Adult Loneliness Narratives Recount Exposure to Relational Loss,Rejection,Emotional Absence,and Excessive Labor: A Critical Realist Approach to Thematic Analysis

Abstract

The U.S. Surgeon General’s 2023 advisory on America’s loneliness epidemic defines loneliness as a discrepancy in relationship quality linked to higher risk for severe mental illness. It is unclear what is meant by relationship quality and how these qualities would scale large enough to produce a loneliness epidemic.

Methods: We used a critical realist approach to thematic analysis, to examine quality in social interactions and underlying causes, during experiences when adults said they were lonely. Secondary data came from 219 online, open-ended survey responses by anonymous adults about loneliness, made publicly available by The Loneliness Project in 2018.

Results: Grieving Relational Loss, Rejection of Who I Truly Am, Present But Emotionally Absent, and Excessive Labor, were four themes found to define poor qualities contributing to feelings of loneliness. Being cared for was the only theme to define a positive quality that was desired during loneliness experiences. Poor qualities in contrast to one positive quality defined the discrepancy in relationship quality in our study sample.

Conclusions: These results specify quality concerns in adults’ social environments that can highlight what’s important for intervention in a broad range of social experiences. They suggest ways that policy and/or institutional interventions can consider structural changes to reduce adult loneliness.

Introduction

In 2023, the U.S. Surgeon General issued an advisory to address serious levels of social isolation or loneliness in up to 40% of U.S. adults, stating, “Social connection is a fundamental human need, as essential to survival as food, water, and shelter” (U.S. Department of Health and Human Services, 2023). Human needs including food, water, shelter, are a distinct type of physiological need. They are considered critical to support the normal functioning of cellular processes (e.g. metabolism, osmotic equilibrium, and body temperature), that are tightly regulated to maintain human survival (McEwen, 1998, 2005). Adding social connection, or human relationships, to this list supports the idea of social homeostasis. Social homeostasis suggests that loneliness is a physiological indicator of deprivation in protective social bonds, generating stress responses that can become chronic until an expected level of exposure to social contact has been met (Cacioppo & Patrick, 2008; Coan & Sbarra, 2015; Fulford & Holt, 2023). Loneliness is thought to be an indicator of poor quality in social connection associated with overall worsening mental health conditions, such as anxiety, depression, suicidal ideation, and severe mental illness (Fulford & Holt, 2023; U.S. Department of Health and Human Services, 2023). Framing social connection as critical to survival, and loneliness as a form of social deprivation and social determinant of mental health, is a paradigm shift that calls for broader policy and institutional participation to intervene (U.S. Department of Health and Human Services, 2023; Wickramaratne et al., 2022). There is a need to better understand what is meant by poor relationship quality to guide loneliness interventions in our communities.

An important obstacle to designing interventions for loneliness is the tension between the objectivity of human need and the subjectivity of loneliness. Loneliness is often distinguished from objective social isolation as a solely subjective reality that individuals feel alone even if they have existing relationships (Lim, Holt-Lunstad, & Badcock, 2020). Loneliness used to be considered a mental health disorder similar to depression (Pettigrew & Roberts, 2008). It can still be treated with psychological interventions to correct dysfunctional or biased perceptions that lonely individuals are thought to have about their social experiences, and discourage behaviors to self-isolate (Cacioppo et al., 2015; Fulford & Holt, 2023; Hickin et al., 2021). Therapeutic interventions for loneliness have shown to be significant in reducing loneliness, but the effect size can be minimal and variable, and seems to depend on the social environment, like living in a group setting in long-term care (Cacioppo et al., 2015; Hickin et al., 2021; Hoang et al., 2022).

Health researchers have also found that objective social experiences such as divorce, death of loved ones, violent assault, and domestic and child abuse, are associated with higher levels of loneliness (DiJulio et al., 2018; Landry et al., 2022; Shepp et al., 2023). An accumulation of these social experiences over the life course increases feelings of loneliness (DiJulio et al., 2018; Liberatore-Maguire et al., 2022). Due to a growing awareness that loneliness is linked to negative social experiences of marginalized populations, loneliness has been repositioned as central to understanding how marginalization of stigmatized communities impacts health outcomes (Shepp et al., 2023). With a historical focus of loneliness and social isolation interventions on older adult experiences, addressing social risk factors like discrimination, domestic abuse, etc., are not being identified as loneliness interventions nor included in systematic reviews to examine their effectiveness on reducing loneliness.

