Why talking about loneliness matters to the mental health of consumers and to the work of the psychiatrist

A new year brings with it opportunities to think and act differently as individuals, families and as a community and to talk openly and take action on what needs to change to improve the mental health of all members of the community. Many investigations have taken place over the last few years that have identified unmet mental health needs; we understand what needs to change, and promises have been made about timely, affordable quality mental health care for all Australians. There is so much promise about mental health reform, yet some of our society’s most pressing challenges to mental health, including family violence, poverty, stigma, discrimination and racism, continue to dominate public discourse. Other issues, such as loneliness, are barely noticed at all.

The voice of lived experience is now pervasive in Australia’s health policy reform agenda, and increasingly so in the design, implementation and delivery of new models of care. The Royal Australian and New Zealand College of Psychiatrists’ (RANZCP) Community Collaboration Committee (CCC) provides lived experience input across the College’s work. In 2019, the CCC identified loneliness as a neglected factor in the understanding and treatment of mental illness and resolved to raise awareness within the College about how addressing loneliness can make a difference to the lives of consumers and carers.

Loneliness refers to the person’s subjective perception of their social world and connection to it (Ma et al., 2020). It is understood to be both a cause and consequence of becoming disconnected. Loneliness is different from social isolation, although the two can be interlinked. While some individuals may feel lonely due to physical or social isolation, others can feel intense loneliness when surrounded by others, including loved ones.

Although attention to loneliness has grown with the emergence of COVID-19, interest in the subject is not new. It has been the subject of literature and poetry for centuries. Exploring the history of loneliness, Worsley (2018) stated that

In the 17th century, when loneliness was usually relegated to the space outside the city, solving it was easy. It merely required a return to society. However, loneliness has since moved inward . . . (and) because it’s taken up residence inside minds . . . it can’t always be solved by company . . . The wilderness is now inside of us.

Almost a quarter of people living in Australia report that they rarely or never feel close to people, rarely or never have someone to talk to, and rarely or never have people they can turn to (Psychweek.org.au, 2018). Individuals who are socially isolated are up to five times more likely to die prematurely than individuals with strong social ties, due to many interlinked factors. People who experience severe mental illness describe loneliness more frequently, with studies reporting rates between two and eight times greater than the general population, increasing to 20 times more frequently for people with more than one mental health condition (Meltzer et al., 2013). Conversely, a sense of social connection, belonging, meaning and purpose, strengthens physical and mental health and builds resilience to deal with adversity, addiction and mental health challenges (Meltzer et al., 2013; Petitte et al., 2015).

As humans, we tend to drive away lonely members of the group to preserve the group; hence, people who feel socially isolated can become objectively isolated (Cacioppo et al., 2009). Loneliness reduces the ties that such individuals may then have within broader community networks. Stigma, discrimination and marginalisation are embedded in these processes. We also know that loneliness is significantly associated with self-stigma and perceived discrimination. Low self-esteem directly influences loneliness, with consequent adverse impacts on recovery when the person who experiences loneliness withdraws from social activities to avoid feelings of shame and worthlessness. Hence, loneliness arises from broad social forces, and efforts to reduce loneliness in our society would benefit from focusing on nurturing, protecting and building social networks of people as part of more inclusive and accepting communities. Lived experience peer workers are clearly one emerging workforce that can help by providing a bridge for people, facilitating trust and safe connections, and more accepting and hopeful service cultures for people to seek and receive support.

The UK Royal College of Psychiatrists and British Geriatric Society (2019) have suggested a range of ways to help alleviate loneliness:

• Improved access to high-quality health and social care;

• Improved identification of loneliness;

• Implementation of social prescribing into routines, holistic care and support;

• Building the volunteer support sector and range of support options in the community;

• Recognising loneliness as a health issue;

• Recognising loneliness as a broader society-wide issue.

