JOURNAL OF THE AMERICAN GERIATRICS SOCIETY Copyright 0 1978 by the American Geriatrics Society
Vol. XXVI, No. 4 Printed in U . S . A .
A Concept of Loneliness in the Elderly‘ LULA M. WILLIAMS, RN, BS, MSN**
Veterans Administration Hospital, Tuskegee, Alabama
ABSTRACT: The author’s concept of loneliness is desciibed, especially as it concerns the elderly. An attempt is made to develop an understanding of the word, with its implications for guidance in the nursing profession. The nurse’s defenses against her own feelings of loneliness and depression can inhibit therapeutic interactions with lonely or depressed patients. Appropriate nursing action depends upon the knowledge, correlation and use of many other concepts such as those related to dynamics of behavior, personality structure and development, or problem solving. Practical recommendations for nursing intervention are outlined. Emphasized is the necessity for the nurse to understand the concept of loneliness so that she may render effective service. The concept described in this paper is “loneliness,” defined and discussed with reference to the elderly. During a group experience with elderly patients, we found that they verbalized periods of loneliness. As a result, the aim of this paper is to develop an understanding of the word and to stress its implications for the nursing profession. Several authors have pointed out negative influences by showing how the nurse’s own feelings of loneliness and depression and her defenses against them can inhibit therapeutic interactions with lonely or depressed patients. On the other hand, nursing has been cited as an example of constructive manipulation and as a certain kind of “loving.” Multiple concepts are possible in view of the patient’s behavior. In every case, appropriate nursing action depends upon one’s knowledge and use of many other concepts such as those related to the dynamics of behavior, personality structure and development, or problem solving. These related concepts require recognition or even detailed spelling-out in the descriptions. It is necessary to trace the developmental pattern of the behavioral concept, noting possible overlapping or repetition of steps in the process, and describing interactions over a time period with
the same patient. In addition to citing a specific example of the concept of loneliness, recommendations are made with regard to nursing intervention. Some of the literature on the subject is reviewed (1-15). OPERATIONAL DEFINITION An operational definition serves as a general guide for tracing the origin and progression of loneliness. The following seem to be logical steps toward a definition of the concept of loneliness described here: 1. Man has a need to transcend his separateness. 2. This need produces tension. 3. Relief of tension is sought through selftranscendence by: a) direct means (relationship with others), and b) indirect means (creative expression). 4. If these means are successful, feelings of loneliness are relieved, a t least temporarily. 5. If these means are unsuccessful, barriers exist. (Some barriers to self-transcendence are self-alienation, shame and guilt, social ostracism, cultural mobility and exclusion, lack of trust, and pain.) 6 . If the person is unable to overcome the barriers to self-transcendence, there is an increase in tension which leads to: a) an increase in-anxiety, and b) an increase in the degree of loneliness.
* The author’s statements and conclusions are the results of her own studies and do not necessarily reflect the opinion or policy of the Veterans Administration. ** Formerly, Clinical Specialist, Nursing Service, Veterans Administration Hospital, Tuskegee, AL 36083. Present address: Veterans Administration Hospital, P.O. Box 5841, Nashville, TN 37208.