Critical realism may be able to handle the growing tension between objective and subjective understanding of why loneliness occurs to inform interventions. Critical realism is a philosophy about existence that acknowledges an objective world independent of human perception, that humans can only know through the limitations of socially produced beliefs, values, and other forms of perspective (Koopmans & Schiller, 2022). It integrates how knowledge is produced in the natural and social sciences (Hastings, 2021). A critical realist approach in health research assumes that an approximate reality can be produced to explain causal mechanisms well enough to treat health-related conditions (Koopmans & Schiller, 2022). Conclusions from quantitative research to determine patterns and cause and effect relationships are still important in critical realism, but qualitative research can also produce causal explanations that describe the makeup of key factors and complex relationships they have with underlying forces, like social structures (Hastings, 2021; Koopmans & Schiller, 2022; Wiltshire & Ronkainen, 2021).

We used a critical realist approach to conduct a qualitative research study that examines causal mechanisms to feeling lonely, as observed by adults anonymously describing loneliness experiences in an online art project. Anonymous narratives were selected for this study because recruiting sufficient participants with serious or chronic loneliness is a known challenge in health research due to stigma and shame (Barreto et al., 2022). Theoretical models that incorporate a causal pathway for social connection as a human need and how this can be related to loneliness through relationship qualities, were used to frame narratives to improve explanation of causal mechanisms rather than exploration of unknown ideas (Fryer, 2022). We conducted thematic analysis to understand qualities within direct social interactions contributing to feeling lonely in adults, ages 18 and older, in 219 loneliness narratives. Results from this study are explanatory, to improve cohesive understanding of relationship quality contributing to adult loneliness that can inform the identification and design of interventions for loneliness.

Materials and Methods

Data Source

The University’s Institutional Review Board approved the study as exempt from human subject research (#23-2083). Secondary data come from The Loneliness Project, a public website developed by a Canadian artist in an effort to destigmatize experiences of loneliness (Korda & Rumball, 2017). The intention of The Loneliness Project was to express how loneliness is a shared and human experience (Kassam, 2018). The project was an open response online survey that provided four prompts to describe loneliness: Last time I felt lonely was; To me, loneliness means; One of the first times I realized I was lonely was; Tell me the story of the time you felt the most lonely. The survey was posted on the website to receive responses from the public between October 2017 to the end of 2018. The survey was publicized internationally, first through a personal Facebook post, and then was picked up by local and global news outlets based in Canada, the United States of America, and the United Kingdom (Korda, 2023). Over 2000 survey responses in English were received (Korda, 2023). The artist selected 300 responses to be posted publicly on The Loneliness Project website, to reflect what she found to be the greatest diversity in ages, lived experiences, and geographic locations (M. Korda, personal communication, January 12, 2023). The study authors were not involved in the Loneliness Project and the artist’s selection process of posting survey responses on the website was not intended for scientific research.

Study Population

There is limited sociodemographic information regarding the study sample available from The Loneliness Project website. Survey respondents were allowed to submit responses anonymously, choosing their own first name. There were not controls in place to prevent respondents from submitting more than once, but the artist selected less than 15% of total responses to post publicly that were intentionally selected to “publish enough variety that anyone could find something that speaks to some aspect of their specific [loneliness] experience” (M. Korda, personal communication, January 12, 2023). The artist did not detect any fraudulent participation and there were no financial incentives provided to respondents.

Respondents also self-reported an age that ranged from 4 years to 75 years old. Since the UCLA Loneliness Scale is one of few valid measures to capture the experience of loneliness as a universal phenomenon among adults, it is unclear how loneliness may be experienced or expressed differently among those of younger ages (Cole et al., 2021; Panayiotou et al., 2023). For this reason, only adults self-identified as ages 18 or older are included in our study (Table 1). An additional 30 respondents who were randomly selected for preliminary work from January to May of 2023 were also excluded, as well as 3 narratives that were exact duplicates of other narratives. In total, 219 loneliness narratives from anonymous adults were available for analysis (Figure 1).

Table 1.

Distribution of Self-Reported Age of Respondents (N = 219)

Age ranges	Count (n)
18-30	106
31-40	45
41-50	26
51-60	24
61-70	12
71-80	6

Figure 1.

Selection of Narratives From the Loneliness Project Used in Thematic Analysis

Theoretical Perspectives

A critical realism approach to thematic analysis uses existing theory as a part of the analysis, so that coding is theory-driven to help produce causal explanations that build on existing knowledge (Fryer, 2022). Two conceptual models were selected to guide thematic analysis of loneliness narratives, because they define a causal pathway from social connection as a human need to health outcomes, and how this causal pathway could specifically apply to loneliness.

The Social Exposome Model

The social exposome is a conceptual model about how the entirety of exposure to a social environment over time impacts health outcomes (Gudi-Mindermann et al., 2023). This model was selected because it identifies social interactions as a necessary component for the broader social world, such as culture, to cross through in order to impact health outcomes. The definition of social interactions guided our thematic analysis to consider three components: the actors or people involved in an interaction, the places where social interactions occur, and the dynamic of a social interaction, such as a relationship quality (Gudi-Mindermann et al., 2023). The model describes embodiment as a biological pathway for how exposure to a social environment can become embedded in human physiology, such as the enforcement of gender norms in social interactions that become learned and influence behavior (Gudi-Mindermann et al., 2023; Krieger, 2024). Neuroscience suggests a physiological dependence on physical exposure to other people, that when there is social deprivation, it can produce stress for humans as a social species (Coan & Sbarra, 2015; Fulford & Holt, 2023).

