Loneliness and mental health

There is a plethora of social media platforms, such as Facebook, LinkedIn and Instagram, all of which are predicated at least in part on establishing a virtual network of ‘friends’: locally, nationally and internationally. The ability to establish and participate instantly in these networks using a whole range of communication devices such as computers, tablets and smart phones has never been easier and can be achieved almost anywhere. Yet, therein lies a problem: are such networks real ‘friends’ with whom one can build a lasting relationship based on mutual respect?

Despite these social networks and the ease that they can be engaged in, loneliness and social isolation has perhaps never been greater, more apparent and in some cases more devastating. Loneliness can be caused by and can contribute to social isolation and some forms of mental ill health, such as depression, with isolation and depression leading to thoughts of suicide or actual suicide attempts.

This article will briefly explore the phenomenon of loneliness and its connections to mental health issues such as depression. The possibility that loneliness can be a mental health issue in itself, as well as contributing to mental ill health, will also be briefly explored along with the role of the nurse in supporting those at risk.

What is loneliness?

It could be suggested that loneliness can be difficult to define given peoples and cultures different perceptions of what loneliness is. According to Collins online dictionary, loneliness: ‘is the unhappiness that is felt by someone because they do not have any friends or do not have anyone to talk to. Affected with, characterised by, or causing a depressing feeling of being alone; lonesome. Destitute of sympathetic or friendly companionship, intercourse, support. The state of being alone, solitary, without company’.

Loneliness is a complex and usually unpleasant emotional response to social and emotional isolation, which typically includes anxious feelings about a lack of connection or communication with other beings, both in the present and extending into the future. As such, loneliness can be felt even when surrounded by other people. The causes of loneliness are varied and include social, mental, emotional, and physical factors.

The existentialist school of thought views loneliness as the essence of being human. Each human being comes into the world alone, travels through life as a separate person, and ultimately dies alone. Coping with this, accepting it, and learning how to direct our own lives with some degree of grace and satisfaction is the human condition (Carter, 2000). Some philosophers, such as Sartre, believe in an epistemic loneliness, in which loneliness is a fundamental part of the human condition (Sartre, 1943).

Research has shown that loneliness is prevalent throughout most cultures within contemporary society, including people in marriages, relationships, families and those with successful careers (Peplau and Perlman, 1982). Loneliness is no respecter of social class, financial wealth or status. Loneliness has been a long-explored theme in the literature of human beings since classical antiquity. Loneliness has also been described as social pain: a psychological mechanism meant to motivate an individual to seek social connections (Cacioppo and Patrick, 2008). Loneliness is often defined in terms of one's connectedness to others, or more specifically as ‘the unpleasant experience that occurs when a person's network of social relations is deficient in some important way’ (Pittman and Reich, 2016).

People can experience loneliness for many reasons, and many life events may cause it, such as a lack of friendship relations during childhood and adolescence, marital separation and divorce, ill health, disability, death of a parent, sibling or partner, or the physical absence of meaningful people around a person. In these cases, it may stem both from the loss of a specific person and from the withdrawal from social circles caused by the event or the associated sadness.

There is a clear distinction between feeling lonely and experiencing solitude (for example, being a loner or through personal choice). In particular, one way of thinking about loneliness is as a discrepancy between one's necessary and achieved levels of social interaction (Peplau and Perlman, 1982), while solitude is simply the lack of contact with people. Loneliness is therefore a subjective experience. If a person thinks and says that they are lonely, then they are lonely.

However, many world religions and non-religious forms of spirituality, for example, incorporates and fosters a sense of solitude as an aspect of that spirituality. Likewise, some people seek solitude as a way of dealing with a world that can at times be over-stimulating and therefore threatening. Many of those on the autism spectrum, for example, are likely to seek solitude for this reason.

The other important typology of loneliness focuses on the time perspective (de Jong-Gierveld and Raadschelders 1982). In this respect, loneliness can be viewed as either transient or chronic. It has also been referred to as state and trait loneliness. Transient (state) loneliness is temporary in nature, caused by something in the environment, and is easily relieved. Chronic (trait) loneliness is more permanent, caused by the person or the persons situation or environment, and is not easily relieved (Duck, 1992). For example, when a person is sick and cannot socialise with friends, they may experience transient loneliness. Once the person gets better it would be relatively easy for them to alleviate their loneliness through social interaction and engagement. A person who feels lonely regardless of whether they are at a family gathering, with friends, or alone is experiencing chronic loneliness. It does not matter what goes on in the surrounding environment, the experience of loneliness is always there.

