Isolation and Loneliness

ISOLATION AND LONELINESS An overview of the literature In partnership with

ISOLATION AND LONELINESS An overview of the literature Hardeep Aiden Research, Evaluation and Impact Team British Red Cross January 2016 ISBN 978-0-900228-29-2 2

Contents Background 3 Isolation and loneliness 6 Distinct but related concepts 6 Demographic trends 7 Causes of loneliness 9 Measuring isolation and loneliness 11 Consequences of isolation and loneliness 11 Clustered groups at risk of isolation or loneliness 13 Family-related loneliness 13 Disability and ageing 15 Resource-constrained groups 19 Stigmatised groups 20 Loneliness as occupational hazard 21 Imposed isolation 21 Interventions 23 Characteristics of effective and ineffective interventions 23 Intervention strategies 24 Intervention methods 25 The role of different sectors 28 Conclusion and recommendations 29 References 32 Appendices 39 Appendix 1: data sources 39 Appendix 2: principles of group intervention 41 Front cover photo © Simon Rawles Isolation and loneliness 3

Background The literature on isolation and loneliness has those going through an important, and perhaps grown considerably over the last 40 years to the complex, transition or change in their lives. point where there is a wealth of research on the The majority of the literature reviewed for this causes and impact of isolation and loneliness, report focuses on particular groups or subgroups and the effectiveness of various interventions. of people at risk of isolation or loneliness. In While isolation and loneliness are known to have this review, an attempt has been made to link an impact on health, they can also be viewed as several groups under broader categories, to help important indicators for a whole host of social draw out linkages and to emphasise the need and/or emotional problems that a person may to think beyond demographic strands. These be facing during a particular phase or transition categories could be reconfigured to include more in their lives. or fewer people at risk of loneliness, leading to The purpose of this review is to highlight some less targeted or more targeted interventions. At of the key factors or risks associated with the same time, some groups could be placed isolation and/or loneliness, and to paint a picture in multiple categories. The purpose of the of the groups and subgroups of people who categories is to help kick start a discussion, might meaningfully benefit from interventions rather than to lock people into discrete designed to tackle loneliness or isolation. categories, and to encourage a holistic and non- Despite the growth in the research there are still compartmentalised view of the people affected a number of gaps in the research. Moreover, by loneliness and isolation across the UK. many interventions rely on anecdotal evidence Throughout the review there are several and where data have been collected there are comment boxes containing additional points to often issues around reliability and robustness. consider. Ultimately, the purpose of this review These issues must be taken into account when is to support the decision-making process for making decisions about who might benefit from the project team leading on the partnership a particular intervention and questions about the between the British Red Cross and the Co-op. research that has been conducted to date. However, we hope that by making our findings This review focuses on changes that are, in publicly available, others are able to draw on this many cases, beyond the control of the individual: evidence to inform their own consideration of and ageing, migration, changes in a person’s health, responses to the serious issue of loneliness and changes in a person’s caring responsibilities social isolation in the UK. and deliberate isolation. Almost anyone can experience isolation or loneliness at some point in their lives, but these “risk factors” can be used to help identify and target people potentially susceptible to isolation or loneliness, especially Isolation and loneliness 4

Photo © Simon Rawles Isolation and loneliness 5

Isolation and loneliness Distinct but related concepts Loneliness is the subjective feeling or mood different ways of referring to the emotional associated with actual or perceived isolation. and social aspects of isolation and loneliness. Loneliness occurs when there is something Nicholson suggests that social isolation is “a state missing or lacking in a person’s social in which the individual lacks a sense of belonging relationships or when there is a mismatch socially, lacks engagement with others, has a between a person’s actual social relations and minimal number of social contacts and they are the person’s needs or desires for social contact. deficient in fulfilling and quality relationships” Sometimes loneliness results from a shift in (Nicholson 2009: 1344). an individual’s social needs rather than from a This review maintains the distinction between change in their actual level of social contact. the social and emotional aspects of loneliness, Although it sounds counterintuitive, isolation and because this distinction can help improve our loneliness are not necessarily related. You can understanding of how loneliness develops within feel lonely without being isolated, or isolated individuals (van Baarsen et al. 2001), but it also without feeling lonely, as shown in the diagram important to consider the quality and quantity of below. The idea of feeling lonely even in the midst relationships that people hold. of a large social network can also be described Another important dimension of isolation or as “alienation”. loneliness is that it can be positive as well as Feeling lonely negative. For example, solitude may be an NOT ISOLATED ISOLATED important part of self-growth, allowing time for LONELY LONELY reflection and meditation. The literature reviewed ith othersNOT ISOLATED ISOLATED in this report refers only to isolation and loneliness W NOT LONELY NOT LONELY ithout othersin the negative sense, rather than solitude in the W positive sense. Not feeling lonely Part of the reason for this discrepancy is that The duration of loneliness over time is an isolation and loneliness may be more social important dimension and Young (1982) or emotional in nature. In his seminal work, distinguishes between three types of loneliness: Transient/everyday loneliness includes Weiss (1973) identified two types of loneliness: > loneliness through social isolation and loneliness brief and occasional lonely moods. These through emotional isolation. The former describes experiences have not been of much concern loneliness caused by a lack of social ties, social to researchers or clinicians. integration or sense of community, which might Situational/transitional loneliness involves > be experienced following relocation. The latter people who had satisfying relationships refers to an absence of a personal, intimate until some specific change occurred, such relationship or reliable “attachment figure”, as divorce, bereavement or moving to a such as a partner. While emotional isolation new town. seems to be linked with emotional loneliness, Chronic loneliness occurs when a person has social isolation has stronger associations with > social loneliness. lacked satisfactory social relations for a period of two or more years. On the other hand, Perlman and Peplau (1984: From the standpoint of intervention, greatest 15) describe loneliness as the “unpleasant attention should be directed at preventing experience that occurs when a person’s network situational loneliness from becoming a severe and of social relationships is significantly deficient chronic experience, as the health consequences in either quality or quantity”, although it could of chronic loneliness are more detrimental. be argued that quality and quantity are slightly Isolation and loneliness 6

Demographic trends Research recommendation Several people have suggested that the A discrepancy between reported feelings of prevalence of loneliness could increase in the loneliness in direct and indirect surveys makes coming decades. One of the key factors is the it difficult to assess the levels of isolation and ageing population. Older age is associated with loneliness in the UK. None of the literature disability-related obstacles to social interaction as well as with longer periods of time living reviewed showed reliable, geographical as widows or widowers. Moreover, delayed breakdowns of loneliness or social isolation marriage, increased dual-career families, across the UK. However, it may be possible to increased single-residence households, and get a regional picture of loneliness with analyses reduced fertility rates may also contribute to of existing survey data (see Appendix 1), or by an increased prevalence of loneliness and its identifying areas in the UK with a high prevalence associated health effects (Masi et al. 2010). of some of the risk factors associated with Data from the 2011 census has shown that the isolation and loneliness. proportion of people at retirement age living on their own has dropped from 34% to 31% in the In general, women seem to be more likely to last decade. More than a quarter of a million report feelings of loneliness than men (see people over the age of 65 in England and Wales below), but this does not necessarily mean that are living unmarried with a partner – double the women are lonelier than men. Surveys which number recorded a decade earlier, according assess loneliness indirectly (i.e. without using to the Office for National Statistics. By 2021, the term “lonely”) generally find that men however, it is projected that the proportion of feel lonelier than women (and this difference divorced men over 65 will increase rapidly to is statistically significant). The research also 13%, while the proportion who are widowed will suggests there is a slight U-shape in terms of fall to 13%, mainly because of improvements in age, with younger people (under the age of 25) mortality, and eight per cent will be never married and older people (above the age of 75) most (Davidson et al. 2003: 81-2). likely to experience loneliness. However, findings looking at long-term trends concerning loneliness in Europe showed the opposite trend: levels of loneliness have been decreasing over time, albeit slightly, or they have remained unchanged, depending on the studies that are considered (Veenhoven and Hagerty 2006). Loneliness is not the only outcome showing a change for the better; in so far as they are available, trend data reveal that since the 1950s average happiness has increased slightly in rich nations and considerably in developing nations. However, if the proportion of loneliness remains fairly constant, we can expect an increase in the absolute number of people experiencing loneliness over the next few years as a result of population growth and ageing. Isolation and loneliness 7