The Cognitive Discrepancy Model

In addition, the cognitive discrepancy model is commonly referenced in loneliness research to suggest that loneliness occurs when the quality of relationships one has is different than the quality of relationships that one wants (U.S. Department of Health and Human Services, 2023). For the purposes of this study, the definition of social interactions was used to focus on relationship quality in loneliness experiences to better explain this discrepancy.

Analysis

Secondary Data Considerations

Using online written material that was unintended for research requires additional thought about conducting secondary qualitative data analysis (Chatfield, 2020; Keim-Malpass et al., 2014). Validation of results is improved when research questions are aligned with the original intention of the data (Chatfield, 2020). Data came from a single website focused on sharing stories about loneliness. In news interviews, the artist describes The Loneliness Project as a reaction to social media’s attention on human happiness that does not allow for sharing more difficult parts of human life that are also normal (Kassam, 2018).

After reading respondents’ stories, the artist reaffirms the cognitive discrepancy model – noticing that there is a disconnect between the kinds of relationships that people want and their reality (Kassam, 2018). The artist, though, rejects the idea that loneliness should be treated like a health concern or medical condition, believing this will further stigmatize those who feel lonely. This is an important contradiction we include in our analysis, to allow for loneliness to be normal without need for intervention. It aligns with our approach to include anonymous contributors in loneliness research who may seek out anonymity because they feel stigmatized for their loneliness (Barreto et al., 2022; Rains, 2014). Online written material was also selected to have a large amount of naturalistic information that reflects a wide range of views on the same health topic, as our study is trying to understand a shared human need (Keim-Malpass et al., 2014).

Thematic Analysis

A critical realist approach to thematic analysis of data was conducted. It followed 5 main steps (Campbell et al., 2021; Fryer, 2022). These steps are iterative, being continuously returned to throughout the analytic process.

The first step is to identify the research question (Fryer, 2022). To reiterate, our study primarily examined the question of what are the underlying causes of loneliness in adults, as related to relationship quality?

Step two is developing familiarity with the data (Fryer, 2022). Data were organized using ATLAS.ti 23. A supervising researcher and the lead author conducted preliminary work from January to May 2023 to become familiar with data. We met each week to reflect on initial thoughts about narratives, our contributing areas of expertise, and to improve on study design (Fryer, 2022). We also discussed key term definitions to build a shared understanding. Reflections were documented in an on-going research journal (Fryer, 2022). We used a random number generator to select only 30 narratives to read and analyze to avoid limiting future analysis. The research team was trained and oriented using the selected 30 narratives.

Step three was the act of developing codes for our total sample size of 219 loneliness narratives (Fryer, 2022). Our coding was theory driven. We incorporated our theoretical models into the qualitative analysis itself. For example, we used the components of social interactions (actor, place, dynamic) to guide coding, with an emphasis on understanding relationship qualities (Figure 2).

Figure 2.

Example of How Theory Guided Thematic Analysis

Descriptive codes were used to capture the complexity of social interactions across a diversity of social experiences contributing to loneliness, as well as to incorporate the intentions of the artist and knowledge within our research team (Fryer, 2022). Each narrative was double coded independently between the lead author and a research assistant. To improve validity and reliability, the lead author and research assistant regularly met to standardize the naming and definitions of codes to best reflect the data, and consider consolidating them when the volume of code increased (Fryer, 2022; Wiltshire & Ronkainen, 2021). An advising researcher who is an expert in qualitative research also reviewed code names, definitions, and key decisions for consolidation. These key decisions were tracked in an audit trail (Cutcliffe & McKenna, 2004).

Reflexivity is an important part of critical realism that recognizes it is not possible to remove researcher bias from thematic analysis (Fryer, 2022). As a team we reflected on patterns in the data from the perspective of a social worker trained in clinical interventions to improve systems of relational health, of a research assistant trained in global health to consider cultural differences in health topics, and of the lead author trained in systems biology (e.g. ecology) and public health to address social determinants of health. We found our shared knowledge of systems thinking helped us understand the complexity of social environments found in loneliness experiences (Meadows, 2008). Accepting all loneliness narratives at face value, despite concerns raised about faulty perceptions of survey respondents, was a consistent tension in our research team. This was done to adhere to critical realist philosophy that there is no need to remove or determine subjectivity, as underlying participants’ personal experiences, an approximate understanding of objective reality can still be found (Wiltshire & Ronkainen, 2021). This also aligned with our efforts to include the intentions of the artist and survey respondents in The Loneliness Project to destigmatize loneliness as a normal part of human life (Kassam, 2018).

