when a patient is confused or cognitively impaired, said Maura Kennedy, an emergency physician at Massachusetts General Hospital in Boston.

Beyond helping doctors make treatment decisions in the short term, family caregivers can also affect patients' health and their hospital experience in the long term. One review that examined 15 studies on caregiving outcomes published between 1990 and 2016 found that including caregivers in the hospital discharge planning process was associated with 25% fewer readmissions 90 days after patients went home. A separate study of patients who had surgery found that, compared to patients who were allowed visitors, those who were isolated reported feeling less satisfied with the care they received.

And because caregivers can advocate for patients' treatment choices or even food preferences, it was not surprising that patients in that study were also less likely to report timely access to medications and less likely to agree that their preferences were adequately considered during discharge.

Marsha El - who has been married to her husband for almost 40 years and, as a kidney transplant recipient, knows what it's like being a patient - is one such advocate. During Timothy's stay in the hospital, he relied on her to organize his discharge papers and interact with doctors. "Sometimes when you're sick, you don't feel like asking questions," she said.

The absence of caregivers at a patient's bedside can also negatively impact their mental health. Research shows that social isolation can cause psychological distress and worsen delirium, especially in older patients. Covid-19 highlighted this, leading to higher levels of stress and incidence of anxiety and depression in older adults who were alone.

Kennedy saw this firsthand during one shift in the emergency department. A cognitively impaired patient experiencing an asthma exacerbation became increasingly anxious and fearful, and her blood pressure soared. Eventually, the staff got a family member to calm her down over the phone. "Had a caregiver been sitting by her side, how would that entire episode have changed?" Kennedy wondered.

Visitor restrictions could unfairly impact the most vulnerable populations, particularly people of color whom Kennedy said may have a harder time asking for exceptions to visitor policies. They might have language barriers or less experience with the health care system - and not feel comfortable advocating for themselves. And for patients who don't speak English, family members often serve as interpreters in medical settings.

Experts said that, looking back, there is a lot to be learned about the impact of visitors and how they help patients to inform future practices during emergencies. Even at the height of the pandemic, some physicians such as UNC's Biese said a complete ban of visitors went too far and remained in place "even as they stopped making sense." In some cases, he added, "the downsides of having [restrictions] in place were much greater than the upsides of having them."

Biese said that hospitals need to distinguish caregivers from visitors and be proactive about deciding on visitor policies rather than having to make decisions on the fly. "[Frontline workers] were not the right people to be trying to make the 30,000-foot decisions" when Covid-19 cases were skyrocketing and their main priority was attending to sick patients, he said.

These decisions should involve physician experts at the center but they should be counterbalanced with voices from patients, their families, and advocacy groups to develop patient-centered strategies and consider the humane side of patient care, experts said.

Finally, hospitals need to be clear in their communication about visitor policies. In their review of 350 hospital websites, Kennedy and colleagues found that only 12% had the visitor policy information in a language other than English. Another review found that Michigan hospital websites did not provide contact information to request an exception to the visitor policies, making it hard for patients and their families to get necessary information.

Marsha El experienced this uncertainty around policies herself. As she waited outside the hospital for her husband, she hadn't been told whether she would be able to stay with him or even if she would be able to see him when he was moved to a room. She worried another long night of phone calls with her husband and his doctors awaited.

"It's very, very hard," she said. "I understand what the hospital has to do to protect patients, but I will just be so happy when all of this is over."

About the Author

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Covid-19 kept families and caregivers out of hospitals. Some doctors think that shouldn't happen again

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HILADELPHIA - On an early summer morning in North Philadelphia, Marsha El sits on a bench outside Temple University Hospital, scrolling on her phone. Inside, doctors perform a heart procedure on her husband, Timothy. Barred from being by his side due to Covid-19 visitor restrictions, Marsha, a retired insurance company branch manager, anxiously waits for a phone call with any update on his condition.

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Unintended Consequences: The Unexpected Impacts of Restricting Visitors in the Time of COVID-19

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Unintended Consequences: The Unexpected Impacts of Restricting Visitors in the Time of COVID-19

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Healthcare and Medical News for Atlanta Physicians

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One of the most significant patient safety processes impacted by the COVID-19 response has been how family and friends support ill loved ones and interact with the healthcare team.

No healthcare organization has been spared from enforcing new visitor guidelines and policies. The initial visitor limitations across the Metro Atlanta market uniformly allowed no visitors in healthcare facilities.