In Australia, a national network of organisations called ‘Ending Loneliness Together’ (2022) has identified four key calls for action to address loneliness that include development of a strategic framework for social connection, inclusive of nationally agreed definitions, indicators and outcome measures; improved coordination of government and community organisations efforts; a national campaign to talk about social health to reduce stigma associated with loneliness and empower communities to help each other; and more Australian-based research to build the evidence base.

To address the gap in evidence and ensure the voices of people with lived experience of mental ill-health are heard, Lived Experience Australia, in collaboration with the RANZCP’s CCC, undertook a survey on loneliness with 322 mental health consumers and carers. We asked them what loneliness means to them; what they want others to know about loneliness; how loneliness impacts their mental health and physical health; what they do to alleviate loneliness; and how they think psychiatrists and other mental health professionals could help people reduce their sense of loneliness and help families, whānau and communities to flourish (Lawn and Kaine, 2022).

Both consumer and carer respondents described a core feeling of having no-one who saw, heard or understood them. Having no-one who they could share without judgement their innermost thoughts made them feel invisible to others and themselves. Consumer respondents described how the lack of connection with others and perceived invisibility led them to experience a lack of purpose in life, reinforcing a sense that they ‘don’t matter’ to others, and that they have no value to others and their community. They described having no-one who really ‘gets you’, and with whom you can feel safe knowing that you are loved unconditionally. They also described a strong sense of feeling different, marginalised and stigmatised as a consequence of their mental health. They identified interconnections between loneliness and feelings of stigma, shame, judgement and sense of self-worth, particularly in the context of living with mental ill-health. This was expressed in terms of self-stigma; in the experience of shame in asking for help and telling others that they were lonely; and in the fear of or actual experience of rejection and discrimination by others (Lawn and Kaine, 2022).

Respondents also described loneliness as hard, hidden and harmful and told us that it is connected to physical and mental health more than is realised. They described the impact of loneliness on families, leading to family strain and conflict, and family members coping either by becoming closer or moving further apart. They told us how loneliness can be alleviated by striving to build self-care and self-worth, and by nurturing a sense of meaning and purpose. The importance of routinely connecting with other ‘humans’, nature and pets was emphasised. Respondents told us that loneliness is a social, not an individual, problem. They said that the causes and solutions for loneliness are situated in the social fabric of society and how people fundamentally treat and connect with each other. Solutions, therefore, must be shared endeavours (Lawn and Kaine, 2022).

Several recommendations are apparent from the findings:

Communities can help by:

• Building greater acceptance and inclusion in the community;

• Improving understanding and education about loneliness;

• Tackling stigma and discrimination about mental illness;

• Creating more community spaces that promote meaningful connections with others;

• Nurturing relationships that help people feel safety, trust and membership of the community.

Psychiatrists, and other mental health professionals, can help by:

• Listening, asking about loneliness and validating the person’s experiences of loneliness. This builds the person’s sense of trust and hope and helps them to address self-stigma and low self-worth associated with loneliness;

• Recognising that talking about loneliness may be difficult;

• Helping clients develop confidence and practical skills to overcome loneliness;

• Using more humanistic and holistic approaches to care, instilling hope, and being compassionate and non-judgmental;

• Considering lived experience peer support options;

• Understanding what supports are available and providing assistance to help clients connect with them;

• Being aware of professional privilege and addressing power imbalance in interactions and shared environments of care to ensure safety, trust and trauma-informed contact;

• Not relying on medications alone to fix everything;

• Involving families, carers and whānau where possible and agreed to by the client;

• Seeing the person in the context of their family, community and whānau and providing whole-of-family psychoeducation and support options (Lawn and Kaine, 2022).

What is clear from our lived experience exploration is that loneliness is an intensely personal human experience, with profound impacts on how individuals see themselves, the world around them and their place within it. As such, we believe it is time for psychiatrists and other mental health and support workers to ask the people they serve about their experience of loneliness, social and interpersonal connection, so that loneliness is no longer the silent ‘elephant in the room’. It may be one of the most important conversations they can have with the person.