We found thematic saturation to be an important part of our analysis. Given the diversity of loneliness experiences from anonymous adults around the world, it wasn’t clear that we would be able to consolidate our code to describe what survey respondents had in common. Our team defined thematic saturation as no new ideas were arising from loneliness experiences to understand relationship quality or other causal explanations. Preliminary thematic saturation was reached after coding 83 loneliness narratives (Guest et al., 2020). However, we did not have theoretical reason for stopping and coded the full study sample to ensure saturation (Fryer, 2022; Guest et al., 2020). We divided up remaining narratives to independently code until all 219 narratives had been reviewed, only discussing them as a research team if a new idea was found.

Step four was the development of themes (Fryer, 2022). For a critical realist approach to thematic analysis, the importance of this step is distinguishing among the personal experience of loneliness, identifying shared events contributing to loneliness among a group of narrators, and developing themes to explain a causal mechanism producing the shared events (Fryer, 2022). For example, a survey response in our study may describe the personal experience of loneliness as feeling alone and afraid, the event that led to those feelings as being rejected by a teacher for being gay, and the underlying cause of that event as a cultural message that stigmatizes gay men.

The lead author organized the final codes into shared categories, which guided the discussion in developing themes. The research team discussed themes and reached decisions about thematic definitions. However, we decided to develop all three - experiences, events, and causal explanations - into themes. We found the novel use of the social exposome model to give new insight into each of these considerations. We assessed the validity of our themes that described a causal explanation, based on their explanatory power found within the larger body of loneliness population health research (Fryer, 2022; Hastings, 2021; Wiltshire & Ronkainen, 2021).

The final fifth step was to share and discuss results in the following sections.

Results

All 219 available loneliness narratives of adults ages 18+ were coded from The Loneliness Project website. There were a total of 105 final codes from which 15 themes were developed (Table 2). To answer our main research question about relationship quality, fives themes emerged: Grieving Relational Loss, Rejection of Who I Truly Am, Present but Emotionally Absent, and Excessive Labor describe poor qualities in social interactions that result in feeling lonely. Being Cared For described a positive quality in social interactions that narrators desired while experiencing loneliness (Table 2). The discrepancy between these poor and positive qualities in social interactions is an approximate causal explanation of loneliness that further explains the Cognitive Discrepancy Model. Our results explain what specific qualities lonely adults are observing that contribute to feeling lonely.

Table 2.

Thematic Analysis of Narratives From the Loneliness Project (N = 219)