However, data from the ONS showed a Another possibility is that loneliness amongst W-shaped pattern, with people of middle age middle-aged people has been underestimated in (45-54) reported to be the loneliest (see Fig. 1 previous research. Looking at the Fig. 2 below, below). Middle aged people (aged 45 to 54) were for example, there is a slight peak in reported the most likely to feel lonely of all age groups loneliness in the pre-retirement years (55-64) (15% in 2011 to 2012) and the least likely to for those who always feel lonely. Mid-life is an socialise, with nearly half (49%) reporting meeting important transition and often a stressful time, socially with family, friends or colleagues less burdened with simultaneous demands from work, than once a week (2012 to 2013) (Siegler et childcare and ageing parents, but also a time al. 2015). This discrepancy may be due to the where people re-evaluate and recalibrate their life, way the questions were asked. Most loneliness and might be more likely to suffer from mental research uses indirect measures, while the ONS health issues (Siegler et al. 2015). asked people directly about how lonely they felt. Younger and older people may feel reluctant to responding to direct questions. Fig. 1: Age, gender and loneliness in the UK (2006) Fig. 2: People reporting social interactions and feelings of loneliness in the UK by age group (Siegler et al. 2015) 35% 90% 30% 80% 70% 25% 60% 20% 50% 15% 40% 10% 30% 5% 20% 0% 10% <25 25-34 35-44 45-54 55-64 65-74 75+ 0% <25 25-34 35-44 45-54 55-64 65-74 75+ All Age in years Age in years Female always lonely Feeling lonely more than half, Female sometimes lonely most or all the time Male always lonely Meeting socially at least once a week Male sometimes lonely Isolation and loneliness 8

Causes of loneliness departure of an older child from the family home. Many factors can contribute to the experience Situations that cut us off from the mainstream of of isolation and especially loneliness. Following society, such as unemployment, poverty, mental Perlman and Peplau (1984) it may be helpful to illness or old age, also put us at a heightened distinguish between the predisposing factors risk of feeling lonely, as do those in which people and situational determinants which make people need an unusual level of support: disability, drug vulnerable to loneliness and precipitating events or alcohol addiction, caring for a relative or being that trigger the onset of loneliness. a lone parent. Research carried out in the US suggests that people from ethnic minority groups Predisposing factors can include characteristics may be more prone to experiencing loneliness, of the person (e.g. low self-esteem, shyness, but there is not enough evidence in the UK lack of assertiveness), characteristics of the context to confirm this. situation (e.g. lack of resources, competitive “Precipitating events create a mismatch between environments), and general cultural values (e.g. the person’s actual social relations and the individualism). Precipitating events are factors person’s social needs or desires; a change in such as the breakup of a relationship or moving one of these two factors without a corresponding to a new community which change a person’s change in the other can produce loneliness. Finally, social life in some significant way. we believe that cognitive processes can influence Circumstances that test our resilience to the experience of loneliness.” (Perlman and Peplau loneliness include major transitions such as 1984: 23) These diverse causal factors are outlined moving home or job, bereavement, divorce schematically in the diagram below. or separation, the arrival of a new baby or the Fig. 3: Model of the causes of loneliness (Perlman and Peplau 1984) PREDISPOSING FACTORS Needed or Characteristics desired social of the person  relations Mismatch of needed Experience Characteristics +PRECIPITATING and actual + Cognitions of loneliness of the situation EVENT social and attributions  relations Cultural values  Actual social and norms relations It is important to note that the causes of isolation and loneliness are not necessarily the same, adding more weight to the argument to treat them as separate concepts. For example, one study found that some variables were better at predicting social isolation than loneliness, while some predicted both. Isolation and loneliness 9

Photo © Simon Rawles Table 1: Predictors of social isolation, loneliness or both (Grenade and Boldy 2007) Both Social isolation Loneliness Household composition “Lower” social class Self-assessed health Morale / self-esteem Number of years widowed Desire for new friends Support network type Excluding age and gender, evidence regarding Kalyan Masih 1990). Similarly, the extent to which the impact of other socio-demographic factors people from ethnic minority backgrounds feel on loneliness tends to vary. Steed et al. (2010) isolated or lonely will depend on several factors suggest that this variability may be related other than their ethnicity, including the extent to the type of data (i.e. cross-sectional data to which they are assimilated and their sense of versus longitudinal) or the measures used (e.g. “belonging” (Sharma 2012). Hence, we need to direct questions versus a scale where the word be wary about blanket statements which ignore “loneliness” is not used), and confounding with individuals’ histories and experiences. other variables. Another group of risk factors relate to health, Evidence for an association between level of both physical (e.g. poor self-assessed physical education, geographical location (e.g. rural health status, chronic illness) and mental health versus urban), material circumstances (e.g. (e.g. reported depression). Although deteriorating limited income), ethnicity and loneliness/isolation physical health (or perceived poor health) is one is inconclusive. For example, there is some of the most consistently identified factors, the evidence to suggest that adolescents in rural direction of causation is still not well understood areas are more likely to experience loneliness (Grenade and Boldy 2008: 471). That is to say, it than their peers in urban areas, but this may is unclear whether poor physical health leads to be due to their socio-economic circumstances feelings of loneliness or vice versa. rather than where they live (Woodward and Isolation and loneliness 10

Measuring isolation and loneliness factor for broad-based morbidity and mortality The de Jong-Gierveld loneliness scale and the (Holt-Lunstad et al. 2010). What was especially UCLA loneliness scale (see Appendix 1) are surprising was that social isolation was found widely used to measure loneliness and neither to be as strong a risk factor for morbidity and have any explicit references to loneliness. Unlike mortality as smoking, obesity, sedentary lifestyle, loneliness, for which a number of measures have and high blood pressure (House et al. 1988). In been developed and are widely used, “there are a more recent research project carried out in the no universally accepted measures or established UK, it was found that mortality was higher among criteria for measuring social isolation or its more socially-isolated and lonely participants, but severity” (Grenade and Boldy 2007). The English social isolation was more significantly associated Longitudinal Study of Aging (ELSA) uses a simple with mortality than loneliness, after adjusting for index to measure social isolation, but it is not demographic factors and baseline health (Steptoe clear how robust it is (see Appendix 1). et al. 2013). Surveys have been, and can be, used to The impact of loneliness on cognition has also measure loneliness. However, some research been assessed. Perhaps the most striking finding suggests that levels of reported loneliness will in this literature is the breadth of emotional differ depending on how the data is collected, and cognitive processes and outcomes that e.g. surveys versus in-depth interviews (e.g. seem susceptible to the influence of loneliness. Victor et al. 2003) or aggregate measures versus Loneliness has been associated with personality self-rating scales, i.e. people are less likely to disorders and psychoses, suicide, impaired say they are lonely unless they are experiencing cognitive performance and cognitive decline severe loneliness. This is less of an issue if the over time (Shankar et al. 2013), increased same instrument and method is consistently used risk of dementia (Holwerda et al. 2014), and throughout a research project, but it makes it increases in depressive symptoms (Hawkley and difficult to compare results across projects. Cacioppo 2010: 219). In fact, Holwerda and colleagues (2014) found that people experiencing Consequences of isolation a high degree of loneliness were potentially and loneliness twice as likely to develop Alzheimer’s as those Research has consistently demonstrated the experiencing a lower degree of loneliness. health-damaging effects of social isolation and As Hawkley and Cacioppo point out, “these loneliness, and the health-promoting effects of data suggest that a perceived sense of social social support. connectedness serves as a scaffold for the self A growing body of longitudinal research indicates – damage the scaffold and the rest of the self that loneliness predicts increased morbidity and begins to crumble” (2010: 219). mortality (Hawkley and Cacioppo 2010: 219). Loneliness may also impact on the body’s The effects of loneliness seem to accrue over capacity to restore itself. According to some time to accelerate physiological ageing. For research, the same amount of sleep has instance, the greater the number of measurement fewer health benefits in individuals who feel occasions at which participants were lonely, the more socially isolated and poor sleep further higher the cardiovascular health risk in young exacerbates feelings of social isolation. This adulthood. Similarly, loneliness was associated recursive loop operates outside of consciousness with increased blood pressure and other and speaks to the difficulty of trying to manage symptoms in a population-based sample of loneliness (Hawkley and Cacioppo 2010: 219). middle-aged adults. Loneliness also has a strong relationship with low Social isolation also has damaging effects. Social personal well-being ratings. People who report isolation has been found to be a significant risk feeling lonely are almost 10 times more likely to Isolation and loneliness 11

