When You Feel Not Easy to Be Recognized in Public

Overview

CE credits: 1

Learning objectives: After reading this article, CE candidates will be able to:

1. Identify the effects of social isolation and loneliness on physical, mental and cognitive health.
2. Explore how loneliness differs from social isolation.
3. Discuss evidence-based interventions for combating loneliness.

For more information on earning CE credit for this article, go to www.apa.org/ed/ce/resources/ce-corner.

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According to a 2018 national survey by Cigna, loneliness levels have reached an all-time high, with nearly half of 20,000 U.S. adults reporting they sometimes or always feel alone. Forty percent of survey participants also reported they sometimes or always feel that their relationships are not meaningful and that they feel isolated.

Such numbers are alarming because of the health and mental health risks associated with loneliness. According to a meta-analysis co-authored by Julianne Holt-Lunstad, PhD, a professor of psychology and neuroscience at Brigham Young University, lack of social connection heightens health risks as much as smoking 15 cigarettes a day or having alcohol use disorder. She's also found that loneliness and social isolation are twice as harmful to physical and mental health as obesity ( Perspectives on Psychological Science , Vol. 10, No. 2, 2015 ).

"There is robust evidence that social isolation and loneliness significantly increase risk for premature mortality, and the magnitude of the risk exceeds that of many leading health indicators," Holt­Lunstad says.

In an effort to stem such health risks, campaigns and coalitions to reduce social isolation and loneliness—an individual's perceived level of social isolation—have been launched in Australia, ­Denmark and the United Kingdom. These national programs bring together research experts, nonprofit and government agencies, community groups and skilled volunteers to raise awareness of loneliness and address social isolation through evidence-based interventions and advocacy.

But is loneliness really increasing, or is it a condition that humans have always experienced at various times of life? In other words, are we becoming lonelier or just more inclined to recognize and talk about the problem?

These are tough questions to answer because historical data about loneliness are scant. Still, some research suggests that social isolation is increasing, so loneliness may be, too, says Holt-Lunstad. The most recent U.S. census data, for example, show that more than a quarter of the population lives alone—the highest rate ever recorded. In addition, more than half of the population is unmarried, and marriage rates and the number of children per household have declined since the previous census. Rates of volunteerism have also decreased, according to research by the University of Maryland's Do Good Institute, and an increasing percentage of Americans report no religious affiliation—suggesting declines in the kinds of religious and other institutional connections that can provide community.

"Regardless of whether loneliness is increasing or remaining stable, we have lots of evidence that a significant portion of the population is affected by it," says Holt­Lunstad. "Being connected to others socially is widely considered a fundamental human need—crucial to both well-being and survival."

As experts in behavior change, psychologists are well-positioned to help the nation combat loneliness. Through their research and public policy work, many psychologists have been providing data and detailed recommendations for advancing social connection as a U.S. public health priority on both the societal and individual levels.

"With an increasing aging population, the effects of loneliness on public health are only anticipated to increase," Holt-Lunstad says. "The challenge we face now is figuring out what can be done about it."

Who is most likely?

Loneliness is an experience that has been around since the beginning of time—and we all deal with it, according to Ami Rokach, PhD, an instructor at York University in Canada and a clinical psychologist. "It's something every single one of us deals with from time to time," he explains, and can occur during life transitions such as the death of a loved one, a divorce or a move to a new place. This kind of loneliness is referred to by researchers as reactive loneliness.

Problems can arise, however, when an experience of loneliness becomes chronic, Rokach notes. "If reactive loneliness is painful, chronic loneliness is torturous," he says. Chronic loneliness is most likely to set in when individuals either don't have the emotional, mental or financial resources to get out and satisfy their social needs or they lack a social circle that can provide these benefits, says psychologist Louise Hawkley, PhD, a senior research scientist at the research organization NORC at the University of Chicago.

"That's when things can become very problematic, and when many of the major negative health consequences of loneliness can set in," she says.