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7. The persistent unfulfilled need for selftranscendence leads to: a) a further increase in anxiety, and b) a degree of loneliness experienced as psychic pain. 8. Defenses such as denial, suppression, repression, alcoholism, and somatic complaints, are used to decrease the anxiety and guard against pain. 9. Such defenses result in further alienation from the self and from others. 10. The alienation leads to an increase in loneliness and anxiety. 11. As the loneliness and anxiety increase, the defenses no longer work. 12. As the defenses crumble, the lonely person attempts to escape into a world of unreality (personality disintegration) (1). 13. Loneliness is defined as a character or state of being lonely, especially a state of being cheerlessly solitary; dejection or depression from being alone; love of retirement; or disposition to solitude (2). 14. Loneliness is described as a “state of mind in which hope that there may be interpersonal relationships in one’s future life is ruled out of the realm of expectation or imagination” (3). I conceptualize loneliness as a feeling that comes to a person when there seems to be no one who cares about what happens to him/her. The feeling is expressed as self-pity, thus making that person think only of self and the things expected from others. The social reject is frequently anxious to be part of the mainstream of life but, for a variety of reasons, is rejected by his peers. Reasons range from repulsive appearance to objectionable personal habits. Almost invariably the social reject becomes reclusive or a “loner,” but usually not from personal choice. It should be noted that some common problems in distinguishing concepts from forms of a concept and operationally defining them, stem from the difficulty in describing human behavior, which is affected by many variables. Also, concepts may be overtly or covertly expressed differently by each individual. Concept description requires judgment and careful interpretation as well as close observation. DISCUSSION According to Hofling et a1 (4), loneliness can become a serious problem in old age, particularly
184
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if the person has been somewhat shy and withdrawn by temperament. The older person is apt to feel unsure that he is wanted and therefore finds it difficult to make friendly overtures. The resulting partial ‘isolation may bring further complications, since it favors the development of mistaken impressions about others. The environmental changes are not merely losses of one kind or another. They also involve the arrival of new situations, new means of transportation and communication, and perhaps different living quarters. Such changes may not be of a sort that previously would have constituted stress, but in old age they are apt to be stressful since they all require some expenditure of energy, the supply of which is sharply limited. According to Hofling (4), the crux of the emotional problems of the aged may be summarized by the fact that the old person is frequently called upon to make an increased effort of adjustment a t a time when his abilities for such effort are decreasing. In the face of a diminution of ego strength (resulting from mild organic changes in the central nervous system), the personality usually experiences a certain amount of regression. Hence, aged people, even those in good physical condition, are often described as “childish.” The fewer the unsolved inner conflicts and the stronger the ego during maturity, the less pronounced will be regression during old age. In the person who has enjoyed a healthy maturity, the decline is not apt to progress beyond the point of an acceptable mild and quiet eccentricity. Everyone experiences loneliness at some stage of life. We all have need for meaningful relationship with others. Early unfulfilled need for relationships with others results in personality isolation and stagnation. Nuttin (5) states that a child needs to feel “that he is loved and surrounded by affection” if he is to acquire selfconfidence and develop psychologically. If he does not have self-confidence and lacks an inner consistency, he becomes closed to others. He does not possess the inner strength to form successful relationships. Related to the concept of loneliness are theories on maternal deprivation. In the development of these theories and related studies there is evidence that love is the missing element which results in that degree of loneliness in the woman that is described as painful existence. It is usually against this lack of love that she needs to defend herself; then her defenses become barriers which lead to loneliness (6). During a group experience with five elderly
April 1978
CONCEPT OF
women, which was organized to gain first-hand knowledge of the phases of the group process, the concept of loneliness was mentioned by each member. The purpose of the group was education of the patient in the management of diabetes mellitus. When the author, as the leader of the group, requested each member to verbalize some problems associated with difficulty in adhering to the medical regimen, it was noted that the subject of loneliness predominated throughout the group experience. A constant preoccupation with the state of affairs of being old and lonely indicates depression in the older person. Remarks such as, “I am just in the way,” and, “Why does someone like you want to visit the likes of me?” are common, according to Evans (7). Relationships with others are remembered and dreamed about. Yearnings to see former classmates and acquaintances and to know what they have done with their lives, whether alive or dead, often become a preoccupation. The usual retirement age in this country is 65 for men and 62 to 65 for women. Preparation for retirement should begin early in life, and those who in their earlier years have developed their inner resources will be better equipped for this later period. The older population in this country is becoming more isolated as its knowledge and skills become obsolete. The world and the values of these aging people have become increasingly irrelevant in a highly technologic society with rapidly changing customs. Evans (7) further states that if we are to counteract the dehumanizing aspects of contemporary society, one pathway is through care and concern for aging members. The aged person is forced to make a personal adaptation to his changing needs as, with aging, he is regarded differently by society and also by himself. Even if the older person has the capacity to adapt to his own loss of social and personal resources, society’s restrictive attitudes and stereotypes about the aged may produce problems.
,ONELINESS
seemed important to include it here as a possible method of teaching.