report low feelings of worth (10.5% compared There is no generalizable evidence on the with 1.1%), over 7 times more likely to report low financial costs of loneliness or isolation, but life satisfaction (15.2% compared to 1.9%) and a number of research projects seem to be over 3 times more likely to report feeling unhappy underway to evaluate these costs. Fulton and (18.8% compared to 5.6%) than those who have Jupp (2015) attempted to quantify the financial low ratings of loneliness. They are also twice as impact of loneliness in terms of increased service likely to report feeling anxious (34.8% compared usage by older people, and estimated that this to 15.1%) (Thomas 2015). could cost up to £12,000 per person over the According to Nicholson (2009), researchers have next 15 years. However, the model is based reported a number of specific negative effects on several assumptions about the impact of linked to low social networks, such as heavy loneliness on service usage and until there is drinking, falls, depression/depressive symptoms reliable data about people’s pathways through and poor outcomes after stroke, increased rates health and social care services, it will be difficult of re-hospitalization, loneliness and alteration in to estimate these costs with any certainty. the family process. Other consequences reported were nutritional Evaluating the benefits of the risk (Locher et al. 2005), Researchers from the Second Half Centre Centre for Diet and Activity Research (CEDAR) Based on a Preventative Care Model, the first looked at data from nearly 15,000 adults aged Second Half Centre opened in Kensington, over 50 (Conklin et al. 2014). They found that: Being single or widowed decreased the London in 2012. It has an average of over > 250 people each week coming through its daily variety of fruit and vegetables eaten (compared to those who were married or doors to participate on activities on offer. This living with a partner) report looks at the potential for Second Half Single, separated and widowed men ate Foundation ‘local hubs’ model to reduce social > isolation amongst older people and deliver fewer different vegetables than women in similar circumstances savings to local and national health services. Both living alone and having less frequent The report concluded that services based on > contact with friends increased the effect the model of the Second Half Centre produce of widowhood by reducing the variety of returns of over 135% a year to the NHS and vegetables an individual ate local Clinical Commissioning Groups People who lived alone and had infrequent (Shaw Ruddock 2014). > contact with friends ate fewer vegetables each day. Nutrition plays a key role in healthy ageing. In the UK, it is estimated that around 70,000 avoidable deaths are caused by diets that do not match current guidelines. This research therefore has implications for policy and practice. For example, interventions that increase various types of social relationships could support adults to eat a healthy diet – these could include social activities or targeting health-eating interventions at people who also at risk of loneliness or isolation (e.g. recently bereaved people). Isolation and loneliness 12

Clustered groups at risk of isolation or loneliness In this section people at risk of loneliness or Bereavement isolation have been grouped under six clusters: Widows and widowers do not just suffer from Family-related loneliness emotional loneliness because they have lost an > Disability and ageing intimate relationship. Research has found that > having a partner is also important for keeping Resource-constrained groups > someone connected to a wider circle of friends Stigmatised groups and acquaintances (Dahlberg and McKee 2014). > Occupational loneliness This means services should aim to address both > the loneliness caused by losing a loved one and Deliberately isolated groups. support them to maintain social networks. > These clusters were identified specifically for this In general, though, research investigating stressful review and are not necessarily reflected in the life events such as widowhood emphasises that literature in these terms (with the exception of bereaved people are especially vulnerable to groups experiencing family-related loneliness). emotional isolation rather than social isolation However, the value of clustering groups is that (Weiss, 1973). Stroebe et al. (1996) found that it may help to draw out common themes and marital status affected emotional loneliness linkages amongst different groups at risk of but not social loneliness, while van Baarsen isolation or loneliness. et al. (1999) showed that six months after Certain demographic characteristics cut across bereavement, older widows and widowers felt groups and clusters, and some people are likely emotionally lonelier than before the loss, whereas to fit under more than one cluster. For example, social loneliness had not increased. older people are more likely to have physical or This ties in with the definition of emotional sensory impairments and may have spent several loneliness – as the absence or loss of an years acting as a carer for their partner. People attachment figure – and further underlines the such as these are likely to be at high risk of need to maintain a distinction between these experiencing isolation or loneliness, but may forms of loneliness. Moreover, it points to the need specialised support due to the complexity need for introducing interventions that align with of their situation. isolated/lonely individuals’ experiences. Family-related loneliness Divorce and living without a partner Hombrados-Mendieta et al. (2013) recommend There are several “pathways” leading to living that social intervention programmes should be alone in mid-life (see appendix 2). The research developed that promote positive relationships within showed that divorce (or the end of a cohabiting the family, since the perception of being supported relationship) is the main reason for middle-aged by a partner and family is significantly associated men and women to live alone. Children leaving with decreased loneliness and increased well-being. home and death of a partner were other triggers. Family-related loneliness includes people However, the researchers found a significant experiencing bereavement or divorce, and older proportion of men in mid-life who had never lived people who live alone and/or are widowed, with a partner. Adults living alone in mid-life had separated or divorced are more likely to report that lower incomes than those living with a partner. they feel lonely often or some of the time (Beaumont Further analysis showed two distinct groups 2015). Young people suddenly experiencing that were more likely to lack family and financial independence from their parents or guardians are support: men living alone who do not have also at risk of experiencing loneliness, and this is (or never had) a partner or children, and older especially true of young care leavers who may not mothers who had broken up with their partner. have regular contact (or any contact) with their birth This does not necessarily translate into isolation family or their foster family. or loneliness but the findings indicate that more Isolation and loneliness 13

than one fifth of men living alone in late mid-life parents’ homes) leave home earlier and have will not be able to rely on children for informal less support than their peers. Many go on to face support and might not have sufficient financial outcomes that are much worse than those of the resources to purchase home-based health-care, general population, including those relating to as suggested by their housing tenure status educational achievement, teenage pregnancies, which is strongly related to wealth. Furthermore, homelessness, offending and mental health previous research has shown that those who are (Knight et al. 2006; Gentleman 2009). not home owners face a higher risk of admission The evidence suggests that poor outcomes for to a care home (McCann et al. 2012). Men in care leavers are linked to weak support networks, these situations may be at an increased risk few friends and feelings of isolation and loneliness of becoming isolated or developing situational (Stein 2004). The loneliness, isolation and lack of loneliness, but more research would be needed support felt by care leavers was one of the most to confirm this. frequently recurring themes in a consultation This research is important because middle-aged undertaken by the Centre for Social Justice men and women living alone will have different (CSJ). Three-quarters (77%) of the care leavers social and financial needs as they grow older, surveyed said that feeling lonely or isolated was and we may need to predict these changes. difficult when leaving care and 43% said it was Services may want to consider providing social very difficult; while 11% of care leavers report support to the most “at risk” e.g. middle-age men there were one or no people they would be able living alone who have not had children, have no to tell if they were harmed (Devereux 2014). educational qualifications, are unemployed and Building strong supportive relationships whilst who live in rented housing – as they are more they are in care and ensuring they are maintained likely to need a social and economic ‘safety net’ upon leaving is key if care leavers are going in old age (Demey et al. 2013). to gain resilience and avoid poor outcomes. Anecdotal evidence submitted to the Scottish Protective factors include having someone to turn Parliament’s Equal Opportunities Committee to for support and developing and maintaining inquiry into ageing and social isolation suggested positive links with family or former carers and that LGBT older adults are “more likely to these should be encouraged and worked live alone, to be estranged from their families towards (Stein 2004; NCAS 2009). At the same of origin, not to have had children and not time re-establishing or increasing contact with necessarily to have had a relationship” (Scottish birth families can lead to disappointment or have Parliament 2015). As with ethnicity, while there a negative impact on the young person’s well- is no definitive evidence that LGBT people as being (Munro et al. 2011: 58). a whole are more likely to be lonely or isolated Yet there are key points when opportunities than non-LGBT people, it is worth considering are lost to sustain relationships such as how sexual identity, ethnicity and so on might separation from siblings, frequent movement and interact with other factors to affect the likelihood placements far away from home. Care teams aim of isolation or loneliness. to fully support young people leaving care, but Young care leavers research by the CSJ also found they were often Young people leaving home for the first time too busy to build relationships with young people: are likely to experience feelings of isolation or the average caseload of a personal adviser is 23 loneliness. While this is often temporary, it can young people, going as high as 49 in some local become an issue of concern for some young authorities. 1 people. However, young people leaving the care Despite the fact that the role of family and social system (either care homes or foster relationships and emotional and behavioural 1. http://www.theguardian.com/education/2012/sep/19/lonely-in- support are both in the pathway plan set out as freshers-week Clustered groups at risk of isolation or loneliness 14

