Richard Smith: Loneliness—the “disease” that medicine has promoted but cannot help

richard_smith_2014According to the Canadian psychologist Ami Rokach who has long studied it, “acute loneliness is a terrorising pain, an agonising and frightening experience that leaves a person vulnerable, shaken, and often wounded.” In our world of anomie and divorce and where medicine has extended life beyond usefulness, loneliness is one of the main causes of suffering, and it’s a cause where medicine has nothing to offer.

I haven’t ever experienced what Rokach describes, although he points out that “loneliness is as natural and integral a part of being human as are joy, hunger, and self actualisation. Humans are born alone, they experience the terror of loneliness in death, and often much loneliness in between.” One reason I haven’t experienced such loneliness is that I have rarely been alone, although the relationship between loneliness and being alone is complicated. You can be lonely in a crowd, and be alone and experience nothing but joy and fulfilment.

Two things have alerted me to the desolation of loneliness: an account in a novel, and my mother’s diaries. The account in Zoë Heller’s Notes on a Scandal came first. It’s a novel which tries—and almost succeeds—to give a credible account of a female teacher in her late 30s having an affair with a 15 year old schoolboy. The story is told by an older female teacher, who herself seems to love the younger teacher. The passage in the book that I found the most powerful described not the affair, but the loneliness of the older teacher:

“And then, every once in a while, you wake up and gaze out of the window at another bloody daybreak, and think, I cannot do this anymore. I cannot pull myself together again and spend the next fifteen hours of wakefulness fending off the fact of my own misery. . .

About the drip drip of long haul, no end in sight solitude, they know nothing. They don’t know what it is to construct an entire weekend around a trip to the launderette. Or to sit in a darkened flat on Halloween night, because you can’t bear to express your bleak evening to a crowd of jeering trick or treaters. Or to have the librarian smile pityingly and say, ‘Goodness, you’re a quick reader!’ when you bring back seven books, read from cover to cover, a week after taking them out. They don’t know what it is like to be so chronically untouched that the accidental brush of a bus conductor’s hand on your shoulder sends a jolt of longing straight to your groin. I have sat on park benches and tubes and schoolroom chairs, feeling the great store of unused, objectless love sitting in my belly like a stone until I was sure I would cry out and fall, flailing, to the ground.”

Days later I read of my mother’s loneliness. The entries in her diary were written after my father died. She lived alone, although somebody visited most days, and was aware that she was beginning to dement, as her mother had done before her. She hid her loneliness from others, and I feel badly that I didn’t detect the extent of her pain.

“Wednesday 2 April
Brian [my brother] left—leaves a huge gap and I try to keep my spirits up, but very low. He’s marvellous support.

Thursday 3 May

I really feel hugely miserable and lost. I miss Brian so much—I know this is silly and wrong—I’ve lived alone now for some time and must make an effort to recover my balance.

Friday 13 July
Brian here few days, which is wonderful, but awful when he goes.”

My mother now lives in a nursing home and seems cheerful most of the time. She still uses complex language and has a strong sense of humour. We laugh much of the time we are together each week, but, although she denies it, she is still perhaps lonely. A clue is that sometimes she doesn’t like me to go.

I set out to try and understand more about loneliness, and I found much more help in literature and quotes than from medical journals. Loneliness is not, thank goodness, in DSM V, and it seems to belong more to psychologists and nurses than to doctors, although it must be something that is present in many of the people seen by general practitioners and geriatricians.

“The most terrible poverty is loneliness, and the feeling of being unloved,” said Mother Teresa.

“God, but life is loneliness,” wrote Sylvia Plath in her journal, “despite all the opiates, despite the shrill tinsel gaiety of ‘parties’ with no purpose, despite the false grinning faces we all wear. And when at last you find someone to whom you feel you can pour out your soul, you stop in shock at the words you utter—they are so rusty, so ugly, so meaningless and feeble from being kept in the small cramped dark inside you so long. Yes, there is joy, fulfilment, and companionship—but the loneliness of the soul in its appalling self-consciousness is horrible and overpowering.”

“When you have nobody you can make a cup of tea for, when nobody needs you, that’s when I think life is over,” said Audrey Hepburn.

The best account I could find of loneliness in a health publication was from Colin Killeen, a charge nurse in an elderly unit in Salford. It is, he argues, a modern epidemic, but one that is largely unrecognised because it is taboo to admit to loneliness. And it is not easy to define: Killeen suggests that it lies on a spectrum that runs from the very positive connectedness through solitude, aloneness, social isolation to loneliness, and then beyond to alienation or estrangement. There is less choice at the negative end. People choose connectedness and solitude, whereas loneliness is imposed upon them.

Loneliness is associated with low self esteem, depression, shyness, anxiety, greater neuroticism and lower extroversion, less assertion and more self consciousness, cognitive impairment, and lower educational levels. It is most common in the elderly, the bereaved, adolescents, and, so some studies say, in females.

Suicide is one consequence. As Killeen puts it: “There is nobody to miss them so they may as well kill themselves and end their misery . . . what is the point in staying alive just to feel unending pain and distress.”

People may treat themselves through overeating and using drugs and alcohol. My mother began to drink, which it took us some time to discover. By the time she entered the nursing home she was drinking two and sometimes three bottles of wine a day. Now she drinks little alcohol.

Modern medicine has no treatment for loneliness. “Nurses,” argues Killeen, “are being unrealistic if they think that they can ‘prevent’ or ‘cure’ this distressing condition.” It is, he and others argue, part of being human: “No matter who the individual is, or whatever the circumstances are, people will always be lonely.” Killeen’s prescription is a more caring society, something that it is beyond doctors and nurses to create.

Writers and researchers mostly describe and define loneliness, and write about its associations and consequences. They are largely blank on treatments, but I found this from David Foster Wallace, the American author who killed himself aged 46. “Fiction, poetry, music, really deep serious sex, and, in various ways, religion—these are the places (for me) where loneliness is countenanced, stared down, transfigured, treated.”

It may well be, says a friend, that the decline in religion and the rise in medicine, which in some narrow sense is a replacement, may be important in the epidemic of loneliness. Most religions put an emphasis on togetherness, praying together, welcoming everybody, no matter how miserable or marginalised. Medicine, in contrast, is about individuals, promising too often what it cannot deliver.

Perhaps the best we can hope for is a greater awareness of the potency and destructiveness of loneliness and a lessening of the taboo around it. Then we might do more to build a society that is more caring. The worst response would be to medicalise loneliness.

Richard Smith was the editor of The BMJ until 2004. He is now chair of the board of trustees of icddr,b [formerly International Centre for Diarrhoeal Disease Research, Bangladesh], and chair of the board of Patients Know Best. He is also a trustee of C3 Collaborating for Health.

Competing interests: None declared.