These stringent measures were selected for the urgent protection of healthcare staff, patients and visitors because little was known about the virus. This decision was driven by required adherence to physical distancing guidelines and conservation of personal protective equipment (PPE).

Unfortunately, the populations most significantly impacted by the COVID-19 visitor restrictions are the elderly and those with advanced illness or care needs requiring stays in facilities such as hospitals, skilled nursing facilities and nursing homes. Most of Georgia's nursing home facilities have been locked down to visitors since March, and while it was an important measure needed to keep this vulnerable population safe, there are many unintended consequences for patients, families and healthcare providers.

Our medical group, The Southeast Permanente Medical Group (TSPMG), is affiliated with Kaiser Permanente Georgia across the Metro Atlanta area. Our providers and staff work in a variety of settings, including our 25+ outpatient clinics, plus our contracted 'core' hospitals and nursing home facilities, and have been experiencing the full range of the effects from these visitor restrictions.

The Kaiser Permanente Georgia COVID-19-related visitor policy began in early March 2020 in all open clinic facilities. Strict measures banning any visitors were enforced in all cases except that minors were allowed one parent/guardian and patients with significant cognitive impairment could bring a caretaker. This strict limitation was met with significant dissatisfaction by many patients and families, especially for pregnant patients as milestones and partnership during the entire journey were missed by expectant partners and/or supportive loved ones.

In our three Advanced Care Centers, which provide 24/7 urgent care for acute illness, the impact mirrored that of surrounding facilities to include significant communication challenges for the elderly, the seriously ill and those needing hospital transfer. Since the patient's support system of family and caregivers play such a significant role in helping with patient emotional support during and after the visit, their absence has led to gaps in effective discharge instruction communication and follow-up care execution.

Our facility-based visitor limitation experience has additional challenges. When an ambulatory evaluation results in the need for a hospital admission, the family often experiences increased stress when they are not in the room to fully understand the diagnosis and reason for transfer. Once a patient is in the hospital, the ongoing separation due to hospital-based visitor limitations, communication breakdowns and increased family and patient stress impacts the emotional health of the patient. Certainly prior to this global pandemic, hospitalization was already challenging for older, frail adults and for individuals with advanced illness or caretaking needs.

All healthcare providers aim to do their best to communicate frequently with the family and caregivers of their patients. Our physicians had to quickly adapt to the new constraints of caring for patients during this pandemic. To ensure effective family communication, they quickly pivoted from in-person conversations to leveraging video communication applications, conference calls and phones on speaker while in the room with the patient or scheduled at convenient times for the family.

Use of technology in this way helped to decrease the emotional and physical distance that the patient feels from their family and vice versa. This abrupt shift has also been distressing for the facility-based team who are also committed to providing direct comfort for their patients, particularly when the patient is facing end-of-life.

Healthcare teams worked together to provide the much-needed clinical connection between patients and their families. New processes in response to the pandemic, cohorted units, staffing changes, time-consuming PPE requirements/procedures and a sharp increase in the volume of extremely ill patients have made providing this connection overwhelming.

Providers took on the mantle of responsibility and did their best to turn this disconnection and communication challenge into meaningful moments for their patients and their families. They assumed the role of visiting family and went above and beyond to address the emotional and physical well-being of those in their care. They comforted and held the hands of dying patients in their final moments. They reassured and consoled distraught family. They advocated to get the assistance their patients needed when restrictions seemed too inflexible. They were patients themselves, missing the support of their loved ones by their sides. They were worried caregivers unable to hold their own loved one's hands.

Physical presence of loved ones as well as communication is so valuable in the healing process for our patients. Many of us have heard stories about critically ill patients making a rapid recovery once family visitation was permitted. With the passing of time, as we moved from the acute phase into a more chronic phase of pandemic management, healthcare organizations developed a better understanding of safety processes as well as experience with the deleterious effects of strict limitations on visitors. Thus, many visitor restrictions have been slightly relaxed.

In our Kaiser Permanente Georgia facilities, we have expanded some visitor access to include key milestones or difficult conversations for our obstetrics patients and their families, or expanded caregiver support for disabled, peri-procedure or other patients with extended needs. The hospitals have also adjusted with allowances to include a single visitor the day of discharge for discharge planning, end-of-life care and during obstetrics, and neonatal intensive care services or when patients need one-on-one care. Minors, those with disruptive behavior or those who do not otherwise have the mental capacity to safely be alone while hospitalized are additional examples. Unfortunately, due to unpredictable circumstances, many hospital emergency department policies have had to maintain strict visitor limitations.