a requirement in the Leaving Care Act (2000), shared activities. Overall, both partners need to there remains a gap in the offering of emotional adjust to significant role changes. As a result, one’s support, with studies highlighting that 71% of own and one’s partner’s health condition or disability leaving care professionals and personal advisers can impact on both partners’ well-being. feel that there is insufficient attention paid to To consider both partners’ health is especially emotional support for young care leavers (CSJ relevant for older adults. Older couples are 2008: 165). particularly at risk of disability of both partners for two reasons. First, both partners of the older Advocacy opportunity couple have an increased risk of disabling health The Centre for Social Justice has done problems because of the increased longevity considerable work in this area, with reasonable for both men and women. Second, caring for a disabled spouse is a risk factor for one’s own success in getting the Government to shift its health as mentioned above. If a non-disabled policies towards young care leavers. If young care partner assumes more care responsibilities, he leavers are targeted in work to address loneliness or she is particularly at risk of developing health and social isolation, it may be worth considering problems (Korporaal et al. 2008). whether there is potential to align advocacy The majority of people receiving social care also have objectives with those of the CSJ and whether one or more impairments or long-term conditions there are opportunities for complementary or and are over the age of 65. Around half of the 65 joint advocacy. and over population in England have a longstanding health condition or disability, with most people in this Disability and ageing limited group living at home (93.5%) (Lloyd and Ross 2014). Age notwithstanding, people receiving care This cluster explores embodied changes and how in residential or community-based settings are both they affect people’s relationships and ability to at risk of experiencing social isolation or loneliness. live independently. This includes people whose An unintended consequence of at-home care for impairment or long-term condition has made them some older people may be an increased risk for social more at risk of experiencing isolation or loneliness, isolation. It is therefore important for care providers including older people who are more likely to to take preventative steps, as far as possible, to stop become disabled. these issues from becoming chronic. However, this Physical and sensory impairments also requires awareness on the part of care providers and caregivers of the impact that loneliness and Long-term health conditions and impairments isolation can have on people’s well-being. can have a negative impact on various aspects While disability disproportionately affects older people, of individual well-being. Impairments involve people may acquire a physical or sensory impairment a reduction or loss of function and difficulty in or condition at any age. One study found that for performing activities of normal daily living, such as people with visual impairments, merely having a walking or reading. visual impairment is associated with more feelings of Because disabling health problems are often loneliness, whereas the severity and the duration of the associated with the loss of independence and visual impairment played no additional or significant autonomy, they affect not only the lives of the role (Alma et al. 2011: 14). disabled but also the lives of those who are close to Ageing and later life them. For married older adults with a disability, the partner may be affected the most (Johnson 1983). Unsurprisingly, the literature looking at loneliness Depending on the severity of the disability of the and isolation affecting older people is the most disabled partner, the non-disabled partner might extensive, and the same goes for evaluations of have to assume more responsibilities for previously interventions targeting this age group. Isolation and loneliness 15

The losses associated with becoming old involve Beach and Bamford (2014) found that: not only loss of physical and cognitive capacity Isolated and lonely men were much more and functional ability, but also the loss of friends > and family members (van Baarsen, 2002). Any or likely to be in poor health. Over a quarter all of these losses may contribute to experiences (28%) of the loneliest men said their health of loneliness among the very old (Graneheim and was poor, in contrast to just 1 in 20 (5%) men Lundman 2010). who were not lonely A partner’s poor health also affected men’s According to figures from the ONS (Siegler et al. > 2015), 1 in 8 (13%) people aged 75 and over who isolation and loneliness. Nearly 15% of men reported feeling lonely more than half, most or aged 85 and over were carers and were all the time in 2011 to 2012, the second highest more likely to be lonely than those without proportion of all age groups (see figure 2 above). caring roles Mental health, particularly depression, was Personal circumstances, such as poor health, > living alone, caring for someone else, going also important. Over 1 in 4 (26%) of the most through a relationship break-up or loss, or isolated men were depressed, in contrast to moving to a new area away from existing social just 6% of the least isolated networks can all be factors contributing to Around a third of the most isolated men (36%) > feelings of loneliness. were in the lowest income group compared to Just 1 in 4 people aged 75 and over reported just 7% of the least isolated. meeting with friends, relatives or work colleagues Moreover, work by Scharf et al. (2005) in the less than once week in 2012 to 2013 (see Fig. UK revealed considerably higher estimates of 2 on page 9). It is known that older people, severe loneliness among older people living in especially those aged 75 and over, are vulnerable low income urban neighbourhoods (15%) than to social isolation which can impact on their those found in Victor et al’s (2003) research physical and mental health. People can become (7%), which focused on older people living in the socially isolated for various reasons, including general population. Similarly, research suggests long-term health conditions and illnesses (Lloyd that prevalence rates among specific sub-groups, and Ross 2014), or owing to the deaths of such as older people living alone, and those who partners or friends. Similarly, there was a strong are chronically physically or mentally ill, may also association between age and the presence of be higher than within the general older population at least one close friend. Around 11% of people (Grenade and Boldy 2008). aged 75 and over reported having no close In addition, older adults with lower levels of friend at all in 2011 to 2012 (Siegler et al. 2015), contact with friends and family in receipt of the highest proportion of all age groups. This social care, or those who feel they are not compared to 2% of those aged 18 to 34. Another integrated into their community, are more likely 10% of people aged 75 and over reported having to experience social loneliness. Older adults one close friend only. More men than women are more likely to feel emotionally lonely if they reported having no close friend across all ages, have to rely on informal care and have a physical with the difference between sexes being more disability or simply problems with normal activities marked at older age: around 14% of men aged of daily living. 75 and over reported having no close friend compared to 9% of women aged 75 and over. In general, the research reinforces the need to Of course, older people are not a homogenous minimise the risks of loneliness and social isolation group, with older people of different genders or to maximise health outcomes. Social isolation with different socioeconomic backgrounds more is modifiable, and so there is an opportunity for or less likely to be “at risk”. In their research on creative programs and interventions to foster isolation and loneliness as they affect older men, social connections for older adults. For example, Clustered groups at risk of isolation or loneliness 16

volunteer friendly-visiting programs, psychosocial “Gap in the market” group rehabilitation, or the use of technology for social networking are approaches that could be Most of the research, and interventions, on harnessed to reduce isolation. These types of social isolation and loneliness focuses on interventions have been effective in connecting older people. Much less research has been isolated adults to new network members, inducing carried out with younger and middle-aged feelings of “being needed”, and increasing well- being (Routasalo et al. 2009). people and there have been fewer evaluated An important target for the government is to interventions carried out with people from help improve the quality of the ageing experience these age groups. Organisations such as in the UK and make sure the impact of the Age UK and the Royal Voluntary Service ageing population is a positive one for citizens of provide a range of support for older people, 2 all ages. The UK therefore needs to consider as does the Campaign to End Loneliness. how to minimise some of the impact arising This gap presents opportunities for from risk factors of loneliness, particularly targeted, and much needed, support. bereavement, poor health, and housing tenure. This support could be from public, private or community services, or provided by family, friends and neighbours. The evidence suggests that we are conscious of our roles in supporting older people in our communities; almost half of us (46%) believe we need to keep in touch with elderly family members who may be lonely and 4 in 10 of us feel the need to keep in touch with elderly neighbours 3 who may be lonely. However there is still room for improvement in awareness of the scale of loneliness and its impact, not just in relation to older people but also as it affects younger and middle-aged people. It should be noted that the general public’s perception of loneliness among older people is much higher than the actual reported rate of loneliness. Even allowing for under-reporting, Dykstra (2009) suggests that the mismatch between people’s perceptions and older people’s experiences may well be an example of “ageist stereotyping”. Photo © Simon Rawles 2. https://www.gov.uk/government/collections/future-of-ageing 3. http://cdn.yougov.com/cumulus_uploads/document/zk1wvpxxt3/ Independent%20Age%20Results%20101217%20Barriers%20 to%20the%20Big%20Society.pdf Isolation and loneliness 17