Hunger
Loneliness
The need for food results in feelings of hunger.
The need for relationships results in feelings of loneliness.
Feelings of hunger are the motivational factor in the search for food.
Feelings of loneliness are the motivational factor in the search for relationships.
The ability to procure and utilize food is necessary for the relief of hunger.
The ability to relate to others is necessary for the relief of loneliness.
The quality of the food intake is an essential factor in relieving hunger and in maintaining physical health.
The quality of relationships is an essential factor in relieving loneliness and maintaining emotional health.
Feelings of hunger are experienced in degrees.
Feelings of loneliness are experienced in degrees.
Fear of hunger is a motivational factor in defenses against this feeling (e.g., security measures such as stocking the pantry, hoarding).
Fear of loneliness is a motivational factor in defenses against this feeling (e.g., inability to be alone, extreme dependence or extreme independence, psychosomatic illnesses).
Absence of food over a prolonged period results in starvation.
Absence of meaningful relationships over a prolonged period results in mental illness.
As feelings of hunger increase, behavior becomes more deviant (e.g., stealing, cannibalism, gorging, fantasy and daydreams about food, hallkinations).
As feelings of loneliness increase, behavior becomes more deviant (e.g., sexual promiscuity, exhibitionism, fantasy and daydreams).
Analogy -Loneliness us. Hunger Zderad and Belcher (1) found that, for purpose of teaching, an analogy seems useful in discussing such abstract concepts as loneliness. Zderad has often related feelings of loneliness to feelings of hunger, in an effort to communicate to students the meaning of this concept. Although she feels this analogy needs further development, it
185
L. M. A!
Hunger Physiologic changes occur in the absence of food. These changes are the body’s effort to maintain some homeostasis with the environment (e.g., contraction of the stomach). Treatment of starvation consists of a gradual increase of food intake over a time period sufficiently long to permit body adjustment.
Loneliness Psychologic changes occur in the absence of relationships or efforts to compensate for this lack (e.g., hallucinations, delusions).
Treatment of loneliness consists of gradual replacement of unreality with reality through meaningful relationships.
Displacement seems to occur when the need for relationships cannot be identified and fulfilled. Food is substituted to relieve emotional hunger as well as physical hunger. The rejection of food can be equated with the rejection of others who do not fulfill the need for love.
Nursing Intervention A nurse should be concerned with all that is human. This concern requires an understanding of experiences which make each individual unique and special. All nursing actions are based on this understanding. Loneliness is an inescapable part of man’s human condition. I agree with Zderad (1) that such a definition or point of view raises many questions for nurses. Some are: 1) Why are some people lonelier than others? 2) Is there another kind or degree of loneliness? 3) Are there barriers in relationships which make a difference in the degree of loneliness experienced? 4) Are there implications for nursing intervention?, and 5) If so, a t what point does one intervene? Although most lonely people claim that a lack of understanding on the part of others is a cause of their loneliness, there is a note of sadness, depression, and hopelessness. This was the general explanation I encountered in dealing with the group of elderly women mentioned earlier. In this interaction, these women moved toward the nurse in an effort to relate and share with her their experiences. Before the group process could become meaningful, it was necessary to
186
(LIAMS
Vol. X X V I
listen to their experiences in order to establish rapport. In the nurse’s efforts to assist the patient, it is essential that she not deny her own feelings. If she denies her own loneliness, she may be unable to accept the patient’s expression of these feelings, or she may ignore any obvious clues to loneliness in the patient’s behavior. She should seek to avoid the influence of any feeling expressed by the patient which might arouse similar feelings within herself. In dealing with the aforementioned group, I used the concept of touch as each patient verbalized personal feelings. As the leader of that group, I felt that this set the stage for significant group interaction for the purpose of the patients’ education. If the nurse is directive and becomes anxious in her interaction, the patient may feel she is denying him or her the right to express individual feelings. The result is withdrawal by the