These visitor restrictions were put into place with the best of intentions during a scary and chaotic time in our community. The well-intended purpose of these strict visitor limitations was to support provider, staff, patient and family safety from COVID-19 exposures; to support physical distancing guidance; to limit indoor occupancy; and to conserve limited PPE.

Now we have seen some of the unintended, although not entirely unpredictable, negative consequences of these restrictions, including healthcare team and patient and family distress, decreased clinical care plan communication, more difficulty facilitating complex conversations and perhaps even negative health outcomes.

As we collectively enter this "new norm" phase of COVID-19, which will be with us for at least the near-term future, we must reckon with our approach to visitor restrictions in both the ambulatory and facility-based settings. We will need to thoughtfully balance the arguments for limitation with those arguments for a more lenient approach and likely settle into an in-between space where we identify patient-specific or clinical scenarios that benefit from having family present, versus less acute/significant moments where an individual patient can navigate their care on their own. Let us be open to continuing to learn in this space, and to amending our approach as needed to best support safety, clinical care and the patient/family experience.

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Unintended Consequences: The Unexpected Impacts of Restricting Visitors in the Time of COVID-19

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One of the most significant patient safety processes impacted by the COVID-19 response has been how family and friends support ill loved ones and interact with the healthcare team. No healthcare organization has been spared from enforcing new visitor guidelines and policies.

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Ban on hospital visitors has profound effect on patients, families

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Ban on hospital visitors has profound effect on patients, families

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Russ Morgan has some dementia, and often forgets both that he's had a stroke and the reasons why his loved ones can't visit.

"It can be very heartbreaking on the phone when ... we have to explain to him why we're not there," his daughter, Donna Morgan, told 's Dr. Brian Goldman.

The 87-year-old suffered a stroke in February and was admitted to a hospital in B.C.'s Lower Mainland, which began restricting visitors March 21 amid the COVID-19 pandemic.

The ban on most hospital visitors is having a profound effect on patients and their families, caregivers and advocates say.

"It's just been terrible because the worry that we have about both his physical health and his mental health - being so isolated - is very overwhelming," Donna said.

"And it's been very difficult for my mother; she's coping with being on her own for the first time in 64 years and then worrying about her husband so much."

Administrators have had little choice but to put what's been called "an iron ring" around their hospitals, keeping most family members away, regardless of whether the patient is hospitalized for COVID-19 or another condition.

The idea is that by limiting the number of asymptomatic people who could be carrying the virus, the hospital can protect front-line health workers and the most vulnerable patients from contracting the coronavirus.

Before physical distancing measures were implemented, Donna and other family members would plan their visits around mealtimes to help Russ with eating.

"He has some use of his right arm," she said. "But his left side is paralyzed, and so we would help him open the packages and containers for his lunch and get him the things he needed."

But Donna said she thinks their most important role is cheerleading.

"I really think he needs the encouragement that family gives him to work on his healing."

Families play crucial role in care

Patient advocate Julie Drury of the Canadian Foundation for Healthcare Improvement said families provide essential services to people in hospital. That's been the case well before COVID-19 put a strain on already stretched hospital resources.

"Nursing isn't what it was back in the 1950s when nurses were doing every little part of a personal care for a person in hospital," said Drury, who lives in Ottawa. "Families do personal hygiene for their loved one. They change beds. They monitor wounds. Maybe [provide] medication oversight."

They also play an important role as care co-ordinators and advocates for patients, she said, adding that there's compelling evidence having a family member present reduces things like medication errors and falls.

"Not only does the experience of the patient change, but the emotional well-being of the patient changes."

She said policy-makers could look to pediatric units for examples of how infection control is managed even with parent caregivers in the mix.

Parents of minor patients are one of a few notable exceptions to no-visitor policies, along with labour partners in maternity wards and family members of those who are dying.

"I would say that many families who are long-term caregivers at bedside in hospitals understand infection control really, really well. You want to see good handwashing? Those families take this very seriously," Drury said.

Even referring to them as visitors is a bit of a misnomer, she said. It's not idle visits from friends or neighbours that's really in question during the pandemic.

"We cannot have visitors in hospital, but we can have one to two designated family members who are essential partners in care," Drury said.

That partnership from family members has been shown to be key for staff satisfaction as well, said Drury.

"Staff feel more engaged and they feel more connected to their patients. And they recognize the families as allies in care."

Disappointment, worry and fear

That's certainly the case for Bryan Regehr, an emergency and cardiac nurse at St. Boniface Hospital in Winnipeg.