Photo © Simon Rawles Clustered groups at risk of isolation or loneliness 18

Resource-constrained groups Life skills Poverty and deprivation Given that a lack of resources can contribute to Generally speaking, the research around poverty or exacerbate isolation and loneliness, it might and social exclusion is well-developed, but there be worth considering how community members seems to be little research that incorporates could use their knowledge and experience isolation or loneliness into poverty studies. to support people experiencing isolation or Similarly, there is a lack of research that explores loneliness. For example while experiencing the connections between unemployment and loneliness many people say that they struggle isolation or loneliness. A recent survey by the Prince’s Trust found that 43% of unemployed with basic life skills such as budgeting and paying young people often or sometimes feel isolated, bills. Supporting people with practical skills might but it is not clear whether this is due to being put them in a better position to tackle the other 5 unemployed or other factors. problems that they are facing. A report by New Economics Foundation (2013) concluded that poverty in inner-city areas such as 6 Islington is contributing to, and made worse by, Transport and mobility social isolation. They found that people on lower Although it might be assumed that frequent incomes often have very small and weak social home-moving increases loneliness, empirical networks, rarely go out and have few friends evidence fails to support this view (Perlman and (who in turn were also affected by poverty and Peplau 1984: 25). While the immediate impact of isolation). Rising housing rents are also pushing moving may be to create loneliness, these effects lower and middle-income residents out of areas are typically short-lived. For example, Rubenstein like Islington, separating families and making it and Shaver (1982) found no relationship harder for neighbours to mix. Feelings of isolation between current loneliness and how frequently were made significantly worse by poor mental an individual had moved during his or her life health (nef 2013). time. Constraints on mobility, on the other hand, While some studies have found that urban density are linked to isolation and loneliness, and may levels may contribute to feelings of isolation or be more of an issue in underserved rural areas loneliness (e.g., Delmelle et al., 2013), other (Scottish Parliament 2015). studies have not found evidence to support his While the impact of mobility characteristics claim (van den Berg et al. 2015). However, people on loneliness are often overlooked, the use who are more satisfied with their neighbourhood of different transport modes (bicycle, car and and the facilities in the neighbourhood tend to public transport) significantly reduces loneliness feel less lonely. The availability of local facilities and may even explain age-related effects (van and amenities (shops, post offices, libraries, den Berg et al. 2015). Transportation modes pharmacies, cafes, pubs and parks), transport, provide access to social relations outside the perceptions of safety and freedom from crime neighbourhood and may be essential to maintain can all affect an individual’s ability and readiness one’s social network. In addition, public transport to get out and about and maintain their social provides a space where people are in close connections (van den Berg et al. 2015). proximity and where social interactions can take place. Being able to use the public transport network isn’t just about getting around. It is also about 5. https://www.princes-trust.org.uk/support-our-work/news-views/ feeling part of the community and having a anxiety-is-gripping-young-lives chance to interact with other people, especially 6. While mobility has a range of meanings, here it refers to how on the bus network (Green et al. 2014). The people travel in the course of their everyday lives (Green et al. 2014). Isolation and loneliness 19

freedom to just take a bus to get out and based on robust evidence. This may be because about was widely reported as a major and non- most of the data focuses on other aspects of the stigmatising defence against isolation, particularly migration process (such as integration) and wider for older people who live alone (Green et al. physical and mental health issues, with loneliness 2014: 481). being mentioned in passing rather than explored For groups of friends and peers, bus journeys in detail. may be the core of an organised outing, ranging Many young refugees and asylum seekers from regular shared trips to local shopping report depression, loneliness and isolation amenities, to more ambitious projects such as and experience difficulties making friends as visits to places of interest, or (for one group) opportunities for creating social networks are educational outings linked to museums, or limited by language, cultural differences, racism, lectures (Green et al. 2014: 482). Of course, and exclusion from education and employment older people also recognise the negative aspects opportunities. Unaccompanied minors frequently of using public transport, including adverse experience social and economic exclusion which interactions with rude, loud or aggressive people, are known risk factors for problematic drug use but generally the freedom that older people have (Kapasi 2009). Some researchers have noted that in being able to use public transport is, for many although (limited) opportunities for assimilation older people, an important “lifeline”. may protect some from adopting local drug-using It’s not just older people who benefit from free patterns, they may be highly vulnerable to future bus travel. Some research suggests that free problematic drug use. bus travel may also provide a route to social Many immigrants also have experience of moving participation for younger people (Jones et al. internally within the UK – especially if they feel 2000). While older people and younger people in isolated from co-ethnics or their community or London value their ability to use public transport, experience discrimination in their present location many disabled people are forced to use special (Kapasi 2009: 20). Others will actively avoid people transport or taxi cabs. This puts a limit on from similar ethnic or linguistic backgrounds, some people’s freedom to travel, but also their despite facing language and cultural barriers, opportunities for everyday interactions that many because they may have different values or beliefs, of us take for granted. or due to the circumstances under which they left Stigmatised groups their home country (Griffin 2010). Stigmatised groups are at risk of social (and Housing providers can play a crucial role in emotional) isolation and a key part of supporting preventing isolation. Housing Officers, concierges, such groups will involve tackling the stigma and other case workers provide a unique means too. However, it is also worth considering that of communication and link between individual identifying or labelling particular groups as being refugees and community groups and services. at risk of loneliness could also contribute to this Records enabling the identification of new stigma. It could even lead to stereotyping where refugees would facilitate outreach to those who previously none existed. Being mindful of this risk, have become withdrawn and reluctant to engage and thinking of ways to mitigate it, is an important (Strang and Quinn 2010). consideration for any intervention. People with developmental disabilities or Refugees and asylum seekers mental health conditions Despite several researchers identifying refugees Many people with mental health conditions or and asylum seekers as people potentially learning disabilities experience stigma (Scottish vulnerable to social isolation and loneliness as Parliament 2015), but their conditions may also a result of the migration process, much of the influence the way in which they engage and research seems to be speculative rather than interact with the people around them. Clustered groups at risk of isolation or loneliness 20

Individuals with autism spectrum disorder Informal carers (ASD), for instance, suffer direct and indirect While the social care system supports over a consequences related to social interaction million people, the majority of care and support deficits. Youth with ASD often report a desire is provided informally by family and close friends. for more peer social interaction, and may also These “informal carers” are also at risk of becoming express poor social support and more loneliness isolated or lonely in their roles as carers. It is than their peers (Bauminger & Kasari 2000). important to remember that this role is a form of When integrated with peers in mainstream unpaid work with an estimated value of over £60bn classrooms, children and adolescents with ASD 7 may be at increased risk of peer rejection and to the economy. Without adequate support, young social isolation (Chamberlain et al. 2007). There is carers are also at risk of developing feelings of also evidence that social skill deficits in youth with loneliness and other health issues. ASD contribute to academic and occupational Many informal carers have care duties that take under-achievement (Howlin and Goode 1998), 20 or more hours per week. Charities such as and may point to mood and anxiety problems Carers UK have been pushing the government to later in life (Myles et al. 2001). provide more respite care for informal carers, and, Supporting people with enduring mental illness where appropriate, training to handle difficult to socialise, either by being matched with a health conditions. volunteer or by being given the financial means Imposed isolation (a small stipend) to engage in social activities, Some people have isolation imposed on them as a leads to improved social functioning, reduced form of punishment (especially those people who levels of social isolation and loneliness (Sheridan have been incarcerated) and others experience et al. 2015). isolation as a form of bullying. In both cases Loneliness as occupational hazard isolation is deliberately imposed on individuals to harm them in some way. Loneliness in the workplace Relational bullying is a form of bullying that In her review of three separate studies involves damaging an individual’s social relations, assessing loneliness in managers and non- for example by ignoring them or by spreading managers, Wright (2012) concluded that rumours about them. This leaves the targeted loneliness did not differ by managerial status. person at a greater risk of becoming socially or In other words, managers were found to be emotionally isolated and of feeling lonely. Disabled no more or less lonely than their non-manager young people, young people who identify as LGBT counterparts. This suggests that factors beyond and young people from minority ethnic / religious seniority may be contributing to loneliness in backgrounds are more likely to experience bullying organisational settings. In earlier work, Wright (EHRC 2010), but it is not clear whether this (2005) found that a negative emotional climate increases the risk of isolation or loneliness. and lack of collegial support adversely influences While relational bullying may directly increase the the experience of loneliness in workers. The risk of isolation, other forms of bullying (physical, results suggest that addressing interpersonal cyber) may also increase the risk of isolation or problems in the workplace and improving loneliness in later life. Research undertaken with the psychological work environment within young adults and their parents in the US showed an organisation may enhance the social and that parental loneliness and a history of being bullied emotional well-being of employees. There is also each had direct effects on young adults’ loneliness a question about the wider role that employers as well as indirect effects through reduced social could take in helping to tackle social isolation. skills (Segrin et al. 2012). A family environment that supports open communication can act as a buffer 7. http://www.ons.gov.uk/ons/dcp171766_315820.pdf against young adults’ loneliness. Isolation and loneliness 21