patient. The roots of man’s loneliness are in his need for relatedness. The nurselpatient relationship suggests an openness to involvement in which two human beings relate to one another as persons rather than as objects. A human experience is shared with another without anything being asked for in return. The nurse must communicate to the patient that she accepts all the qualities within him that are human. Each human being has experienced fear, happiness, loneliness, pain, anger, depression and every other human emotion. Therefore, there is no need to hide these feelings either from the patient or from oneself. If there is evidence of withdrawal by the patient, then the nurse can help him explore the reasons, either on a one-to-one basis or by using the group process. The nurse’s attitude toward the patient is an essential part of maintaining the helping nature of her profession. Her attitude will set the pace for acceptance and expression of feelings. Social ostracism and feelings of shame and guilt can result from a communicable disease, pain and suffering, or a physical handicap, as well as the psychic components of the patient. Nursing services in these instances should be centered around public education and assisting the person to cope with the changes in his lifestyle. If these patients already have developed a healthy coping mechanism, the nurse must be careful not to destroy it, for this misstep can create new problems. If the patient feels that his family is the cause of many of his problems, there may be a need for
April 1978
CONCEPT OF LONELINESS
family psychotherapy. The patient’s rate of recovery often is influenced by his family’s attitudes. Elderly people have been known to express a desire for death simply because they felt unwanted by their family. When rejection of self and rejection of others is involved, the nurse can help the patient re-evaluate his condition and view it in a different light. If the nurse can convey the fact that she values the patient as a person, then the patient may incorporate these feelings as his own. It is hoped that he will so generalize this experience with the nurse as to make it apply to others. A different approach to barriers in relationships is expressed by Weigert (16). She views loneliness as the inability to trust. To establish relationships with others, man must achieve some degree of trust in his fellow man. In the absence of this trust, the isolated person “feels the urgent need to justify his existence against the onslaught of the non-self, the horror of nonbeing.” A relationship in which the elements of trust exist can be provided by the nurse, through identifying and meeting the patient’s needs with honesty and consistency. This can be a relearning experience for aged persons who feel that they cannot trust anyone. It is basic for the nurse to understand the concept of loneliness in order to render appropriate services. Loneliness can be relieved by relating with others. There are degrees of loneliness and each person has his own method of coping; whether this method is functional or dysfunctional will influence nursing intervention. For
many persons, the provision of material aid acts as the only effective proof of personal interest. REFERENCES 1. Zderad L and Belcher HC: Developing Behavioral Concepts in Nursing. Atlanta, GA, Southern Regional Education Board, 1968. 2. Webster: Third New International Dictionary. Springfield, MA, Merriam Company, 1961, p 1454. 3. Fromm-Reichmann F: Loneliness, Psychiatry 22, 1, 1959. 4. Hofling CK et al: Basic Psychiatric Concepts in Nursing. Philadelphia, PA, J B Lippincott Company, 1967, pp 202-203. 5. Nuttin J : Psychoanalysis and Personality. New York, Sheed and Ward, 1953. 6. Burr HT: Psychological Functioning of Older People. Springfield, IL, Charles C Thomas, Publisher, 1971, p 62. 7. Evans MC: Psychosocial Nursing: Theory and Practice in Hospital and Community Mental Health. New York, Macmillan Company, 1971, pp 1-16. 8. Maustakos GE: Loneliness. New York, Prentice-Hall Inc, 1961. 9. Barrett JH: Gerontological Psychology. Springfield, IL, Charles C Thomas Publisher, 1972. 10. Barry MJ J r : Depression, shame, loneliness, and the psychiatrist’s position, Am J Psychother 16: 580, 1962. 11. Britton J H and Britton JA: Personality Changes in Aging. New York, Springer, 1972. 12. Jourad S: The Transparent Self. New Jersey, D Van Nostrand Company, 1964. 13. Patterson RD and Granick S: Human Aging. 11. An eleven year follow-up. Biomedical Behavior Study. Rockville, MD, National Institute of Mental Health, 1971. 14. Burton A: On the nature of loneliness, Am J Psychoanalysis 21: 31, 1961. 15. Ruesch J : TheraDeutic Communication. New York. WW Norton & Company, 1961. 16. Weigert E: Loneliness and trust - basic factors of human existence, Psychiatry 23: 121, 1960.