Themes: Immediate causes of loneliness	Quotes
Being Cared For In loneliness, being cared for was the relationship quality that survey respondents desired. It was a “real” connection of knowing you, an authentic understanding of who the narrator is. Being cared for has a physical presence that is close – hug me, hold my hand, talk to me, see me. It was further described as being paid attention to, showing up in person, having someone to talk to in shared experiences of everyday social life, having someone to turn to in times of crisis, and having something in common	“Caring deeply for and about other people, purely because you like making other people feel loved and cared for and realizing that no one feels that way about you.” (story 147) “Lack of touching, not in a sexual way, in a way that acknowledges me and sees and feels me as a person.” (story 12) “A lot of times I’m just screaming in my head ‘Look at me! see me!’” (story 88)
Rejection Of Who I Truly Am A primary type of social interaction in loneliness experiences was feeling rejected by a person, a group of people, or an entire community. Feelings of rejection included feeling criticized or disregarded. Rejection occurred within explicit experiences of bullying and abuse. It also occurred when socially excluded or during a significant break in trust. Rejection ultimately felt like a rejection of the self, and a judgment on who a person is or a dismissal that a person doesn’t matter	“I saw one of my roommates leave the building with a big group of people I’m assuming were friends or classmates. I Waved to him. He begrudgingly nodded back. I felt my heart drop.” (story 43) “When I was young it meant pain. It represented some sort of punishment for the crime of just being me.” (story 21) “When I was in seventh grade and realised I was gay – no one else was attracted to people of the same sex, and the first person I talked to about this, my class teacher, looked at me with this repulsion I have not gotten over.” (story 202)
Present But Emotionally Absent A primary type of social interaction in loneliness experiences was the possibility for a relationship, person, or a crowd of people to be physically present, but still not have connection. Being present but emotionally absent emphasized the need for connection to be emotional. The juxtaposition of presence with emotional absence was explained by survey respondents as having nothing in common, having existing relationships that are too busy to spend time together, an inauthenticity in the relationship, or feeling ignored or invisible in relationships. This results in someone still feeling alone	“Sitting next to my husband, while he was buried in his phone, texting with other people….It’s like I’m sitting there all by myself and resort to looking around and people watching.” (story 88) “I was, still am I guess, a foster kid. The feeling of abandonment never leaves you, it just continues to grow…I just drifted in and out of the family experience, feeling like I could disappear any moment and it would be easier for everyone.” (story 94)
Excessive Labor A primary type of social interaction in loneliness experiences was an inability to share unpaid or paid labor responsibilities with other people. Survey respondents were faced with labor that exceeded their capacity or with a significant responsibility or decision being required or asked of them to do alone. These conditions may occur naturally in situations of working or living alone, or being a primary caretaker. Survey respondents also felt pressured into excessive labor or caregiving roles, that could lend to feelings of being used and overwhelmed	“Whenever I am tired after work, or sick…and there is no one there I can ask “hey, can you do me a favor and go get Sudafed”…”(Story 105) “The loneliest I feel is when I am at work as a resident physician in a large canadian hospital. I stay awake for 26 to 28 hours overnight caring for my patients who believe doctors cannot do their jobs…” (story 130)
Grieving Relational Loss A primary type of social interaction in loneliness experiences was loss of relationships due to death, breaking off relationships, or feeling left behind as relationships changed over time. Loss could also describe the loss of a future relationship or the loss of one’s own body due to a serious health event. Feelings of grief were a common part of loss	“My mom died a month ago, and I feel as if the whole world has continued moving but I’m still stuck in that hospital room with her.” (story 206) “The doctor told me I wouldn’t be able to have kids… I Was in pain, I was scared, I’d been told something I always wanted wouldn’t happen…” (story 14)
Themes: Underlying causes of loneliness	Quotes
Breaking Expectations Of Dominant Social Narratives Dominant social narratives played a key role in loneliness experiences by establishing a social expectation that survey respondents struggled with confronting, because it conflicted with their lived experience. Dominant social narratives were made explicit through social pressure, social events, social interactions, institutional rules, or societal laws that reinforced social expectations. To not align with a dominant social narrative could result in experiences such as rejection, exclusion, or invisibility	“…When I got engaged. Life was supposed to be fun and exciting and my family was happy and his were happy…I felt an overwhelming sense of loneliness not being able to talk to friends or family about how I felt.” (story 20) “At about two years old when my brother came along. He was literally the fair-haired boy. What’s a girl? Not anything, you see.” (story 53) “When I told my dad I was feeling scared, depressed and wanting to harm myself. He wasn’t equipped to deal with my struggles…and told me not to ‘be stupid’ and to ‘get back to work’. (Story 114)
Transitioning Of My Social Life Beyond My Control Major life events contributed to changes in a narrator’s social life and/or social identity that were beyond the narrator’s ability to control. These changes could be expected (e.g. the process of aging) or unexpected (e.g. sudden death) and initiated feelings of loneliness. The change could be traumatic and hard to reconcile with or accept. They changed the narrator’s ability to relate to others, even to relationships they already have	“September 11th. All of New York was coming together and I couldn’t find security in another human.” (story 144) “When my husband showed the first signs of dementia.” (story 47) “I’ve been a journalist for about 3 years now and have covered mostly crime and war. I’ve seen enough death, bloodshed and devastation to last a lifetime, and I don’t really know anyone with whom I can relate to anymore.” (story 79)
Barriers And Refuge in Social Isolation Survey respondents described barriers to connecting with others due to the absence of a social structure. Survey respondents expressed concern when having a fragmented structure of relationships that can easily deteriorate and contributes to a sense of vulnerability or fear of the future. Without a social structure, survey respondents felt unmoored, or completely detached. To protect themselves or to find fulfilling relationships, survey respondents also intentionally broke off relationships	“Worrying about today, tomorrow – how will I cope, few friends – no-one interested in me. days are long, holidays unbearable.” (story 17) “It is a deep wound, to be emotionally estranged from your family out of self-preservation.” (story 71) “My mom was a single mom, and we moved around a lot. I Always read, but I think I didn’t have a single ’realisation’ of loneliness – that was just my constant state of being. It’s hard to keep friends when you’re at each school for a few months.” (story 180)