Photo © iStock Interventions 22

Interventions As the literature on loneliness and isolation has Characteristics of effective and grown, researchers have been able to identify ineffective interventions. characteristics of effective (as well as ineffective) interventions. However, these characteristics Despite the limited evaluation evidence available, have been drawn from a finite pool of academic it has been suggested that the most effective evaluations of interventions. Most interventions interventions share a number of common have never been held up to scrutiny, perhaps characteristics. These include: involving a due to a lack of resources or capacity, a lack combination of strategies; involving [older] people of understanding about the benefits of rigorous and/or their representative groups in intervention evaluations, or even reluctance to undertake planning and implementation; having well trained, research that could be critical of the intervention appropriately supported and resourced facilitators in question. Whatever the reasons, it remains the and coordinators; utilising existing community case that there are many effective and ineffective resources; and targeting specific groups interventions currently underway about which we (Grenade and Boldy 2008). know very little. In their review of the literature, Cattan and others This section makes a clear distinction between (2005: 57) found that effective interventions approaches and methods, which is often unclear shared several characteristics. In general, ones in much of the literature. Four primary strategies for which were effective: reducing loneliness or isolation are presented here: Included group-based interventions with > improving social skills, enhancing social support, a focused educational input, or ones that increasing opportunities for social interaction, and provided targeted support activities addressing negative thoughts about self-worth. Targeted specific groups, such as women, > Common types of intervention include self- care-givers, the widowed, the physically management, peer support, community-based inactive, or people with serious mental interventions, technology-based interventions and health conditions animal-assisted interventions, and so on. There is Enabled some level of participant and/ no “right” approach or intervention, but the literature > stresses the importance of matching individuals or facilitator control or consulted with the with appropriate approaches and interventions. This intended target group before the intervention Evaluated an existing service or activity often boils down to asking people about their needs > and involving them in choosing an appropriate (demonstration study) or were developed and intervention, which seems to be more effective than conducted within an existing service one-sided approaches such as self-selection. Identified participants from agency lists > Framework for loneliness (GPs, social services, service waiting lists), interventions obituaries, or through mass-media solicitation (while self-selection was a problem noted in The Campaign to End Loneliness has produced many studies) a comprehensive framework to tackle loneliness Included some form of process evaluation > (http://campaigntoendloneliness.org/guidance/ and their quality was judged to be high. theoretical-framework/. Their framework The same authors found that the only distinguishes between direct interventions or major characteristic among the “ineffective” “foundation services” (such as lunch clubs or book interventions was that they were one-to-one groups) and “structural enablers” – the mechanisms interventions conducted in people’s own homes. by which these groups come into being (including Four evaluated home-visiting schemes, while the neighbourhood approaches, asset-based fifth considered the effectiveness of social support community development and volunteering). using the telephone. Inconclusive studies covered diverse interventions and were characterised by Isolation and loneliness 23

poor reporting, weak study design, high attrition social interactions by delivering training in related rates, and small or unrepresentative samples skills, such as play behaviour and language, (Cattan et al. 2005: 57-8). rather than training specific social behaviours. This should not be seen as conclusive evidence Peer mediated interventions involve training that one-to-one or at-home interventions non-disabled peers to direct and respond to the do not work. It may be the case that these social behaviours of children with ASD. Finally, interventions were ineffective in particular comprehensive interventions involve social skills studies, but equally the study design or choice interventions that combine two or more of the of outcome measurements may have been aforementioned intervention categories (Bellini problematic (Dickens et al. 2011). Either way, it et al. 2007). does emphasise the need to fully engage with, Gresham and others noted that the weak and consider the needs of, the individuals being outcomes of social skills interventions may be supported while designing and implementing attributed to location: they often take place in any interventions. “contrived, restricted, and decontextualised” Intervention strategies (2001: 340) settings. In contrast, interventions that are implemented in a normal classroom Improving social skills setting are more effective across a range of Social skills can take a range of forms, including measures (Bellini et al. 2007). This finding has conversational skills, speaking on the telephone, clear implications for school-based social skills giving and receiving compliments, handling interventions, but it also suggests that social skills periods of silence, non-verbal communication interventions in general may be more effective methods, and approaches to physical intimacy in natural, rather than artificial, settings. The (Masi et al. 2008). researchers also recommended that social skills Social skills training (SST) is one type of child- interventions be implemented more intensely and specific intervention, which involves teaching frequently than the level presently delivered to specific skills (e.g. maintaining eye contact, children with social skills deficits. initiating conversation) through behavioural and Underdeveloped social skills can impede one’s social learning techniques (Cooper et al. 1999). ability to establish meaningful social relationships, SST is an appealing intervention approach for which often leads to withdrawal and a life of use with children with ASD because it provides social isolation, yet few children receive adequate the opportunity to practise newly learned skills social skills training (Hume, Bellini and Pratt in a relatively natural format that may promote 2005). Social skills are an important factor in interaction with other children (Barry et al. 2003). ensuring successful social, emotional, and Other promising strategies were developed cognitive development. As such, effective social based on knowledge of the literature, including skills training from a young age can help reduce characteristic learning styles and specific deficits the risk of isolation and loneliness in later life. associated with ASD, as well as knowledge of Enhancing social support the individual participants in the groups (Williams To some extent, loneliness and social support can White et al. 2007). be seen as opposite concepts. Loneliness refers According to McConnell (2002), environmental to the experience of deficits in social relations, modifications involve modifications to the physical while social support refers to the availability of and social environment that promote social interpersonal resources (Perlman and Peplau interactions between children with ASD and 1984: 18). Research on social support has their peers. Child-specific interventions involve investigated both subjective (perceived) support the direct instruction of social behaviours, such and objective social support (House 1981). as initiating and responding. Collateral skills Researchers also distinguish between tangible interventions involve strategies that promote Interventions 24