187
Vol. XXVI, No. 4 Printed in U . S . A .
A Concept of Loneliness in the Elderly‘ LULA M. WILLIAMS, RN, BS, MSN**
Veterans Administration Hospital, Tuskegee, Alabama
ABSTRACT: The author’s concept of loneliness is desciibed, especially as it concerns the elderly. An attempt is made to develop an understanding of the word, with its implications for guidance in the nursing profession. The nurse’s defenses against her own feelings of loneliness and depression can inhibit therapeutic interactions with lonely or depressed patients. Appropriate nursing action depends upon the knowledge, correlation and use of many other concepts such as those related to dynamics of behavior, personality structure and development, or problem solving. Practical recommendations for nursing intervention are outlined. Emphasized is the necessity for the nurse to understand the concept of loneliness so that she may render effective service. The concept described in this paper is “loneliness,” defined and discussed with reference to the elderly. During a group experience with elderly patients, we found that they verbalized periods of loneliness. As a result, the aim of this paper is to develop an understanding of the word and to stress its implications for the nursing profession. Several authors have pointed out negative influences by showing how the nurse’s own feelings of loneliness and depression and her defenses against them can inhibit therapeutic interactions with lonely or depressed patients. On the other hand, nursing has been cited as an example of constructive manipulation and as a certain kind of “loving.” Multiple concepts are possible in view of the patient’s behavior. In every case, appropriate nursing action depends upon one’s knowledge and use of many other concepts such as those related to the dynamics of behavior, personality structure and development, or problem solving. These related concepts require recognition or even detailed spelling-out in the descriptions. It is necessary to trace the developmental pattern of the behavioral concept, noting possible overlapping or repetition of steps in the process, and describing interactions over a time period with
the same patient. In addition to citing a specific example of the concept of loneliness, recommendations are made with regard to nursing intervention. Some of the literature on the subject is reviewed (1-15). OPERATIONAL DEFINITION An operational definition serves as a general guide for tracing the origin and progression of loneliness. The following seem to be logical steps toward a definition of the concept of loneliness described here: 1. Man has a need to transcend his separateness. 2. This need produces tension. 3. Relief of tension is sought through selftranscendence by: a) direct means (relationship with others), and b) indirect means (creative expression). 4. If these means are successful, feelings of loneliness are relieved, a t least temporarily. 5. If these means are unsuccessful, barriers exist. (Some barriers to self-transcendence are self-alienation, shame and guilt, social ostracism, cultural mobility and exclusion, lack of trust, and pain.) 6 . If the person is unable to overcome the barriers to self-transcendence, there is an increase in tension which leads to: a) an increase in-anxiety, and b) an increase in the degree of loneliness.
* The author’s statements and conclusions are the results of her own studies and do not necessarily reflect the opinion or policy of the Veterans Administration. ** Formerly, Clinical Specialist, Nursing Service, Veterans Administration Hospital, Tuskegee, AL 36083. Present address: Veterans Administration Hospital, P.O. Box 5841, Nashville, TN 37208.