Tackling loneliness

GPs in England will be able to prescribe patients social activities, such as dance classes to tackle loneliness, especially for older people, who may not have had any social contact for several weeks (BBC News, 2018). This is in response to the work the late Jo Cox was undertaking in order to combat loneliness. Jo Cox set up a cross-party Loneliness Commission. The Commission's work culminated in the publication of the report: ‘Combating loneliness one conversation at a time’, which was published in 2017 (Jo Cox Commission on Loneliness, 2017).

The Commission's recommendations were taken up by the government, and a new Minister for Loneliness, Tracey Crouch MP, was appointed in January 2018. In October 2018, the Prime Minister Theresa May launched the first cross-Government strategy, called ‘A Connected Society to tackle loneliness’ (Department for Digital, Culture, Media & Sport et al, 2018). The strategy includes plans to build ‘social prescribing’ into the NHS by 2023 (mentioned earlier), the first ever ‘Employer Pledge’ to tackle loneliness in the workplace, a new Royal Mail scheme which will see postal workers check up on lonely people as part of their usual delivery rounds, and £1.8m funding to increase the number of community spaces in England.

Loneliness and mental health

Consider for a moment the two statements: ‘My mental health has made me lonely’ and ‘feeling lonely has damaged my mental health’. These may not be two separate issues or experiences but an organically linked whole with one half of the equation (loneliness and social isolation) both causing and resulting from the other half (a mental health condition) (Mind, 2013). While feeling lonely and loneliness in themselves may not be forms of mental ill health, Mind (2013) suggests that there is a very strong link between the two.

Mustaq et al (2014) suggests that loneliness can lead to various psychiatric disorders such as depression, alcohol abuse, child abuse, sleep problems, personality disorders and Alzheimer's disease. Loneliness can also lead to various physical disorders (e.g. diabetes), autoimmune disorders (e.g. rheumatoid arthritis, lupus), and cardiovascular diseases (e.g. coronary heart disease), hypertension, obesity, physiological aging, cancer, poor hearing, and poor health in general.

However, the links between loneliness and its harmful physical and mental health consequences are complex (Griffin, 2010). In a survey carried out by the Mental Health Foundation (Griffin, 2010), the following is of note:

• Only 22% of survey respondents say that they have never felt lonely

• 11% of the survey respondents say that they often feel lonely

• 42% of those experience depression as a result of being alone

• 57% of those who experience depression and anxiety isolate themselves from family and friends

• 48% feel that people are getting lonelier in general

• 35% would like to live closer to family members such as siblings, parents or adult children for support

• 30% feel embarrassed about admitting that they are lonely

• In terms of gender, women are more likely than men to feel lonely sometimes (38%, compared with 30%). A greater number of women (47%) than men (36%) have felt depressed because they felt alone and have sought help for feeling lonely (13% women, compared to 10% men).

Loneliness and gender

Although women may experience loneliness more than men and may seek help more than men, there is a difference between people experiencing loneliness and reporting that they experience loneliness and seeking help for that loneliness. Again, historically, men may feel embarrassed about acknowledging that they experience loneliness and may feel that such acknowledgement means that they are weak. This must be seen against a culture of the powerful male who learns from a very young age to ‘pick themselves up, dust themselves down and carry on’ (the ‘stiff upper lip’ syndrome) and that to show weakness is not appropriate or ‘manly’. Griffin (2010) suggests that some people do not accept that it is normal to feel loneliness occasionally and fail to realise that it might be a prompt to look for contact with others.

Loneliness and age

Loneliness affects all ages and loneliness among the elderly, for example, is linked to social exclusion. A 2015 report by Age UK found several factors were associated with being at severe risk of social exclusion including poor health, living in rented accommodation, being a member of a minority ethnic community, having low occupational status and never having been married (Age UK, 2015).

Griffin (2010) suggests that middle age is a time when key risks for loneliness accumulate, such as retirement, children leaving the family home, divorce and bereavement. All of these involves separation of one form or another. Griffin (2010) also suggests that loneliness weakens willpower and perseverance over time, so people who have been lonely for a while are more likely to indulge in behaviour that damages their health. Lonely people are more likely to withdraw from engaging with others and less likely to seek emotional support, which makes them more isolated.