Last year, a Pew Research Center survey of more than 6,000 U.S. adults linked frequent loneliness to dissatisfaction with one's family, social and community life. About 28 percent of those dissatisfied with their family life feel lonely all or most of the time, compared with just 7 percent of those satisfied with their family life. Satisfaction with one's social life follows a similar pattern: 26 percent of those dissatisfied with their social lives are frequently lonely, compared with just 5 percent of those who are satisfied with their social lives. One in five Americans who say they are not satisfied with the quality of life in their local communities feel frequent loneliness, roughly triple the 7 percent of Americans who are satisfied with the quality of life in their communities.

And, of course, loneliness can occur when people are surrounded by others—on the subway, in a classroom, or even with their spouses and children, according to Rokach, who adds that loneliness is not synonymous with chosen isolation or solitude. Rather, loneliness is defined by people's levels of satisfaction with their connectedness, or their perceived social isolation.

Effects of loneliness and isolation

As demonstrated by a review of the effects of perceived social isolation across the life span, co-authored by Hawkley, loneliness can wreak havoc on an individual's physical, mental and cognitive health ( Philosophical Transactions of the Royal Society B , Vol. 370, No. 1669, 2015 ). Hawkley points to evidence linking perceived social isolation with adverse health consequences including depression, poor sleep quality, impaired executive function, accelerated cognitive decline, poor cardiovascular function and impaired immunity at every stage of life. In addition, a 2019 study led by Kassandra Alcaraz, PhD, MPH, a public health researcher with the American Cancer Society, analyzed data from more than 580,000 adults and found that social isolation increases the risk of premature death from every cause for every race ( American Journal of Epidemiology , Vol. 188, No. 1, 2019 ). According to Alcaraz, among black participants, social isolation doubled the risk of early death, while it increased the risk among white participants by 60 to 84 percent.

"Our research really shows that the magnitude of risk presented by social isolation is very similar in magnitude to that of obesity, smoking, lack of access to care and physical inactivity," she says. In the study, investigators weighted several standard measures of social isolation, including marital status, frequency of religious service attendance, club meetings/group activities and number of close friends or relatives. They found that overall, race seemed to be a stronger predictor of social isolation than sex; white men and women were more likely to be in the least isolated category than were black men and women.

The American Cancer Society study is the largest to date on all races and genders, but previous research has provided glimpses into the harmful effects of social isolation and loneliness. A 2016 study led by Newcastle University epidemiologist Nicole Valtorta, PhD, for example, linked loneliness to a 30 percent increase in risk of stroke or the development of coronary heart disease ( Heart , Vol. 102, No. 13 ). Valtorta notes that a lonely individual's higher risk of ill health likely stems from several combined factors: behavioral, biological and psychological.

"Lacking encouragement from family or friends, those who are lonely may slide into unhealthy habits," Valtorta says. "In addition, loneliness has been found to raise levels of stress, impede sleep and, in turn, harm the body. Loneliness can also augment depression or anxiety."

Last year, researchers at the Florida State University College of Medicine also found that loneliness is associated with a 40 percent increase in a person's risk of dementia (The Journals of Gerontology: Series B, online 2018). Led by Angelina Sutin, PhD, the study examined data on more than 12,000 U.S. adults ages 50 years and older. Participants rated their levels of loneliness and social isolation and completed a cognitive battery every two years for up to 10 years.

Among older adults in particular, loneliness is more likely to set in when an individual is dealing with functional limitations and has low family support, Hawkley says. Better self-rated health, more social interaction and less family strain reduce older adults' feelings of loneliness, according to a study, led by Hawkley, examining data from more than 2,200 older adults ( Research on Aging , Vol. 40, No. 4, 2018 ). "Even among those who started out lonely, those who were in better health and socialized with others more often had much better odds of subsequently recovering from their loneliness," she says.

A 2015 study led by Steven Cole, MD, a professor of medicine at the University of California, Los Angeles, provides additional clues as to why loneliness can harm overall health ( PNAS , Vol. 112, No. 49, 2015). He and his colleagues examined gene expressions in leukocytes, white blood cells that play key roles in the immune system's response to infection. They found that the leukocytes of lonely participants—both humans and rhesus macaques—showed an increased expression of genes involved in inflammation and a decreased expression of genes involved in antiviral responses.

Loneliness, it seems, can lead to long-term "fight-or-flight" stress signaling, which negatively affects immune system functioning. Simply put, people who feel lonely have less immunity and more inflammation than people who don't.