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L. M. WILLIAMS
7. The persistent unfulfilled need for selftranscendence leads to: a) a further increase in anxiety, and b) a degree of loneliness experienced as psychic pain. 8. Defenses such as denial, suppression, repression, alcoholism, and somatic complaints, are used to decrease the anxiety and guard against pain. 9. Such defenses result in further alienation from the self and from others. 10. The alienation leads to an increase in loneliness and anxiety. 11. As the loneliness and anxiety increase, the defenses no longer work. 12. As the defenses crumble, the lonely person attempts to escape into a world of unreality (personality disintegration) (1). 13. Loneliness is defined as a character or state of being lonely, especially a state of being cheerlessly solitary; dejection or depression from being alone; love of retirement; or disposition to solitude (2). 14. Loneliness is described as a “state of mind in which hope that there may be interpersonal relationships in one’s future life is ruled out of the realm of expectation or imagination” (3). I conceptualize loneliness as a feeling that comes to a person when there seems to be no one who cares about what happens to him/her. The feeling is expressed as self-pity, thus making that person think only of self and the things expected from others. The social reject is frequently anxious to be part of the mainstream of life but, for a variety of reasons, is rejected by his peers. Reasons range from repulsive appearance to objectionable personal habits. Almost invariably the social reject becomes reclusive or a “loner,” but usually not from personal choice. It should be noted that some common problems in distinguishing concepts from forms of a concept and operationally defining them, stem from the difficulty in describing human behavior, which is affected by many variables. Also, concepts may be overtly or covertly expressed differently by each individual. Concept description requires judgment and careful interpretation as well as close observation. DISCUSSION According to Hofling et a1 (4), loneliness can become a serious problem in old age, particularly
184
Val. X X V I
if the person has been somewhat shy and withdrawn by temperament. The older person is apt to feel unsure that he is wanted and therefore finds it difficult to make friendly overtures. The resulting partial ‘isolation may bring further complications, since it favors the development of mistaken impressions about others. The environmental changes are not merely losses of one kind or another. They also involve the arrival of new situations, new means of transportation and communication, and perhaps different living quarters. Such changes may not be of a sort that previously would have constituted stress, but in old age they are apt to be stressful since they all require some expenditure of energy, the supply of which is sharply limited. According to Hofling (4), the crux of the emotional problems of the aged may be summarized by the fact that the old person is frequently called upon to make an increased effort of adjustment a t a time when his abilities for such effort are decreasing. In the face of a diminution of ego strength (resulting from mild organic changes in the central nervous system), the personality usually experiences a certain amount of regression. Hence, aged people, even those in good physical condition, are often described as “childish.” The fewer the unsolved inner conflicts and the stronger the ego during maturity, the less pronounced will be regression during old age. In the person who has enjoyed a healthy maturity, the decline is not apt to progress beyond the point of an acceptable mild and quiet eccentricity. Everyone experiences loneliness at some stage of life. We all have need for meaningful relationship with others. Early unfulfilled need for relationships with others results in personality isolation and stagnation. Nuttin (5) states that a child needs to feel “that he is loved and surrounded by affection” if he is to acquire selfconfidence and develop psychologically. If he does not have self-confidence and lacks an inner consistency, he becomes closed to others. He does not possess the inner strength to form successful relationships. Related to the concept of loneliness are theories on maternal deprivation. In the development of these theories and related studies there is evidence that love is the missing element which results in that degree of loneliness in the woman that is described as painful existence. It is usually against this lack of love that she needs to defend herself; then her defenses become barriers which lead to loneliness (6). During a group experience with five elderly
April 1978
CONCEPT OF
women, which was organized to gain first-hand knowledge of the phases of the group process, the concept of loneliness was mentioned by each member. The purpose of the group was education of the patient in the management of diabetes mellitus. When the author, as the leader of the group, requested each member to verbalize some problems associated with difficulty in adhering to the medical regimen, it was noted that the subject of loneliness predominated throughout the group experience. A constant preoccupation with the state of affairs of being old and lonely indicates depression in the older person. Remarks such as, “I am just in the way,” and, “Why does someone like you want to visit the likes of me?” are common, according to Evans (7). Relationships with others are remembered and dreamed about. Yearnings to see former classmates and acquaintances and to know what they have done with their lives, whether alive or dead, often become a preoccupation. The usual retirement age in this country is 65 for men and 62 to 65 for women. Preparation for retirement should begin early in life, and those who in their earlier years have developed their inner resources will be better equipped for this later period. The older population in this country is becoming more isolated as its knowledge and skills become obsolete. The world and the values of these aging people have become increasingly irrelevant in a highly technologic society with rapidly changing customs. Evans (7) further states that if we are to counteract the dehumanizing aspects of contemporary society, one pathway is through care and concern for aging members. The aged person is forced to make a personal adaptation to his changing needs as, with aging, he is regarded differently by society and also by himself. Even if the older person has the capacity to adapt to his own loss of social and personal resources, society’s restrictive attitudes and stereotypes about the aged may produce problems.
,ONELINESS
seemed important to include it here as a possible method of teaching.
