Ahead of National Loneliness Awareness Week, the APS spoke with a psychologist with expertise in loneliness to learn about effective intervention methods.
Summary:
- It's important for psychologists to think in a transdiagnostic way when managing experiences of loneliness in their clients.
- While people assume older people are more susceptible to loneliness, the most at-risk cohort is 15-25 year-olds.
- Research shows that a new manualised psychotherapy program called 'Groups 4 Health' is more effective at reducing loneliness in clients in the long-term than cognitive behavioural therapy targeting depression.
- Participating in a community-focused event protected people from poor mental health up to nine months following the event.
Loneliness is often considered a symptom of poor mental health.
"This is perhaps most commonly recognised for depression, where social withdrawal would be seen as a symptom that someone already has depression," says Tegan Cruwys, a clinical psychologist and Professor of Psychology at the Australian National University.
"If you look at the Diagnostic and Statistical Manual, it's talked about as a symptom or a secondary outcome for a whole lot of different conditions. For example, autism spectrum, social anxiety disorder and psychosis: you'll see social withdrawal, disconnection or dysfunction mentioned as a feature."
On the other hand, a lot of empirical research suggests the relationship goes the other way, she says.
"When people become isolated and withdraw from their social networks, it's a warning sign that they're likely to experience mental health decline down the track. So the isolation happens first –and the mental health declines subsequently."
However, in her own research paper, which included a nationally representative sample of over 22,000 New Zealanders, Professor Cruwys and her co-authors found a bidirectional relationship between social connectedness and mental health. In other words, both factors affect one another.
"If you become isolated, you're more likely to see mental health decline in subsequent years. But also, if your mental health declines, you're likely to see growing isolation in subsequent years," she says.
"One of the most important findings to come out of that research for psychologists is that the relationship is three times stronger going from social connection to mental health than the other way around. So when we're seeing people in our practice who are both isolated and mentally unwell, often it's the case – three times more often, in fact – that the social isolation came first."
This has implications for the types of interventions that psychologists utilise, she says.
For example, rather than focusing solely on cognitive interventions, they might also provide support to help clients manage social or structural challenges that might be impacting their ability to connect socially.
"The people who are most likely to be experiencing loneliness tend to be those who are being excluded from society. It could be because they have a disability or because they don't have money to go out with their friends. That aspect of intersectionality is really important to consider."
It's also important to think about mental health in a "transdiagnostic way", she says, for people to understand experiences such as loneliness.
"There's a growing recognition in health professions and psychology that our traditional diagnostic systems sometimes obscure the similarities that occur across conditions. A lot of risk factors for mental health aren't specific to any one condition, and loneliness is a good example of that. It places people at risk, not for one specific disorder, but for a whole raft of mental health conditions," she says.
For example, it can increase people's risk for psychosis, social anxiety, depression, as well as physical conditions such as cardiovascular disease and cancer.
"We don't want to miss the bigger picture: which is about holistic health."
Who is most at risk?
Many people conflate loneliness and isolation, says Professor Cruwys, which leads them to assume older people are the loneliest of the generational cohorts. But that's not accurate.
"There is a small cohort of older people who are desperately lonely, but if you look at the population level, we should probably be directing more resources towards tackling loneliness in young people, for whom loneliness is more prevalent," she says.
While the research isn't definitive, many people cite the COVID-19 pandemic as a key driver behind this, with many young people missing out on key moments of in-person social connection, such as during key years of school and their first years of university and work.
The most at-risk group are 15-25 year-olds, with social connectedness seeming to increase for people as they reach their mid-20s and beyond.
"We've got some local data from young people in Australian schools that is showing a pretty clear trend of post-COVID reduced social engagement and mental health, compared to [other] cohorts.
"There's an argument to be made that youth loneliness has been a problem for a long time, but that doesn't rule out the idea that there's also a particularly high-risk cohort that has emerged in the past few years."
Helpful interventions to curb loneliness levels
One of the common interventions to manage loneliness levels is social prescribing, which Professor Cruwys says is particularly popular in the UK but is growing in popularity in Australia.
"It's based on the idea that given the strong links between social connection and health, our frontline primary care health professionals need to be taking a more active role in recommending not just biomedical solutions to health issues, but also proactively helping people form social connections that might benefit their health."