Combating loneliness

While the harmful effects of loneliness are well established in the research literature, finding solutions to curb chronic loneliness has proven more challenging, says Holt-Lunstad.

Developing effective interventions is not a simple task because there's no single underlying cause of loneliness, she says. "Different people may be lonely for different reasons, and so a one-size-fits-all kind of intervention is not likely to work because you need something that is going to address the underlying cause." Rokach notes that efforts to minimize loneliness can start at home, with teaching children that aloneness does not mean loneliness. Also, he says, schools can help foster environments in which children look for, identify and intervene when a peer seems lonely or disconnected from others.

In terms of additional ways to address social isolation and feelings of loneliness, research led by Christopher Masi, MD, and a team of researchers at the University of Chicago suggests that interventions that focus inward and address the negative thoughts underlying loneliness in the first place seem to help combat loneliness more than those designed to improve social skills, enhance social support or increase opportunities for social interaction (Personality and Social Psychology Review, Vol. 15, No. 3, 2011). The meta-analysis reviewed 20 randomized trials of interventions to decrease loneliness in children, adolescents and adults and showed that addressing what the researchers termed maladaptive social cognition through cognitive-behavioral therapy (CBT) worked best because it empowered patients to recognize and deal with their negative thoughts about self-worth and how others perceive them, says Hawkley, one of the study's co-authors.

Still, some research has found that engaging older adults in community and social groups can lead to positive mental health effects and reduce feelings of loneliness. Last year, Julene Johnson, PhD, a University of California, San Francisco researcher on aging, examined how joining a choir might combat feelings of loneliness among older adults ( The Journals of Gerontology: Series B , online 2018 ). Half of the study's 12 senior centers were randomly selected for the choir program, which involved weekly 90-minute choir sessions, including informal public performances. The other half of the centers did not participate in choir sessions. After six months, the researchers found no significant differences between the two groups on tests of cognitive function, lower body strength and overall psychosocial health. But they did find significant improvements in two components of the psychosocial evaluation among choir participants: This group reported feeling less lonely and indicated they had more interest in life. Seniors in the non-choir group saw no change in their loneliness, and their interest in life declined slightly.

Researchers at the University of Queensland in Australia have also found that older adults who take part in social groups such as book clubs or church groups have a lower risk of death ( BMJ Open , Vol. 6, No. 2, 2016 ). Led by psychologist Niklas Steffens, PhD, the team tracked the health of 424 people for six years after they had retired and found that social group membership had a compounding effect on quality of life and risk of death. Compared with those still working, every group membership lost after retirement was associated with around a 10 percent drop in quality of life six years later. In addition, if participants belonged to two groups before retirement and kept these up over the following six years, their risk of death was 2 percent, rising to 5 percent if they gave up membership in one group and to 12 percent if they gave up membership in both.

"In this regard, practical interventions need to focus on helping retirees to maintain their sense of purpose and belonging by assisting them to connect to groups and communities that are meaningful to them," the authors say.

To that end, cohousing appears to be growing in popularity among young and old around the world as a way to improve social connections and decrease loneliness, among other benefits. Cohousing communities and mixed-age residences are intentionally built to bring older and younger generations together, either in whole neighborhoods within single-family homes or in larger apartment buildings, where they share dining, laundry and recreational spaces. Neighbors gather for parties, games, movies or other events, and the co­housing piece makes it easy to form clubs, organize child and elder care, and carpool. Hawkley and other psychologists argue that these living situations may also provide an antidote to loneliness, particularly among older adults. Although formal evaluations of their effectiveness in reducing loneliness remain scarce, cohousing communities in the United States now number 165 nationwide, according to the Cohousing Association, with another 140 in the planning stages.

"Older adults have become so marginalized and made to feel as though they are no longer productive members of society, which is lonely-making in and of itself," Hawkley says. "For society to be healthy, we have to find ways to include all segments of the population, and many of these intergenerational housing programs seem to be doing a lot in terms of dispelling myths about old age and helping older individuals feel like they are important and valued members of society again."

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Source: https://www.apa.org/monitor/2019/05/ce-corner-isolation