"I believe family is best at bedside with patients. I think it helps patients with outcomes. I think it helps with decision-making and in recovery," said Regehr.

He's had to deliver the news that family members can't stay because of COVID-19 precautions, and that's been upsetting, he said.

"You can tell there's disappointment. There is worry. There's fear [from] not knowing ... what's going to happen, how you're going to get information."

While Regehr said he understands the rationale, the no-visitor policy also makes his job harder.

"When we're missing this really vital resource, it makes things that much more difficult," he said.

His hospital is trying to help patients connect remotely with family by doing things like making bedside phones available for free.

Donna Morgan said that staying in the loop with her father's care, and getting through to speak with him, has been one of the most frustrating fallouts from the COVID-19 visiting restrictions. The family set Russ up with a simple cellphone, but he finds it hard to operate, leaving them reliant on calls to the nurses' station.

"I'm sure they're busy but you feel they could do more to be in touch with you to let you know how he's doing," she said. "I know they're doing the best they can to care for him. But I think there wasn't a plan in place for this situation where families wouldn't actually be there and able to see what's going on."

"I think my biggest fear is that he's feeling quite lonely and sad, and that he'll become depressed and lose his motivation, lose his will to see us again."

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Ban on hospital visitors has profound effect on patients, families | CBC Radio

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Russ Morgan has some dementia, and often forgets both that he's had a stroke and the reasons why his loved ones can't visit. "It can be very heartbreaking on the phone when ... we have to explain to him why we're not there," his daughter, Donna Morgan, told 's Dr. Brian Goldman.

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Hospital Visitation Restrictions Are Hurting Patients and Nurses

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Hospital Visitation Restrictions Are Hurting Patients and Nurses

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As COVID-19 began rapidly spreading across the U.S., hospitals adopted policies that prohibited patient visitation -- a move that was designed to prevent the spread of the virus and ensure the safest environment possible. A year and a half later, we are battling new variants of COVID-19 and finding ourselves in the same predicament: nurses are serving as surrogates for family members as patients take their final breaths so they won't die alone.

Many organizations began opening up visitation as vaccines rolled out, but are now returning to restrictions, particularly in hard-hit parts of the country. Images from the early days of the pandemic are returning as nurses, physicians, and other hospital workers feel the strain of caring for patients who are isolated and have limited human contact.
The Impact of Visitor Restrictions on Patient Care
Policies prohibiting or limiting family members and friends from visiting are meant to address public health and safety issues. However, the absence or limited presence of patient support systems are creating, once again, additional strains on nurses.

Prohibited or limited visitation can also contribute to unintended safety consequences for patients, such as an increased potential for missed care, falls, and delayed recognition of deterioration. Limited visitation also exacerbates inequities among patients and families of different socioeconomic status, since not everyone has equal access to the technologies needed to connect virtually with their loved ones.

The close friends and family members of patients are an essential component of our healthcare teams. They provide an added layer of patient support and patient safety, and act as advocates for their loved ones. Without them, patient care is put at risk.
Balancing Patient Care With Visitation Precautions
We can remedy the challenges created by a lack of patient visitation, which has been detailed in recent research, by reopening visitation in a safe, thoughtful, and reasonable manner. This virus is much better understood now than when it first appeared last year, supplies of PPE are available, and with the proper protocols, continued vaccine efforts, and other mitigation techniques, safe visitation is possible -- without exacerbating the spread of SARS-CoV-2. For example, in California, visitors to acute healthcare and long-term care facilities are required to show proof of vaccination or negative COVID-19 tests.

Reengaging the silent safety net of patient visitation will quickly reduce the oversized burden on nurses and improve patient outcomes and experience. A review that examined research on caregiving outcomes over a 26-year period found that including caregivers in the hospital discharge planning process was associated with 25% fewer readmissions 90 days after patients went home. Family members can once again advocate for them, and ensure they receive the care they need for a successful recovery and transition to home.
Reducing Strain on Nurses and Other Healthcare Workers
Even before COVID-19, nurses were often overworked and understaffed. And now, the impact on stress and well-being has only been exacerbated during the pandemic, with many nurses even leaving patient care altogether, leading to extreme staffing challenges. As we try to better support the nursing workforce, we should not underestimate the emotional impact on nurses of watching their patients suffer in isolation and having to act in lieu of family or friends.