While Professor Cruwys says this approach has "a lot of potential", there are also some potential downsides.
"At its worst, it could come across as a patronising experience for a marginalised group of people who are often experiencing complex illness and issues."
It could also give the impression of shifting responsibility to address loneliness away from the health sector to sit within the social sector, she adds.
However, if delivered carefully and intentionally, she believes it can be an effective method.
"At its best, what it can look like is skilled link workers who are specialists in helping people find their social connections and groups that will work well for them. That can really change people's lives."
From a psychotherapy perspective, in partnership with a research team at the University of Queensland, Professor Cruwys has developed a manualised psychotherapy program called 'Groups 4 Health,' which is a skill-building social connection program.
"It has been accepted for publication in Oxford University's 'Treatments That Work' series, which is a book series that specialises in evidence-based psychotherapy programs that have the strongest evidence base."
In another research paper, Professor Cruwys and her co-researchers compared the 'Groups 4 Health' approach with cognitive behavioural therapy (CBT) among young people with severe loneliness and clinical depression.
"As a clinical psychologist, we know that CBT is an incredibly effective and powerful technique, which is why we chose it as our comparison in this trial: because it is best practice.
"A CBT approach exclusively targets thoughts and behaviours that are seen to be maintaining the depression symptoms. That might be challenging negative thinking, and helping people become more engaged in positive activities.
"Whereas the Groups 4 Health program doesn't talk about symptoms of depression at all. It entirely focuses on helping people become more socially connected, and provides opportunities for them to form group-based connections. So it has a social prescribing element but also a social skills component."
Their research found that CBT and a Groups 4 Health approach were equally as effective in reducing depression symptoms.
Over a longer period, however, the results diverged for loneliness.
"Over a 12-month period, we found that Groups 4 Health outperformed CBT in terms of reducing loneliness symptoms, and that was particularly true for the cohort who completed their follow-up assessments during the first COVID lockdown.
"In that cohort, we saw a relapse of loneliness among the group who completed the CBT program, whereas we did not see that relapse for those in the Groups 4 Health program. It seemed to inoculate people a little against a future, unanticipated threat to social connection."
Scaling support
While Professor Cruwys says there's an important place for small, targeted interventions when it comes to addressing loneliness, she is also a proponent for community-focused initiatives.
"The advantage of a community intervention is that it shifts the onus of responsibility for loneliness beyond just the lonely individual. It's all of our responsibility as community members to create inclusive environments that enable people to have connection to one another."
She became involved in an initiative called Neighbour Day, which helps people connect with others in their local communities and is championed by Relationships Australia. Volunteers are encouraged to set up events, which could be anything from bake sales and neighbourhood WhatsApp groups to setting up a larger fete day or community gardening initiative.
After assessing the wellbeing levels of people who participated in Neighbour Day, Professor Cruwys and her co-researchers found that this initiative led to positive mental health months after the events took place.
"Those results have now been replicated over multiple years. Perhaps the most compelling data we collected was during COVID. We followed them with some research participants before and after the prolonged lockdowns that happened in 2021 across most of Australia.
"For people who hadn't participated in Neighbour Day, they experienced a decline in their wellbeing and an increase in psychological distress during that period. But people who had participated in Neighbour Day were protected against that. And that was up to nine months after a Neighbour Day event.
"That was fully explained by an increased sense of connection to and identity with their local community. That speaks to the fact that it's not just about how often you're seeing people; it's very much about the subjective sense of connection and inclusion in the community."
When looking at combating an issue as large as reducing Australia's loneliness levels, people might assume interventions need to be intensive and expensive, but Professor Cruwys says Neighbour Day proves that's not the case.
"We don't necessarily always look at how we can use psychological principles to benefit mental health across a whole community. If we do that, it only has to be a very small effect at an individual level to be meaningful across the community.
"Neighbour Day reaches over 300,000 people a year. If we're having a small effect on each of those individuals, that's going to add up to more [impact] than any psychologist working one-on-one could have in a lifetime.
"For me, it's a good example of how it's important for psychology to move beyond that one-to-one therapy model if we really want to do something about loneliness and mental health."
The APS has a range of helpful tools to help curb loneliness. Click here to view resources. You can also sign up to view our on-demand webinars, such as ‘Overcoming prolonged isolation and loneliness later in life’.