How Painful is Lonely?
Peplau,1 in a classic article, defined loneliness as an "unnoticed inability to do anything while alone." She goes on to explain that loneliness is so unbearable that it is expressed and defended against in automatic behavior that draws the attention of others. The patterns of defense against loneliness can be grouped into time-oriented complaints, time-related feelings of familiarity, and planlessness or overplanning.
"The days are so long" - an echo of the pain of loneliness that is frequently heard. Despite the routines in the institutions, there are gaps of unfilled time and the elderly are left alone to do something meaningful. The early morning is filled with rituals and activities, but after lunch there is a lull when most of the elderly are silent or appear to be meditating.
It was after lunch, and a group of residents were sitting in the common lounge. This interaction occurred with one of the residents.
Resident: There is nothing to do. This is one of the lonelier times of the day. (sighs)
Nurse: What do you mean, Mrs O.?
Resident: I can't do anything, and I can't wait until the busyness starts again; I mean suppertime when someone will wheel me downstairs. Even for that brief time someone will pay attention to me as a person.
Time-related feelings of familiarity are similar to the distortion experienced under severe anxiety. Peplau contends that the familiarity is with things rather than with people.1 The lonely individual categorizes events that precipitated anxiety in the past with events in the present, but is unable to deal with the real issue of loneliness.
A student nurse has been working with an elderly resident for ten days. In the morning of the student's last day, the resident complained of nausea and feeling unwell. The student attended to Mrs A.'s physical needs, but she did not explore the possible causes any further.
After lunch, Mrs A. told the instructor that the student promised to do her nails for her and she hoped that the student had not forgotten about her. In exploring the situation further with the student, the instructor discovered that earlier in the day the student had reminded the resident that she would be leaving and had given Mrs A. a small bottle of cologne.
Following this interaction, the resident complained of nausea. Mrs A. later verbalized to the instructor that she was feeling rather unwell and remembered experiencing the same feelings when some of her friends moved away.
Planlessness is another defense against the pangs of loneliness.1 It is as though the person's life is a series of unrelated events over which he or she does not have control. An 80-year-old widow living with her son in an apartment in the suburbs describes her day as a "coming and going of folks and things; not a confusing thing, but the day just happens and the next day happens and the next and the next." There is a possibility that the individual's dwelling on the past instead of attending to the present is an aspect of planlessness.
Overplanning, the opposite of planlessness, involves the individual projecting too much into the future or making extensive lists of what to do. Peplau feels that this behavior helps the individual to avoid feeling frantic about the emptiness and disorder in his or her surroundings.1
The Elderly and Loneliness
Sullivan and Pîplau subscribe to the concept that the origins of loneliness stem from early life experiences in which remoteness, indifference, and emptiness characterize relationships with others.1 However, this conceptual formulation may not always be the case for the elderly.
If one examines the life events that generally take place in the life of the elderly, one can find a gamut of experiences that may incite "a sense of feeling deprived from expected human relationships."2 Some aspects of the elderly 's experience include relocation, decline in certain physiological functioning, retirement and the concomitant loss or modification of roles, and the widespread social changes. Burnside enumerates the causes of loneliness as loss of spouse or significant others, loss of a pet, and pain.3
Can loneliness be an iatrogenic condition? Burnside quotes several authors who identify the mental changes caused by institutionalization as iatrogenic mental illnesses.3 The changes precipitated by relocation to an institution, whether voluntary or not, produces a conflict in the elderly. The move represents the conflict between the desire to remain in familiar surroundings and be independent and the fact that the institutional environment will be different and will probably require the curtailment of independence. The conflict leads to an unchosen state of loneliness in which the individual is unable to function while alone, yet does not recognize the cause of this inability. This individual feels that relationships are now disrupted and are not within reach. When this happens, the feeling of loneliness is feared and defended against, and the individual is left feeling impotent and segregates him- or herself from others.
This isolation decreases self-esteem because every human being needs contact with others to maintain a sense of self- worth. Gordon defines the nursing diagnosis of powerlessness as the perceived lack of control over situations. The person feels that his or her actions will not significantly affect an outcome. Social isolation is a condition of aloneness experienced by the individual and is perceived as imposed by others and as a negative and threatening state.4 This vicious cycle of loneliness, powerlessness, social isolation, and decreased self-esteem may go on indefinitely unless interrupted (see Figure).
A case study should serve to illustrate fully the pain of loneliness.
Mr H., a 70-year-old widower, lives with his daughter and her family. His wife died eight years ago and his daughter, worried that he would not be able to care for himself, arranged for her father to live with her. Grief-stricken, he buried himself in his work as a tailor for two more years and then retired. He welcomed his retirement, and he was able to do things he said he never had time to do before, such as traveling and fishing. Because there were no financial concerns, he seemed to have adjusted quite well to the life events that occurred.
