Can “social architecture” reverse the loneliness epidemic?
April 11, 2025

By Mike McNulty
Originally appeared in The Explorer: Journal of USC Student Research published by the Ostrow School of Dentistry of USC

Feeling lonely? You’re not alone.

Recent surveys show that approximately half of adults in the United States experience loneliness, with some of the highest rates occurring among young adults. By these estimates, loneliness and isolation are more widespread than many health issues including smoking, diabetes and obesity.

The phenomena of loneliness and isolation have proliferated in contemporary American life to such an extent that, in 2023, the U.S. Surgeon General labeled them a joint “epidemic” with profound consequences to the health and well-being of individuals and communities. Research shows that loneliness and isolation are associated with increased risks of heart disease, stroke, depression, anxiety and early mortality.

Because there is no single source of isolation and loneliness, ending this epidemic will require a constellation of strategies to help strengthen social relationships and support community-wide efforts for making meaningful connections. For example, the first plank in the Surgeon General’s six-part “national strategy” for advancing social connection is to develop communities’ social infrastructure — defined as a community’s physical assets such as libraries and green spaces, the programs available to a community such as volunteer organizations and member associations, and local policies like transportation and housing that impact social connections. The logic is that people will better connect when they have more places to go and more things to do once they get there, while encountering relatively fewer barriers on their way.

For occupational therapists like Assistant Professor Joy Agner, working at this intersection between people, environment and occupation is second nature.

“Occupations are the building blocks of community,” Agner says. “Occupational therapists and occupational scientists have a unique role to play in ending the loneliness epidemic because meaningful relationships are developed by working side-by-side towards a shared goal.”

A first-generation college student from a small rural community in Oregon, Agner earned her master’s degree in occupational science and therapy from the University of North Carolina at Chapel Hill, and her PhD degree in community and cultural psychology from the University of Hawaiʻi at Mānoa. Her scholarship has been recognized with numerous awards, including two NIH-funded Career Development awards, a Fulbright Research Grant and a six-year Ford Family Foundation Ford Scholar award.

At USC Chan, Agner directs the Health Equity Action Lab (HEAL), which uses community-based participatory research (CBPR) approaches to improve health systems and services for underserved populations, including racial minorities, people in poverty and individuals with chronic disability or severe mental illness (SMI). Some current HEAL projects include: examining the impact of care coordination and integrated care on health and quality of life for individuals with multiple, complex health needs; understanding how peer support networks impact health literacy, health outcomes and quality of life; and advancing theory on cultural humility in occupational science by using culturally-informed models to promote health equity among racial minorities, such as Native Hawaiians and Pacific Islanders.

“An overarching theme of my work is to use collaborative community-engaged research processes that center community partners’ ideas, priorities, and lived experiences.”

Putting down roots

Just a half block south of the Hollywood Boulevard Walk of Fame is The Mark Twain, a one-time inn that now operates as an interim housing facility for adults and transitional age youth who have experienced chronic homelessness. There, 56 residents have a safe private room, access to 24/7 on-site clinical care and, just as importantly, newfound levels of stability, safety and dignity.

Facing the concurrent epidemics of social isolation, mental illness and homelessness, the Los Angeles County Department of Mental Health (LACDMH) has embarked upon a $116 million pilot project to transform the mental health care system in Hollywood focused on people, place and purpose. Launched in 2022, Hollywood 2.0 is a five-year pilot project funded by the California Mental Health Services Oversight and Accountability Commission, in collaboration with multiple community partners. Hollywood 2.0 — H20 for short — aims to provide comprehensive, community-based “wraparound” care services to people living with SMI in Hollywood. The Mark Twain is one of three housing assets made possible by the project thus far.

In 2024, Agner’s lab began collaborating with the nonprofit Heart Forward LA (HFLA) to develop social architecture theory and practice to better design physical spaces, rules and norms — the “architecture” — in order to optimize human activity and interaction that occurs within them — the “social.”

As The Mark Twain came online, Agner, along with occupational science doctoral student Heldevam Pereira PhD ’28, and the HFLA team, understood the need to modify its social architecture in order to increase residents’ engagement and social interactions. Together with The Mark Twain residents, throughout the past year they have collectively spent more than 600 hours on-site in order to co-design a social architecture intervention: a community garden space.

“By eliciting resident’s input and then following their lead, we wanted to see if we could turn a dead zone — an empty, lifeless common area with barbed wire and cigarette butts — into an inviting space that people actually want to spend time in,” Agner says. “Could we create a space that gave people a reason for spending time there, either to be with others or because there is something worthwhile to do?”