Hunger
Loneliness
The need for food results in feelings of hunger.
The need for relationships results in feelings of loneliness.
Feelings of hunger are the motivational factor in the search for food.
Feelings of loneliness are the motivational factor in the search for relationships.
The ability to procure and utilize food is necessary for the relief of hunger.
The ability to relate to others is necessary for the relief of loneliness.
The quality of the food intake is an essential factor in relieving hunger and in maintaining physical health.
The quality of relationships is an essential factor in relieving loneliness and maintaining emotional health.
Feelings of hunger are experienced in degrees.
Feelings of loneliness are experienced in degrees.
Fear of hunger is a motivational factor in defenses against this feeling (e.g., security measures such as stocking the pantry, hoarding).
Fear of loneliness is a motivational factor in defenses against this feeling (e.g., inability to be alone, extreme dependence or extreme independence, psychosomatic illnesses).
Absence of food over a prolonged period results in starvation.
Absence of meaningful relationships over a prolonged period results in mental illness.
As feelings of hunger increase, behavior becomes more deviant (e.g., stealing, cannibalism, gorging, fantasy and daydreams about food, hallkinations).
As feelings of loneliness increase, behavior becomes more deviant (e.g., sexual promiscuity, exhibitionism, fantasy and daydreams).
Analogy -Loneliness us. Hunger Zderad and Belcher (1) found that, for purpose of teaching, an analogy seems useful in discussing such abstract concepts as loneliness. Zderad has often related feelings of loneliness to feelings of hunger, in an effort to communicate to students the meaning of this concept. Although she feels this analogy needs further development, it
185
L. M. A!
Hunger Physiologic changes occur in the absence of food. These changes are the body’s effort to maintain some homeostasis with the environment (e.g., contraction of the stomach). Treatment of starvation consists of a gradual increase of food intake over a time period sufficiently long to permit body adjustment.
Loneliness Psychologic changes occur in the absence of relationships or efforts to compensate for this lack (e.g., hallucinations, delusions).
Treatment of loneliness consists of gradual replacement of unreality with reality through meaningful relationships.
Displacement seems to occur when the need for relationships cannot be identified and fulfilled. Food is substituted to relieve emotional hunger as well as physical hunger. The rejection of food can be equated with the rejection of others who do not fulfill the need for love.
Nursing Intervention A nurse should be concerned with all that is human. This concern requires an understanding of experiences which make each individual unique and special. All nursing actions are based on this understanding. Loneliness is an inescapable part of man’s human condition. I agree with Zderad (1) that such a definition or point of view raises many questions for nurses. Some are: 1) Why are some people lonelier than others? 2) Is there another kind or degree of loneliness? 3) Are there barriers in relationships which make a difference in the degree of loneliness experienced? 4) Are there implications for nursing intervention?, and 5) If so, a t what point does one intervene? Although most lonely people claim that a lack of understanding on the part of others is a cause of their loneliness, there is a note of sadness, depression, and hopelessness. This was the general explanation I encountered in dealing with the group of elderly women mentioned earlier. In this interaction, these women moved toward the nurse in an effort to relate and share with her their experiences. Before the group process could become meaningful, it was necessary to
186
(LIAMS
Vol. X X V I
listen to their experiences in order to establish rapport. In the nurse’s efforts to assist the patient, it is essential that she not deny her own feelings. If she denies her own loneliness, she may be unable to accept the patient’s expression of these feelings, or she may ignore any obvious clues to loneliness in the patient’s behavior. She should seek to avoid the influence of any feeling expressed by the patient which might arouse similar feelings within herself. In dealing with the aforementioned group, I used the concept of touch as each patient verbalized personal feelings. As the leader of that group, I felt that this set the stage for significant group interaction for the purpose of the patients’ education. If the nurse is directive and becomes anxious in her interaction, the patient may feel she is denying him or her the right to express individual feelings. The result is withdrawal by the patient. The roots of man’s