Eventually, however, his family became anxious about Mr H. 's behavior and contacted me to see him as a friend. At this point, Mr H. had been to see his family doctor and was deemed physically healthy. He was definitely not depressed, but was apparently suffering from what the doctor labeled as "adjustment syndrome." The family was puzzled because they did not believe that there were any adjustments that remained to be made. What bothered the family was that Mr H. seemed to be retreating from them by isolating himself in his room when the family was home. He did not attend any of the meetings he used to enjoy and refused to talk to his old friends.
I agreed to see Mr H. after having met with Mr H., his family, and the doctor. The first home visit was attended by Mr H. and his daughter. Mr H. complained that he was having difficulties, but could not identify why and how they came about. He did not have cognitive or affective impairments. When asked to sequence events, he was able to explain that this "unknown feeling has been something that has been with me since my wife died." His description of the feeling was vague, but he did associate it with the restlessness he felt when alone and his inability to do anything anymore. His retreat from his family and friends was an attempt to conquer this feeling, but he admitted that withdrawal was not effective. When I proposed that loneliness could be the cause of this disturbance, he said he wanted to think about it.
THE CYCLE OF LONELINESS
On the second visit, two weeks later, Mr H. suggested that he had a fullblown case of loneliness. When asked to elaborate, he maintained that his grief, although not capable of being fully resolved, had some bearing on his loneliness. He referred to the fact that when his wife was alive, he always had someone with whom to share thoughts and feelings; someone was there on whom he could depend and who could depend on him. He was a proud man and could not admit to these feelings of loneliness before and, therefore, never really considered loneliness as the cause of his behavior. When asked to explain his loneliness in greater detail, he described it as "not a fear of being alone, not really sadness, but not being able to attend to anything that was meaningful when alone, wanting to be important, and not looking forward to anything anymore." These moments were "not a feeling of terror, rather some callousness to what was going on, and a very subtle reminder of some degree of impotence. "
Three more visits were formally arranged with Mr H., and then it was left to him to contact me if he felt the need to. We met four months later "just for a chat. "
After making sensitive observations of the elderly person's condition, the nurse needs to validate these observations. The importance of checking out observations cannot be underestimated as they are the basis of accurate nursing diagnosis. Examples of techniques for seeking consensual validation are: "I notice that you sit with a group of people, but I don't see you chatting with them;" "I wonder what you think of when you are so silent even when you are with the others;" "I have observed that you would rather be alone than with the others." These comments provide the elderly with a chance to deny or affirm the observations. If the elderly gives a reason for his or her behavior, the nurse may need to investigate further. An attempt to look for clues as to why the person behaves in a particular way provides the nurse with an understanding of the etiologic factors.
As part of the total assessment, a mental status assessment needs to be done to rule out the possibility of depression or other functional emotional disorders. Examples of nursing diagnoses include:
1 . Social isolation related to inability to form new networks;
2. Powerlessness related to unfamiliarity with the expectations and routines;
3. Social isolation related to feelings of loneliness; and
4. Social isolation related to perceived low self-esteem.
Nursing interventions revolve around the dynamics of the nurse-elderly relationship. It is well documented that a relationship goes through the phases of orientation, working, and termination. With the elderly, it is crucial that the expectations are realistic, otherwise it is doomed for failure.
The nurse can apply the assumptions used by Duhl and Duhl5 in their integrative family therapy. "Life is sacred," the first assumption, is highly applicable for the elderly. It is important to realize that individuals are more than the sum of their experiences, environment, and genes. The "spirit" has to be added to the human dimension of life. The elderly individual's spiritual needs are important and have to be respected whatever these needs are.
The other assumptions, "every person has a story" and "therapists cannot want more for clients than patients want for themselves," are important considerations. When a person has the opportunity to tell the story of his experiences, "it grounds him in his own reality." The elderly person likes to reminisce about the old times and this may alleviate the loneliness he or she may be experiencing. In institutions or even in the community, it is important to understand that forcing a person to socialize without finding out the reasons, preferences, and feelings associated with the isolation is to provide conditions for what Peplau calls "mutual loneliness."1 An example would be the tendency of some nurses to compel all of the elderly to join the activities in a residential setting just so that they will not be alone. The act of forcing anyone to associate with others despite persistent wishes to be alone is a violation of the person's decision-making capacity. The nurse may need to explain the rationale behind group activities and negotiate with the elderly as to how to alleviate the feelings of loneliness.
The defenses discussed earlier occur within an interpersonal context; therefore the lonely individual expresses loneliness through dependency on others, somatic preoccupations, and expressions of a distortion of selfesteem. By displaying these behaviors, the individual gains the attention of others. Freud's work gave nursing an important principle: "all behavior has meaning." This principle can be applied to the behaviors that nurses deal with in the clinical setting.