Loneliness and society

Many observers believe that changes in the way we work and live in the 21st century in Western society are having a negative impact on our mental and emotional health. Layard (2005) has observed that although we are better off materially, we are no happier than we used to be, a theory supported by the Office for National Statistics Social Trends survey in 2016, which suggests that around 28% of the UK population scores either low or medium on scales that measure happiness (Office for National Statistics, 2016). Griffin (2010) suggests that there is a link between our individualistic society and the possible increase in common mental health disorders in the last 50 years, and it could be suggested that mental health problems occur more frequently in unequal societies that leave behind more vulnerable people.

Loneliness as mental ill health?

Loneliness and mental health can become a vicious circle of negative thoughts and emotions. Being socially isolated can be a big factor in loneliness, which in turn often leads to depression, with depression and other forms of mental ill health often leading to social isolation and loneliness (Public Health Havering, 2015).

However, can loneliness ever be viewed as a form of, as well as contributing to or resulting from mental ill health? In some ways, yes. ‘Autophobia’, ‘eremphobia’ or ‘monophobia’ is the specific phobia of isolation, a morbid fear or a dread of being alone or isolated. Sufferers need not be physically alone, but just to believe that they are being ignored or unloved.

Contrary to what would be implied by a literal reading of the term, autophobia does not describe a ‘fear of oneself’. The condition typically develops from and is associated with other anxiety conditions such as agoraphobia, although they are not the same and should not be confused with each other. However, there can be subtle differences in meaning: monophobia is an acute fear of being alone, of being unsafe while being alone and having to cope without a specific person, or perhaps any person either in the same building or even the same room.

Eremphobia can be defined as a morbid fear of being isolated, while autophobia can be defined as a morbid fear of solitude or one's self. Yet there is nothing wrong with solitude and whilst ‘no man is an island’, totally self-sufficient and therefore needing other people at least occasionally, it is likely that we all need some level of solitude. Indeed, most world religions encourage a certain level of solitude as a valid and healthy prerequisite to an exploration and expression of spirituality.

The symptoms of autophobia can vary significantly. However, there are some symptoms that most people with this condition experience. An intense amount of apprehension and anxiety when they are alone or think about situations where they would be secluded is one of the most common indications that a person is autophobic. People with this condition also commonly believe that there is an impending disaster waiting to occur whenever they are left alone. For this reason, those with autophobia can often go to extreme lengths to avoid being in isolation. However, those with this condition often do not need to be in physical isolation to feel abandoned and can feel secluded while in a crowded area or with a group of people.

However, a note of caution must be advised. While accepting that autophobia, eremphobia and monophobia may be valid forms of mental ill health, there is danger that loneliness could be pathologised with the possibility of a similar social stigma that is often attached to other forms of mental ill health. If this possibility is realised, those who experience loneliness are likely to experience further social isolation and may be unwilling to acknowledge to themselves let alone other people that they experience loneliness. If the person who experiences loneliness has the courage to seek medical help from their GP, for example, they may well be confronted with a lack of understanding or empathy and even ridicule. It would be only too easy for hard-pressed GPs to reach for the prescription pad and prescribe antidepressants or anxiolytics as an easy solution. While the use of antidepressants and anxiolytics may be helpful in treating or managing the depression and anxiety that can accompany loneliness and social isolation, it would be inappropriate and unsafe to medicalise loneliness.

Role of the mental health nurse

Loneliness is not just a cause of mental health problems but can compound them and lead people to isolate themselves further still and there are a range of blogs that explores the effects that loneliness and isolation can have on the person (Mind, 2014). What, then, can the nurse do to understand and alleviate the effects that loneliness can have on individuals and the wider community and society?

Nurses need to understand what loneliness is, the causes of loneliness and social isolation and the impact that loneliness and social isolation can have on individuals and the wider society. Without this understanding, any nursing intervention in tackling loneliness and its impact on people is likely to be limited. Nurses need to identify people who may be particularly at risk of loneliness and social isolation in their areas. This applies equally to those who work in general acute hospitals, those who work in mental health hospitals or day centres and those who work in community mental health teams.