or instrumental support, which consists of things Interventions that address “maladaptive social such as actual physical assistance, financial cognition” have been found to have a larger assistance, information, or other help useful for mean effect size compared to interventions solving a problem or answering questions; and that addressed social support, social skills, emotional support, on the other hand, which and opportunities for social intervention (Masi refers more to a feeling of group belonging or the et al. 2010). According to Masi et al. this result feeling that one is cared for by some significant is consistent with the model of loneliness as other or others. Second, researchers distinguish “regulatory loop” (Cacioppo and Hawkley 2009), among different sources of support, including in which lonely individuals have increased significant others such as partners or spouses, sensitivity to and surveillance for social threats, family members, friends, co-workers, neighbours, preferentially attend to negative social information, and even pets (Tomaka et al. 2006). tend to remember more of the negative aspects In general, the data confirms that social support of social events, hold more negative social decreases loneliness. Differential analysis of the expectations, and are more likely to behave in three types of support shows that emotional ways that confirm their negative expectations. support is significantly associated with family, Regardless of whether this model is accurate or romantic, and social loneliness, whereas the not, it seems that CBT and related interventions effect of instrumental support is very limited may have a role to play in supporting individuals and informational support does not significantly with chronic loneliness. affect loneliness (Hombrados-Mendieta et al. Intervention methods 2013: 1028-29). There is some consensus that Self-management emotional support is the most relevant regarding a large number of problems (Cutrona 1986), As mentioned from the outset, many people although it is clear that each type of support fulfils experience isolation or feelings of loneliness a specific function. In this regard, some authors at some point in their lives. For the majority of (e.g. Blazer 2002) suggest that emotional support people, these experiences are temporary or is a key element in the experience of loneliness situational and people often learn to manage since this occurs when there is a discrepancy these experiences in some way. between desired emotional support and available Self-management techniques aim to support emotional support. people’s resilience in two key ways. The Interventions which enhance social support first encompasses external resources which include professionally initiated interventions for contribute to well-being from the “outside” the bereaved (Vachon et al. 1980), for the elderly such as friends and social support. The second whose personal networks have been disrupted encompasses internal resources which refer to by relocation (Kowalski 1981), and for children behavioural and cognitive abilities that people whose parents have divorced (Wallerstein & use to manage their external resources and thus Kelly 1977). achieve well-being. Having external resources is Cognitive approaches essential but not sufficient for the maintenance of well-being; people also need to be able to Finally, programmes that focus on addressing manage these external resources (Steverink et al. negative thoughts (e.g. of self-worth) through 2005). For example, having social relationships interventions such as cognitive behavioural requires the management ability to indeed therapy (CBT) appear to be somewhat successful achieve and maintain social support from these in reducing loneliness (Young 1982). The relationships. Steverink et al. (2005) introduced cornerstone of this intervention is to teach lonely the term self-management abilities (SMAs) to individuals to identify automatic negative thoughts represent these internal resources, which were and how to manage these feelings. identified as self-efficacy, positive frame of Isolation and loneliness 25

mind, taking initiatives, investment behaviour, beer with lunch, a snooker table or a computer multi-functionality of resources, and variety club. More importantly, they find themselves in an in resources. environment which enhances quality of life owing Peer support/befriending to increased social involvement, with the potential of reducing social isolation at the same time. The Befriending schemes, where an individual authors recommend that local authorities and befriender provides social support, have been voluntary organisations should offer appropriate shown to have a modest effect on depression facilities and activities for older men, which in a range of population groups, but the benefit support them to lead socially-integrated and of such schemes for individuals experiencing independent lives within the community (Davidson isolation or loneliness in particular circumstances et al. 2003). is unclear. Again, it would depend on assessing the individual’s or group’s needs. Support groups and discussion sessions also Case study: “Friendship lunches”, appear to be beneficial for specific populations, North Yorkshire for example people who are bereaved or have There lies an opportunity for public venues a chronic condition. Findlay (2003) found that (e.g. restaurants, bookstores, sports venues) support groups are only effective for people who to leverage a meal or other leisure occasions have the social skills to participate, and where to help people build relationships in their local they were sustained for at least five months. In another study, the researchers found that communities to address loneliness. A pub in participants attending a particular community North Yorkshire, for example, has been hosting centre became socialised as peer supporters “friendship lunches” since February 2015 – without following any formal system and it marketing itself as “an opportunity for locals seemed to work quite well. to come together for good food and good Community and activity-based company”. The initiative was well received by interventions local consumers and it was quickly rolled out to Although other interventions can be “community- another six different communities. (Source: Mintel) based”, many researchers seem to conflate community-based interventions with activities that involve different members of a local community. Pitkala and others (2009) identified several factors These include community navigator services, which contribute to the effectiveness of group- where navigators act as a link between hard- based interventions such as lunch clubs. These to-reach individuals and local services. These include ensuring that there is some homogeneity “gatekeeper” programmes appear to have been among the group participants and that there are successful in the US at identifying and referring shared experiences and interests. on socially-isolated older people who have In addition, within the community setting, social not routinely come to the attention of services policy makers should analyse existing community (Findlay 2003). support resources and plan actions to meet the In their research on interventions for older people, needs of community support, such as promoting Davidson and colleagues (2003) suggested action to encourage contact between neighbours that policy changes are needed to make day and developing activities that increase the centres, lunch clubs and other clubs more social network and facilitate bonding between congenial for older men so that they do not community members (Hombrados-Mendieta feel they are “yielding up” their individuality, or et al. 2013). admitting some sort of “defeat” by attending. For example, these clubs might offer wine and Interventions 26

Technology-based interventions Animal-assisted interventions There is plenty of debate and there are many Animal-assisted therapy is another method gaps in the research on digital technology, that is currently being used to increase social communication and loneliness, especially in interactions and to combat loneliness. It is older age. For many digital services – including suggested that AAT can be viewed as a vehicle Facebook, Skype, email and Twitter – a study can for social interactions, with the pet as an ice- be found that shows them be successfully used. breaker in community-based social interactions Masi et al. (2010) found that loneliness reduction (Banks and Bank 2005). This therapy is carried interventions have “yet to harness the power out or facilitated by an AAT specialist (often a of technology.” Their article recognises that registered nurse, occupational therapist, social simply making the internet available within elderly worker, psychologist, etc.) who has been trained communities – even with careful and lengthy to integrate the animal into therapy as a modality induction – does not promise a substantial impact (Delta Society 2005). by itself. It considers research that shows how Animal-assisted activities, although not directed the internet can instead be directed towards toward specific therapeutic goals, “provide particular social interactional opportunities. opportunities for motivational, educational, Two systematic reviews included studies recreational, and/or therapeutic benefits to assessing computer training and internet use enhance quality of life” (Delta Society 2005). Such (delivered either individually or in groups) as a activities can include bringing cats or dogs to means to reduce loneliness among older people. visit patients at a hospital or nursing home; fish The reviews covered community-dwelling people tanks located in health care providers’ offices for and people living in residential or nursing homes. patients to watch while waiting; and even a dog- The computer training ranged from two weeks obedience group that gives a demonstration for a to three months and aimed to help older people correctional facility. Specialists helping to facilitate communicate with family and friends, as well as these activities may include but are not limited obtain news and other useful information. There to assistants of licensed professions (nursing, was some limited evidence of benefit but the occupational and physical therapy, as well as poor quality of included studies makes it difficult recreational therapy), students of professionals, to generalise. and animal-shelter workers (Morrison 2007: 53-54). Case study: SharedWalk Animal-assisted interventions have been found to be effective among adolescents as well as older SharedWalk is a service funded by the Nominet people, and found to be more effective in one- Trust and implemented by the Learning to-one settings than group settings. In addition, Science Research Institute at the University prompted or guided human-animal interactions of Nottingham. It allows someone with a appear to be more effective in improving social smartphone to capture and send (narrated) functioning than spontaneous interactions. Less videos to a partner with access to this website. intensive and longer animal-assisted interventions tended to show higher effects on daily living It is hoped that this will be particularly valuable skills, suggesting that short but highly intensive for individuals who are relatively housebound programmes in elderly and psychiatric patients and who wish to keep in contact with the may lead to an exhaustion of the intervention experiences of friends and loved ones. There is effect (Virués-Ortega et al. 2012: 216). no evidence on the effectiveness of SharedWalk, Older adults who reported owning a pet are as yet, but it is an example of the kind of 36% less likely to report loneliness than older innovations happening in this area. adults not reporting pet ownership. Further, “an Isolation and loneliness 27