loneliness are in his need for relatedness. The nurselpatient relationship suggests an openness to involvement in which two human beings relate to one another as persons rather than as objects. A human experience is shared with another without anything being asked for in return. The nurse must communicate to the patient that she accepts all the qualities within him that are human. Each human being has experienced fear, happiness, loneliness, pain, anger, depression and every other human emotion. Therefore, there is no need to hide these feelings either from the patient or from oneself. If there is evidence of withdrawal by the patient, then the nurse can help him explore the reasons, either on a one-to-one basis or by using the group process. The nurse’s attitude toward the patient is an essential part of maintaining the helping nature of her profession. Her attitude will set the pace for acceptance and expression of feelings. Social ostracism and feelings of shame and guilt can result from a communicable disease, pain and suffering, or a physical handicap, as well as the psychic components of the patient. Nursing services in these instances should be centered around public education and assisting the person to cope with the changes in his lifestyle. If these patients already have developed a healthy coping mechanism, the nurse must be careful not to destroy it, for this misstep can create new problems. If the patient feels that his family is the cause of many of his problems, there may be a need for
April 1978
CONCEPT OF LONELINESS
family psychotherapy. The patient’s rate of recovery often is influenced by his family’s attitudes. Elderly people have been known to express a desire for death simply because they felt unwanted by their family. When rejection of self and rejection of others is involved, the nurse can help the patient re-evaluate his condition and view it in a different light. If the nurse can convey the fact that she values the patient as a person, then the patient may incorporate these feelings as his own. It is hoped that he will so generalize this experience with the nurse as to make it apply to others. A different approach to barriers in relationships is expressed by Weigert (16). She views loneliness as the inability to trust. To establish relationships with others, man must achieve some degree of trust in his fellow man. In the absence of this trust, the isolated person “feels the urgent need to justify his existence against the onslaught of the non-self, the horror of nonbeing.” A relationship in which the elements of trust exist can be provided by the nurse, through identifying and meeting the patient’s needs with honesty and consistency. This can be a relearning experience for aged persons who feel that they cannot trust anyone. It is basic for the nurse to understand the concept of loneliness in order to render appropriate services. Loneliness can be relieved by relating with others. There are degrees of loneliness and each person has his own method of coping; whether this method is functional or dysfunctional will influence nursing intervention. For
many persons, the provision of material aid acts as the only effective proof of personal interest. REFERENCES 1. Zderad L and Belcher HC: Developing Behavioral Concepts in Nursing. Atlanta, GA, Southern Regional Education Board, 1968. 2. Webster: Third New International Dictionary. Springfield, MA, Merriam Company, 1961, p 1454. 3. Fromm-Reichmann F: Loneliness, Psychiatry 22, 1, 1959. 4. Hofling CK et al: Basic Psychiatric Concepts in Nursing. Philadelphia, PA, J B Lippincott Company, 1967, pp 202-203. 5. Nuttin J : Psychoanalysis and Personality. New York, Sheed and Ward, 1953. 6. Burr HT: Psychological Functioning of Older People. Springfield, IL, Charles C Thomas, Publisher, 1971, p 62. 7. Evans MC: Psychosocial Nursing: Theory and Practice in Hospital and Community Mental Health. New York, Macmillan Company, 1971, pp 1-16. 8. Maustakos GE: Loneliness. New York, Prentice-Hall Inc, 1961. 9. Barrett JH: Gerontological Psychology. Springfield, IL, Charles C Thomas Publisher, 1972. 10. Barry MJ J r : Depression, shame, loneliness, and the psychiatrist’s position, Am J Psychother 16: 580, 1962. 11. Britton J H and Britton JA: Personality Changes in Aging. New York, Springer, 1972. 12. Jourad S: The Transparent Self. New Jersey, D Van Nostrand Company, 1964. 13. Patterson RD and Granick S: Human Aging. 11. An eleven year follow-up. Biomedical Behavior Study. Rockville, MD, National Institute of Mental Health, 1971. 14. Burton A: On the nature of loneliness, Am J Psychoanalysis 21: 31, 1961. 15. Ruesch J : TheraDeutic Communication. New York. WW Norton & Company, 1961. 16. Weigert E: Loneliness and trust - basic factors of human existence, Psychiatry 23: 121, 1960.
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