The lonely person expresses the inability to do things for him- or herself and relies on others. He or she calls the nurse for trivial things in order to have someone provide attention and is frequently labeled as demanding. If one ponders the meaning of this behavior, one may find that the individual is trying to ward off intense feelings of loneliness. In the same vein, frequent complaints of bodily aches and pains should trigger exploration of the meaning of the behavior. An individual who berates him- or herself may be looking for approval and is warding off pain.
It is important to realize that loneliness is nonproductive. The individual expends energy trying to protect himor herself from this dreaded feeling and, therefore, needs assistance to bear this feeling. An intervention, such as offering oneself or spending time quietly with the individual, is a simplistic approach; however, it indicates to the person that he or she is a worthwhile human being.
Example: A student nurse had been working with an elderly resident, Mrs C1 and she was becoming frustrated because all the resident wanted to do was sleep. After a student-instructor discussion, it was decided that the student try to schedule her visits with the resident at consistent times during the day and emphasize that she would be there whether Mrs C. wanted to talk or not. During the first few visits, the resident just closed her eyes while the student sat in silence next to the bed. After the third visit, the student tried holding Mrs Cs hand and stroked it gently until it was time to leave. She told the resident when she would be back. When the student returned, Mrs C. opened her eyes as the student greeted her. Again, the student held the resident's hand and then, when the student was ready to leave, the resident thanked her. On the student's last day, she gave Mrs C. a flower and the two of them went down to the coffee shop for the first time. "Saying good-bye to her was so hard, but when she motioned me to come near her, I couldn't believe it. Then she hugged me and closed her eyes again," the student reported.
Bahr6 suggests that touch is a major component in communicating with the elderly. As seen in the above example, the student nurse's use of touch was therapeutic in establishing a bond between the two of them. Aside from the spontaneity of touch, the nurse can increase the effectiveness of touch by other nonverbal behaviors such as posture and facial expressions.
In dealing with dependent behavior, the nurse needs to assess the degree of dependency that the individual is exhibiting. Another factor to be considered is the degree of trust in the relationship. In the beginning of the relationship, it may be necessary to let the elderly depend on the care giver. As the nurse and the elderly person start to work out some of the issues in the healthcare environment, whether physical or emotional, the nurse is in a better position to assist the elderly to look at the behavior of dependency. Exploration of the behavior can lead to plans to decrease dependency. Assisting the individual in meeting physiological needs can help establish more trust and promote a sense of worth.
Hirst and Metcalf7 suggest that providing the elderly with some decision-making involvement regarding their bodily needs promotes selfesteem. This task is often difficult, however, and the nurse needs to be creative in devising ways to assist the elderly's regaining of self-worth. Encouraging the elderly to regain control over important issues, such as privacy or territorial space, is as important as increasing decision-making responsibilities.
It is worth noting that loneliness, powerlessness, social isolation, and decreased self-esteem can lead to reactive depression; hence it is crucial for the nurse to reassess the elderly person's situation continually and be able to decide when a referral may be necessary.
Loneliness is an unchosen state, that frequently affects the elderly because of the many life events that have been encountered. It can be an iatrogenic emotional problem in which nurses can intervene. By establishing a therapeutic relationship with an elderly person, the cycle of loneliness, powerlessness, social isolation, and decreased selfesteem can be broken and the individual can use his or her energies in a more meaningful way. It is through caring that the human experience can unfold in the nurse's eyes. When the lonely individual can share life experiences, the nurse can better understand the aged's conflicts, sorrows, and happiness.
- 1 . Peplau H: Loneliness, in Smoyak S, Rouslin S (eds): A Collection of Classics in Psychiatric Nursing Literature. New Jersey, Charles B. Slack Inc. 1982, pp 244-250.
- 2. Gordon S: Lonely in America. New York, Simon & Schuster Inc. 1976.
- 3. Burnside IM: Nursing and the Aged. New York, McGraw-Hill Book Co, 1981.
- 4. Gordon M: Manual of Nursing Diagnosis. New York, McGraw-Hill Book Co, 1985.
- 5. Duhl B, Duhl FJ: Integrative family therapy, in Gurman A, Kniskern D (eds): Handbook of Family Therapy. New York, Brunner/Mazel Publishers, 1981, pp 483-516.
- 6. Bahr RT: Touch: A means of communicating with the elderly, in Hall B (ed): Mental Health and the Elderly. Orlando, Florida, Grune and Stratton, Inc. 1984, pp 87-109.
- 7. Hirst SP, Metcalf BJ: Promoting self-esteem. J Gerontol Nur s 1984; 10(2):72-77.