Ultimately, the participants and researchers together identified a narrow breezeway alongside the building that was ripe for renovation. During the summer of 2024, they together built and planted a new urban garden. Where there was once cold and nondescript concrete, flowers and grasses are now in bloom. Their co-occupations revolve around the garden, but also involve arts-based projects, cooking, celebrating holidays and all of the sub-tasks to collaboratively plan and carry out activities.

The researchers and HFLA were meticulous all along the way, engaging in critical reflections, taking field notes, and discussing and interpreting their findings to ensure they were engaging with residents in a way that fostered shared decision-making, egalitarianism and purpose.

“There were doubts when we first started, but overall it has been a great success, and the staff and residents have been essential partners in this process,” Agner says.

Radical hospitality and the mental health system

From Agner’s scholarly perspective, the process of co-designing and -delivering the social architecture intervention was as critical as its outcome. Consistent with the HEAL lab’s ethos, Agner and the researcher team served as co-designers and interventionists, positioned as horizontal partners rather than as vertical experts or uninvested observers. Working with HFLA fostered opportunities to co-develop a novel intervention with potential for impact, which enhanced creativity, established sustainable relationships at The Mark Twain and directly influenced the lives of residents who participated in the design process.

“The process was infused throughout with what HFLA calls radical hospitality, an alternative approach to the status quo of American mental health care,” Agner says. “When projects and partners enact radical hospitality, people are seen, heard, valued and appreciated for who they are as human beings. They are a part of the decision-making process — not passive recipients of advice or care; we couldn’t do this without them.”

That concept of radical hospitality, which defines HFLA’s vision for the American mental health system, is based on what’s called the Trieste model of mental health care. In the city of Trieste, Italy, thanks in part to the public funding sources that enable it, social architecture includes an interconnected network of community-based mental health centers, clubs, civic associations and social cooperatives that enable people with SMI to continue working and participating fully in community life. Occupation is at the center of the Trieste model, as are values of mutual trust between system users and providers, and the right to a meaningful life.

The model has been widely lauded for its focus on rights-oriented, collaborative treatment and recovery and prevention, with a range of positive outcomes demonstrating its effectiveness.

Last October, Agner traveled to Trieste with HFLA and a delegation of two dozen prominent U.S. mental health policy leaders to see the Trieste model firsthand as part of a larger, year-long initiative funded by The Hilton Foundation. Her co-delegates included policy experts, former and current government officials, national leaders of peer-health services and mental health administrators in high-ranking positions. All are dedicated to advancing a more humane and holistic mental health care system, realizing that the status quo contributes directly to suffering, homelessness and incarceration.

“Seeing the system of care in Trieste has transformed my vision of community-based mental health care and what is possible in the U.S.,” Agner says. “We have to hold an ambitious, long-term vision of transformative change, while advancing more humane, rights-oriented, occupation-centered approaches to mental health care within our spheres of influence today.”

Making a difference, together

Looking ahead, Agner hopes to refine the theory of change underlying the approach combining social architecture and radical hospitality: What are its basic elements and principles for effecting sustainable change? Then, she wants to manualize it using a multi-phase refinement model, and implement the manualized intervention to test its short- and long-term outcomes in a comparative pilot study in permanent supportive housing (PSH) settings.

The process of transitioning from homelessness into PSH — a housing model typically funded by public agencies that also offers residents an array of services related to their physical and psychosocial health needs — comes with an elevated risk of social isolation and loneliness. Many residents are housed away from their original neighborhoods and, once they arrive, stay isolated in their rooms. As PSH becomes an increasingly frequent care model, there is an urgent need to work alongside formerly homeless individuals to develop evidence-based interventions that improve social connection in PSH. Occupational therapists and scientists are well positioned to be part of this work, partnered with forward-thinking community organizations such as HFLA.

Agner’s latest grant award will surely accelerate her toward those goals. Last year, she received a K01 Mentored Research Scientist Career Development Award from the NIH National Institute of Mental Health. The award, “Designing belonging: Advancing science on environmental modifications to foster activity engagement and social connection among individuals with serious mental illness,” provides Agner with protected time to advance her research on socio-spatial research methods, theory development and co-design of environmental interventions based on CBPR principles.

But for now, Agner says she is grateful and optimistic for the ways that occupational scientists can partner with community organizations to address some of the most consequential health issues of our time.

“I’m so excited for the promise that social architecture and radical hospitality holds across multiple settings,” Agner says. “We’ve shown how researchers and community partners can together design and deliver occupation-based and people-first interventions that make a real difference in individual and community life.”

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