Barriers And Refuge in Physical Isolation Survey respondents also described physical structures as barriers to connecting with others, such as infrastructure, the interior rooms of buildings, and even the structure of their bodies. Within these physical structures survey respondents could feel trapped, lending to isolation from others. However, survey respondents also used structural barriers to protect themselves through hiding or finding refuge from other people	“When I sat in a coffee shop and realized everyone around me was locked into their electronic device. Earbuds in place, there was not an inch of space into which I could start a conversation.” (story 9) “I am deaf and I work with all hearing people. No matter how much my boss knows about deafness, she still doesn’t realize that I miss a lot and I feel invisible at work, that I’m not worth more than just saying hi to.” (story 100) “No one ever invited me to play at recess, so I hid in a bathroom stall rather than face the prospect of standing alone in the schoolyard.” (story 118)
Themes: Experiences of loneliness	Quotes
Darkness Of Loneliness Survey respondents describe connection through the senses as the presence of specific kinds of sights, sounds, warmth, and touch that are physically close. They describe loneliness through the absence of light, the absence of touch, silence, coldness, numbness, and physical distance. Loneliness could manifest physically in the form of illness, nausea, or pain. Unmoored helped explain total loneliness as complete disconnection from all life through one’s senses. Trapped described a different kind of total loneliness as the sense of being surrounded and unable to escape	“Loneliness lives in my stomach constantly, and I can feel it eating all my organs with each week that passes. It’s like a parasite.” (story 43) “Feeling like a single balloon released into the sky, moving further and further away from love and connection and floating uncontrollably into a terrifyingly dark and unknown abyss.” (story 144) “It’s a prison in which you’re both the prisoner and the tormentor.” (story 169)
A Diversity Of Life Relationships And Spaces Survey respondents mentioned a broad range of actors in their loneliness social interactions: The self, nuclear and extended family, romantic partners, friends, pets, work relationships, school relationships, religion relationships, social groups, an entire town, strangers, nature, spiritual relationships, and imaginary friends in fictional places. Relationships were often defined by their longevity, many starting in childhood. These social interactions could take place anywhere	“My mom had recently separated from my stepfather and had started dating a new man. My younger sister was living with her father (my soon to be ex-stepfather) and my older sister was out with her friends. I spent my 13th birthday by myself sitting on a climbing apparatus in a local school yard. I Remember looking up at the very few twinkling stars and thinking this is loneliness.” (story 21) “I was raised as a Jehovah’s witness. I struggled to leave the faith for years, living a secret life where I hid many things about myself. When you leave that faith you get cut off from everyone in it. I Knew what would come and I couldn’t bare to say goodbye.” (story 7)
Feeling Intense And Complex Emotions Survey respondents felt a spectrum of emotions in loneliness experiences, often happening at the same time and in conflict with each other, including emotions describing sadness, fear, anger, embarrassment, confidence, excitement, and love. It could leave survey respondents feeling confused, lost or overwhelmed in addressing them. Feeling sadness and being afraid were key emotions in loneliness experiences, with sadness typically describing grief from a loss or disappointment from not meeting expectations, and fear typically describing a fear of reactions from others or fear of uncertainty	“Scrolling through my phone looking for someone to reach out to, I found no shortage of business associates, old college buddies, some far of relatives but no one that I could share my most inner feelings with. This was when I felt the hurt in my chest knowing that this time I really was alone. I had a bomb of emotions inside me and I needed to diffuse it.” (story 51) “I spent two hours alone wandering around an IKEA because I was too nervous to ask people to come with me. I Ate two hotdogs and bought nothing.” (story 31) “My wife has a chronic illness that causes her daily pain. The loneliest feeling in the world is watching the person you love most in the world shake in pain and not being able to do anything. After the attack passes and she falls asleep, I’m too wired to sleep and cry alone on the couch.” (story 125)
Themes: Responses to loneliness	Quotes
Adapting With Disconnection In response to loneliness, survey respondents describe their efforts to take care of themselves. Survey respondents explained how effective their approaches were at helping or worsening loneliness, and their limits. Examples of approaches included hiding or pretending; finding connection to fictional characters and places in books, television, or imagination; finding an enjoyable place to take refuge; seeking out professional help; using substances; or filling one’s time with tasks or hobbies	“I’d spend hours in a dreamland in my head, creating elaborate places to go and wild adventures to have.” (story 56) “Luckily, I stopped before the scissors pierced my skin, and soon after, I found help with twelve-step recovery groups for compulsive eating/bulimia/anorexia. It saved my life, and those groups continue to save my life each day.” (story 103) “When things became really challenging, I would take long walks, stay in the washroom for longer periods of time, or I would get sick and stay home from work.” (story 10)
Learning To Be By Myself In loneliness experiences, the relationship that survey respondents had with themselves stood out. Survey respondents described building a relationship with themself as a learning experience and a necessary part of life, accepting that over the course of a life and an accumulation of experiences, being alone in some regards is inevitable. By myself may not be a form of loneliness, as survey respondents also described it as a form of solitude	“When I was a teenager and understood for the first time what a solitary journey our life’s path truly is.” (story 4) “Really discovering who you are. There is no one in the world but you, in the end, and you have to be really lonely to understand, accept, and love yourself.” (story 40)
Appreciating The Value Of Loneliness Survey respondents described changes in perspective and in their life after significant experiences of loneliness. Survey respondents recognized how loneliness helped them treat relationships as special and valuable. Survey respondents recognized how loneliness encouraged them to change relationships that were harmful or unfulfilling. Survey respondents also described personal growth after loneliness experiences as life changing	“I met my best friend from one of my freshman classes. We talked about anything and everything...But then I got hooked on drugs and I became a completely different person...We sat down and talked about it, and ended our friendship in the most civilized way. It broke my heart… Our friendship breakup changed me forever, for the better.” (story 151) “When I shifted my perspective the universe brought in more people into my life, people who genuinely care and I am forever thankful. I Would not be the person I am right now if it was not for the excruciating lonely phase I experienced from 2013-2015.” (story 67)