Open visitation will likely lead to better, safer patient outcomes and reduced stress on fatigued and relentlessly strained nurses across the nation. As we rethink policies that limit family and friend access, both in COVID-19 units and other inpatient areas, we encourage hospitals and healthcare systems to find the appropriate balance. Reopening visitation, and keeping it open, in a safe and appropriate manner is essential.
Karen Cox, PhD, RN, is President of Chamberlain University. Tejal K. Gandhi, MD, MPH, is Chief Safety and Transformation Officer of Press Ganey Associates LLC.
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Karen Cox, PhD, RN, and Tejal K. Gandhi, MD, MPH

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Opinion | Hospital Visitation Restrictions Are Hurting Patients and Nurses

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As COVID-19 began rapidly spreading across the U.S., hospitals adopted policies that prohibited patient visitation -- a move that was designed to prevent the spread of the virus and ensure the safest environment possible.

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https://nami.org/Blogs/NAMI-Blog/November-2019/The-Importance-of-Community-and-Mental-Health

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Mental health heavily influences our quality of life. So it makes sense that mental health, just like physical health, needs to be taken care of and maintained. And one way that it can be maintained is through finding a sense of community.

Community can be defined in many ways, but when simplified down to its most important element, community is all about connection. Community is not just an entity or a group of people, it's a feeling. It's feeling connected to others, feeling accepted for who you are and feeling supported. Having connection can help us feel wanted and loved.

Why Is Community Important to Mental Health?

We're social beings, and we are not meant to live in isolation. Community is critical for us to thrive, especially for someone with mental illness who is already experiencing the common symptoms of loneliness and isolation.

Community provides many elements that are critical to mental health, but here are three of the most beneficial aspects.

Belonging
If you've ever felt like you don't fit in, you know it can be a lonely experience. Community provides a sense of belonging - a group you identify as being a part of. This is different than conforming to be in a group. A true sense of belonging includes the ability for you to feel you are a part of the community as your true self. There is not anything you have to change to be a part of the community, but instead, you are embraced and appreciated for your unique qualities.

Support
Who do you turn to when you need something? Having people you can call on when you need to talk or need help with something can help you through difficult situations that might feel insurmountable alone. Knowing there are people who support you can help you feel cared for and safe, and can benefit your outlook on life.

Purpose
In community, people fill different roles. Perhaps you're the friend who enjoys cooking and can be counted on to bring a hot meal over when someone is going through something. Or you're the friend who others know they can call when they need to talk about their struggles. These roles can give you a sense of purpose through bettering other people's lives. Having purpose, and helping others, helps give meaning to life.

How to Find Community

When looking for a stronger sense of connection, you have to start with self-reflection. Being aware of what's important to you can help you find ways to connect with other like-minded people.

Interests
What do you like to do? Perhaps you enjoy reading and could try joining a book club. Or maybe you've always wanted to try soccer and could try joining a team. The possibilities are endless, and you might find it easier to connect with others while doing activities you enjoy.

Values
What are your values? This category could include charities or volunteer work. Being of service is rewarding, and you can connect with others who have similar values or care about the same causes as you. A big part of building your community is giving back to each other, and finding volunteer work is a great way to start.

Beliefs
What do you believe in? If you connect with a spiritual practice or religion, try going to a speaking engagement, introductory class or service. Or if a political cause speaks to you, you can join a group that works toward a goal that's meaningful to you. Connecting with something bigger than you is another helpful way to broaden your community.

Humans crave connection. Feeling accepted for who you truly are can give you validation and self-worth. Knowing there are people who support you and will be there for you when you're struggling provides a sense of safety. And knowing you're needed, that you have a purpose, reminds you that you are valued. Community provides all these qualities and more.

Where you find community is up to you; there is no one-size-fits-all. And if you haven't found a strong sense of community yet, keep trying. No matter if your community is big or small, finding people you connect with is vital for your mental health. And remember, just as it's important for you to find your community, it's also important for others to have you as a part of their community. We all need each other.

Stephanie Gilbert, AMFT, is the program director and therapist at Mindfulpath, Inc. located in Calabasas and Santa Monica, California. She provides individual and group therapy, incorporating depth psychology, mindfulness practices and cognitive behavioral therapy. For more information about Stephanie, please visit mindfulpath.com.

We're always accepting submissions to the NAMI Blog! We feature the latest research, stories of recovery, ways to end stigma and strategies for living well with mental illness. Most importantly: We feature your voices.

Check out our Submission Guidelines for more information.

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NAMI, the National Alliance on Mental Illness, is the nation's largest grassroots mental health organization dedicated to building better lives for the millions of Americans affected by mental illness.