interaction effect was found, such that older active in their communities. Strong partnership adults who lived alone and did not own a pet arrangements need to be in place between were at increased odds of reporting loneliness” organisations to ensure that developed services regardless of gender (Stanley et al. 2014). This can be sustained (Windle et al. 2011). finding indicates that pets may function as a A good example comes from the Campaign to meaningful source of social connectedness. End Loneliness, a network of national, regional Notably, pets depend on their owners for survival, and local organisations working together to potentially giving their owner a sense of worth reduce loneliness in later life, who have produced and responsibility for another living being. This a toolkit for health and wellbeing boards. is consistent with studies of human interactions, The toolkit provides guidance on identifying which show that providing support to others, local prevalence of loneliness, strengthening rather than receiving it, may confer greater health partnerships and evaluating implementation when benefits (Brown et al. 2003). Caring for a pet also producing Joint Strategic Needs Assessments requires behavioural activation, such as walking and Joint Health and Wellbeing Strategies. It is or going to the veterinary office, which may bring too early to say how successful this initiative has about interactions with other people and, by been, but it demonstrates the need to tackle virtue of increased mobility, extend into other loneliness and isolation by working with key domains of health as well. stakeholders across different sectors. However, it should be noted that loneliness is only a single indicator of health, and that pet ownership, if not managed properly, may actually be deleterious to the well-being of an older adult. Although limitations of pet ownership do exist, careful planning could mitigate any negative consequences of pet ownership. The role of different sectors Given the health-related, financial and wider community imperatives, there has been a national policy consensus that support must be provided to reduce isolation and loneliness as it affects older people. There is now an opportunity to extend this recognition to younger and working- age people. Although there is clear recognition that the third sector must be involved in some way, there is no consensus about the roles of the third sector vis-à-vis the statutory sector, or the potential role of the private sector. However, there have been some promising developments on this front in the Scottish Parliament, largely through the efforts of the Equal Opportunities Committee (Scottish Parliament 2015). What is clear is that GPs, social workers, housing associations, and other frontline services are well placed to identify people who are at risk of isolation or loneliness, but so are people who are Interventions 28

Conclusion and recommendations Over 100 articles and reports have been Coherence between target groups reviewed for this report. While several and interventions potential target groups have been identified, It is important not to think of target groups and there are many more to consider and for interventions in isolation, but to keep both in each group there may be several articles, mind throughout the decision-making process. reports or book chapters that further our Any decisions made about which groups to understanding of those groups’ experiences support through the partnership should be able of loneliness or isolation. There are also to demonstrate coherence between the choice of groups who are likely to experience several groups and the potential interventions designed of the risk factors associated with different to support those groups. In other words, it might clusters, making them much more likely to not be possible to support certain groups due to be socially isolated and/or lonely. Special the nature of the interventions needed, whereas consideration should be given to whether certain interventions may sound attractive but these groups might be supported through may not be effective for the groups selected. the the British Red Cross and Co-op partnership. Further research Regardless of which groups are selected, it should be expected that the primary research partners undertake a rapid review of the literature to understand the nature of those groups, the impact of isolation and loneliness on the individuals concerned, and the kinds of interventions that might be effective. Some of this information may also come from experts or stakeholders of interest in different sectors. Isolation and loneliness 29

Involving individuals throughout the Evaluation and monitoring process The characteristics of effective interventions Any individuals from the groups that are should be used as a starting point for designing targeted should be involved in the design and new initiatives (Cattan et al. 2005; Grenade implementation of the intervention as much and Boldy 2008), but innovative interventions as possible. Understanding the specific needs for social isolation and loneliness should be of individuals and the situations they are piloted and evaluated because of the magnitude currently experiencing is essential in order to of the health risks (Coyle and Dugan 2012). identify appropriate responses. According to Interventions targeting loneliness and isolation the research, giving individuals more say in the could potentially be cost neutral, due to the support they receive, and how it is carried out, is potential pay-offs in health care costs that would more likely to lead to better outcomes (Cattan et otherwise occur. Furthermore, many current al. 2005). efforts to reduce social isolation in the community Tackling social versus emotional rely heavily on volunteers, which could also isolation maintain low costs. However, robust process and outcome evaluations would need to be carried Creating opportunities for social relations does out in tandem with the intervention to ensure that not always balance the discrepancy between there is evidence to support any claims about desired and actual levels of social interaction, or the financial and non-financial effectiveness of feelings of loneliness, and these limitations should particular interventions. be considered when designing interventions. Ameliorating feelings of loneliness is more complex, but by reducing social isolation through the provision of social connections, there is a greater possibility to develop emotionally satisfying relationships and thereby reduce feelings of loneliness. Conclusion and recommendations 30

Photo © Simon Rawles Isolation and loneliness 31

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Appendices 38

Appendices Appendix 1: data sources National level surveys Below is a list of national-level surveys that could yield data on loneliness and social isolation. ¤ English Longitudinal Study of Aging (ELSA) ¤ Life Opportunities Survey (LOS) ¤ Lifestyle and Opinion Survey ¤ Understanding Society De Jong Gierveld loneliness scales Items of the 11-Item and 6-Item (green) De Jong Gierveld Loneliness Scales Items Emotional subscale Social subscale 1. There is always someone I can talk to about my day-to-day X problems 2. I miss having a really close friend X 3. I experience a general sense of emptiness X 4. There are plenty of people I can rely on when I have problems X 5. I miss the pleasure of the company of others X 6. I find my circle of friends and acquaintances too limited X 7. There are many people I can trust completely X 8. There are enough people I feel close to X 9. I miss having people around X 10. I often feel rejected X 11. I can call on my friends whenever I need them X The 11-item De Jong Gierveld Loneliness Scale has proved to be a valid and reliable measurement instrument for overall, emotional, and social loneliness, while the 6-item scale may prove more suitable in large surveys. Isolation and loneliness 39

UCLA loneliness scale (version 3) A 20-item scale designed to measure one’s subjective feelings of loneliness as well as feelings of social isolation. Participants rate each item as O (“I often feel this way”), S (“I sometimes feel this way”), R (“I rarely feel this way”) or N (“I never feel this way”). Scoring: O=3, S=2, R=1, N=0 Total scores range from 0, meaning never lonely, to 60, a high degree of loneliness. 1. I am unhappy doing so many things alone O S R N 2. I have nobody to talk to O S R N 3. I cannot tolerate being so alone O S R N 4. I lack companionship O S R N 5. I feel as if nobody really understands me O S R N 6. I find myself waiting for people to call or write O S R N 7. There is no one I can turn to O S R N 8. I am no longer close to anyone O S R N 9. My interests and ideas are not shared by those around me O S R N 10. I feel left out O S R N 11. I feel completely alone O S R N 12. I am unable to reach out and communicate with those around me O S R N 13. My social relationships are superficial O S R N 14. I feel starved for company O S R N 15. No one really knows me well O S R N 16. I feel isolated from others O S R N 17. I am unhappy being so withdrawn O S R N 18. It is difficult for me to make friends O S R N 19. I feel shut out and excluded by others O S R N 20. People are around me but not with me O S R N Social isolation index This index is used in ELSA and consists of a simple scoring system, with higher scores implying higher levels of social isolation. The index is composed of five parts: Partnership: score of 1 if not married or not cohabiting with a partner Contact: score of 1 for each where there is less than monthly contact (meeting in person, speaking on the telephone, or written communication including emails) with: ¤ children ¤ other family members ¤ friends Respondents also score 1 for each if contact is less than monthly for all modes. Organisational membership: score of 1 if participant does not identify membership in a social organisation. Appendices 40

Appendix 2: principles of group intervention GROUP PARTICIPATS nsuring homogeneit o the group common eelings o loneliness, common interest in the group content, similar leel o cognition and unctioning, willingness to change one’s own lie situation GROUP ACTIVITIES GROUP EA­ERS • According to the participants’ GROUP INTERVENTION • Proessionals in gerontolog interest (exercise, art, writing). • ƒhorough training and tutoring • Participants able to influence or group leading the group programme • work as acilitators • objectie orinted work Initial stage: tendion, unclear roles Feeling solidarity: Formation of the grou: adjustment, courage to humour, “our group” spirit, take responsibilit “honemoon” or the group Group dynamics, maturation of a group Conflits: Confidene: courage to be critical, participants dare to speak disagreements between about sensitie matters the group members and their loneliness COO FEATURES I A GROUPS ­oing interesting things together and sharing experiences, sharing lonliness, receiing and giing peer support, oercoming own limits, eeling togetherness €ocial actiation, gaining new riends, making arrangements to continue group meetings. mpowerment, increased sel esteem and master oer one’s own lie ‚ alleiation o loneliness Source: Pitkala et al. (2009) Isolation and loneliness 41

Where we are: British Red Cross 44 Moorfields London EC2Y 9AL redcross.org.uk Published 2016 The British Red Cross Society, incorporated by Royal Charter 1908, is a charity registered in England and Wales (220949), Scotland (SC037738) and Isle of Man (0752).