A critical realist approach may consider these themes about relationship quality to be events, rather than underlying causal explanations, because they describe characteristics that were observable in direct social interactions. However, the theory we used in our analysis already explains the underlying force of human need for social connection, that we found it more accurate to describe themes about relationship qualities as an immediate causal explanation for how social interactions can result in adult loneliness.

The remaining themes were grouped into Underlying Causal Explanations to describe underlying forces contributing to the discrepancy in qualities in social interactions, Experiences of Loneliness to describe the personal or internal experience of loneliness, and Responses to Loneliness to describe how survey respondents ultimately reacted to the experience. Underlying causal explanations do not have to be observable, but need to explain how and why events, like poor quality social interactions, are taking place (Fryer, 2022; Hastings, 2021).

Discussion

Our results further explain the Cognitive Discrepancy Model that suggests loneliness develops when there is a discrepancy in the quality of relationships that someone wants versus what they have (U.S. Department of Health and Human Services, 2023). Our study explains the discrepancy as four poor qualities in social interactions that are different ways of lacking being cared for by others. These qualities could encompass a large range of social experiences. Review studies trying to understand risk factors for loneliness often end up collecting a long list of demographic and social factors that can be difficult to make sense of how to address (Barjaková et al., 2023; Lim, Eres, & Vasan, 2020). By using a critical realist approach to consider the hypothesized biological pathway of social connection as a human need and personal accounts of loneliness experiences, a short list of approximate causes of loneliness emerged in our study as simpler ideas that could contain a great deal of complexity within them.

When considering which relationship qualities lonely adults may need, survey respondents in our study desired to be cared for by others (Table 2). Being Cared For encompassed a group of physical actions that helped adults feel visible and known as their authentic selves, such as showing up in person or being engaged in conversation to be understood. Social support that is provided in personal relationships may be a similar idea that has been found in loneliness research to reduce loneliness levels (Zhang & Dong, 2022). While social support can have many definitions, perceived social support scales often measure emotional and functional help provided by friends, family, and partners, such as listening to problems or helping with chores (Zhang & Dong, 2022). These measures overlook exposure to the broader social environment, as adults in our study also described needing to be cared for in any social space, such as at work or in healthcare settings that won’t involve intimate relationships. Science that has studied and researched what “caring” means has been developed in nursing, that could serve as a guide for how to measure and provide care across our communities (Turkel et al., 2017).

Grieving Relational Loss, Rejection of Who I Truly Am, and Excessive Labor (Table 1) are three social interaction qualities we identified in our study that contributed to feeling lonely and have been documented in loneliness research. With regards to loss, loneliness has a long history of being studied in older populations, recognizing that death in significant relationships impacts feeling lonely (O'Rourke et al., 2018). Older adults were also found to lose relationships due to major health problems that can create communication barriers with others and lead to isolation in homes or care facilities (O'Rourke et al., 2018). Our study indentified these same life transitions can result in loneliness at any adult age, in addition to the loss of relationships from moving away. Moving is known as a significant stressful life event, especially for children, due to the impact it has on changes in relationships (McMahon et al., 2020). Loneliness studies on older populations have mentioned that adult children moving away can impact loneliness in parents (Schröders et al., 2021). Our study found moving away was important across adult ages, especially frequent moving described by military families or working adults finding new jobs.

The second relationship quality of Rejection of Who I Truly Am, was described by survey respondents as feeling criticized or disregarded. It resulted in loneliness because rejection pointed out something wrong or unlikeable about the adult. This highlights the importance of incorporating anonymous stories into loneliness research and the need to address stigma. Rejection has been discussed in loneliness research by Dr. John T. Cacioppo, the founder of social neuroscience, who conducted psychology experiments that intentionally rejected individuals who ended up feeling lonely (Cacioppo & Patrick, 2008). However, these experiments were in controlled environments. Rejection described in our study was complex, as it was often being informed by dominant cultural messages to reject an individual based on a social identity or life experience. Known stigmas against sexual and gender minorities or those of certain weights (Gillani et al., 2024; Talumaa et al., 2022), for example, showed up in our study, as well as unrecognized stigmas, such as the social exclusion of single adults. Narratives in our study also described more severe forms of rejection as abuse and bullying. Recent loneliness research has found correlations between perceived discrimination, violence, and childhood and domestic abuse with population loneliness (Landry et al., 2022; Refaeli & Achdut, 2024; Shepp et al., 2023).