As nursing assessments form a crucial aspect of any nurse interventions, so it must be with supporting those at risk of or are experiencing loneliness and social isolation, regardless of the cause. Where there are no formal assessment tools available that focuses on loneliness, existing assessments that focus on ‘activities of daily living’ could be amended or tweaked to include open-ended questions around perceptions of loneliness and isolation, how loneliness and isolation impact upon the person, social engagement and social and family networks. Where such assessments highlight possible causes and effects of loneliness and isolation, a lack of social engagement or social and family networks, the reasons for such a lack must be ascertained with how the patient or service user would like engagement and networks to be improved. Plans for nursing and local action to address these challenges must be included within any assessments that are carried out. Local communities and those who experience loneliness and social isolation must demand evidence that their political, health and faith community leaders are taking loneliness seriously.

While there are likely to be a range of ways in which nurses can support those experiencing loneliness and social isolation, it must be kept in mind that a ‘one size does not fit all’ approach must be followed: an approach that may work for some may not work for others.

Case study

Anastasia is a 45-year-old woman who has experienced frequent periods of severe depression and has previously tried to commit suicide. She lives on her own on a housing estate that has a range of socioeconomic challenges. Anastasia says that she feels very lonely and isolated and that no-one cares about her. Zoe is her named community mental health nurse.

Zoe's first task is to gain Anastasia's trust given that Anastasia feels let down and ignored by care professionals. Without trust, any nursing intervention is unlikely to succeed.

An assessment of Anastasia's strengths and needs reveals that she used to enjoy doing voluntary work and says that she felt valued because of such work. Zoe knew the housing estate well, having previously liaised with a range of local community action groups, and understood that communities need safe social spaces in which they can come together to be vital. She suggested several ways to combat loneliness and isolation that Anastasia may wish to consider:

• Access to a range of ‘talking therapies’ that may be helpful in managing and treating the depression

• A ‘knit and natter’ social group that meets once a week in a local community centre

• Volunteering as an adult basic education tutor

• Working on a small allotment and café set up and run by people with a mental health problem or a learning disability

• Participating in the local ‘neighbourhood watch’ scheme

• Reclaiming the estate. The social and economic challenges within the estate, in line with many other housing estates, such as poverty, drug dealing, vandalism, burglary, and car crimes were well known, and Zoe discussed the roles that Anastasia could play in making the estate safe for the local community. Anastasia suggested that many of these were likely to be ‘political’ in nature and raised the issue of engagement in local community or disability politics.

While the above ‘suggestions’ are just that and are not meant to be exhaustive or prescriptive, they have at least four benefits for the service user in common:

• Social networking and engagement

• Being an active presence within local communities for the benefit of those communities

• Economic to run. Many of these interventions such as a ‘knit and natter’ group or volunteering may only need ‘start-up’ funding and small grants may be available to cover such funding

• User led. For many this is important as the service user become active agents, as ‘do-ers’, within their own therapeutic intervention programmes rather than being the much more passive ‘done to’. This is likely to have a positive impact upon their levels of motivation and mental well-being.

As such, these suggestions may be applicable to many others who face similar loneliness and social isolation. However, caution must be noted: any nursing intervention must be driven by the service user or patient and result from a thorough assessment that includes the reasons and root causes for the loneliness and social isolation. Interventions must meet the needs of the individual and not the individual meet the needs of the interventions. Again, beware of attempting to fill a void in a person's life with endless activity, as some may still feel intense loneliness while being very busy and surrounded by people.

Those with autophobia, eremphobia or monophobia may benefit from a range of interventions including anxiolytics and the ‘talking therapies’, such as cognitive behavioural therapy, counselling and interpersonal psychotherapy; a number of NHS Trusts provide specific talking therapy services.

Conclusion

Despite the many forms of human contact afforded by social media platforms, loneliness and social isolation is endemic within society, an issue that was picked up and championed by the late Labour MP, Jo Cox. Those who experience mental health issues are at particular risk of experiencing loneliness and social isolation, with mental ill health both contributing to and resulting from such experiences. Do not forget that loneliness can affect anyone at one time or another so be aware of the possibility that some of your colleagues could also be experiencing loneliness and may need your support.

KEY POINTS

• Loneliness and social isolation has perhaps never been greater, more apparent and in some cases more devastating

• Loneliness is a complex and usually unpleasant emotional response to social and emotional isolation and can be viewed as either transient or chronic

• 42% of those who experience depression do so due to being alone and isolated

• 57% of those who experience depression and anxiety isolate themselves from family and friends

• Interventions must be based on a thorough assessment and history taking and meet the needs of the individual and not the individual meet the needs of the interventions.