The third relationship quality of Excessive Labor, was described by survey respondents as any kind of labor that exceeded their capacity, either at work or in caring for others at home. They felt lonely because they were solely responsible for the labor. Job burnout was found to be related to loneliness levels by Dr. Daniel W. Russel, who developed the UCLA Loneliness Scale as a validated psychometric measure (Russell, 1996). Public school teachers and hospital-based nurses were studied as a population to help develop the scale, and the high job burnout in their professions continues to be correlated with loneliness (Russell, 1996; Wood et al., 2023). Loneliness has also been recognized as a common experience among caregivers for children or adults with serious mental or physical health problems (Vasileiou et al., 2017). Burnout may not fully capture the experience as survey respondents in our study described being in crisis with suicidal thoughts when unable to meet labor demands, from an inability to pay bills as a single parent to working 24-hour shifts at a hospital.

Present But Emotionally Absent (Table 2) is the fourth relationship quality we identified in our study that contributed to feeling lonely but is scant in loneliness research. Survey respondents described emotional absence as lacking in fulfilling interaction, such as an individual sitting in silence while others talked, or a person crying among a crowd of people who walk by. Emotional neglect has been examined in few loneliness studies to describe a lack of “love, support, a sense of belonging, and care”, primarily as it relates to children (Musetti et al., 2021). A sense of belonging is more commonly measured in adult loneliness research, that captures an individual’s feeling of being valued, accepted, and fitting in a community (Mellinger et al., 2024). Fitting in was included in our study under the umbrella of Present But Emotionally Absent, but it should not be confused with rejection. Instead, survey respondents described a misalignment between their authentic self and the people around them as lacking common ground. This quality may require further exploration.

Beyond the Cognitive Discrepancy Model, our study identified approximate underlying causes to to the quality of social interactions adults experienced. For example, Breaking Expectations of Dominant Social Narratives seemed to be an underlying force contributing to poor qualities in social interactions. One survey respondent described stigmatized stories about homosexuality in their culture as a way to explain why they were rejected as a gay man in their social interactions with others. The Social Exposome Model describes this as the process of embodying the social environment (Gudi-Mindermann et al., 2023). Cultural norms as stories can take on a physical form when stored in our brains, acted out in our behavior with others, and can be enforced through our social interactions (Gudi-Mindermann et al., 2023).

However, the four underlying causes we identified seemed to have a complex relationship with each other, that could not be easily described through thematic analysis alone (Fryer, 2022). They may reflect what critical realist approaches in healthcare call an open system (Koopmans & Schiller, 2022). Systems science is used to describe a collection of interacting factors that ultimately contribute to a single outcome in a dynamic way (Meadows, 2008). Systems methods are used to identify key causes in complex health issues, that can have bidirectional relationships and multiple pathways to an outcome (de Pinho & Larsen, 2015; Diez Roux, 2011). Our study found the qualities of social interactions, dominant social narratives, significant life transitions, physical isolation, and social isolation, could interact with each other to ultimately contribute to loneliness experiences in adults.

Limitations & Strengths

Secondary data for this study is anonymous and 300 survey responses out of the 2000 submitted were selected by one individual to be publicly posted. Those who submitted survey responses may be different than lonely persons who chose not to submit a survey response. As our study aim is to understand causes of loneliness as a health-related issue, health researchers will be concerned about generalizability and selection bias to understand which populations these results may apply to. We can only confirm that these results apply to our study sample of adults; however, we incorporated theory in our analysis to understand a human need that will have shared characteristics across all adult humans. We found that after analyzing 83 loneliness survey responses from anonymous adults, there were no new ideas in the remaining 136 responses to develop causal explanations for loneliness, indicating our results might be broadly shared among adults.

Understanding of loneliness from our study sample may emphasize a Western perspective that would be improved by examining loneliness experiences in other languages than English and across cultures. However, survey responses in our study sample described a rich diversity in loneliness experiences that could be positive or negative, and range in severity. Some survey respondents also explicitly described being from other countries or cultures that are not Western. We intentionally included contradictions in our analysis and final results, that maintained this diversity, to allow for loneliness to be a normal part of any adult life.

Conclusions

In interventions to reduce loneliness at any adult age, there are at least 5 key relationship qualities to consider: Being Cared For, Grieving Relational Loss, Rejection of Who I Truly Am, Excessive Labor, and Present But Emotionally Absent. These qualities overall reflect a wide range of well understood social concerns, that it may be more useful to identify health interventions already addressing these issues, and reframe or readjust them as loneliness interventions. Our results support the paradigm shift of understanding the need for social connection as a broad need across all relationship types in a community. Meaning, loneliness interventions should not limit themselves to fostering new or personal relationships, but should consider existing social structures at work, in healthcare, in religion, in neighborhoods, etc., in which poor quality social connection can be embedded. Our future research will improve upon these results to understand the system of underlying causes contributing to poor quality connection in social environments.