overcoming the practical, social and emotional barriers to better relationships

Loneliness has been identified as a significant challenge for people with psychosis (Lim et al., 2020) and has been ranked as a major barrier to recovery (Morgan et al., 2017). In a large Australian survey, 80% of adults diagnosed with psychosis endorsed feeling lonely in the past year (Stain et al., 2012), which may be exacerbated by low levels of social support among individuals with psychosis (Sündermann et al., 2014). This statistic is particularly concerning given the association between loneliness and chronic health conditions, including heart disease, hypertension, and stroke (Petitte et al., 2015). Moreover, research suggests that loneliness may further limit social support and increase the risk of psychotic episodes (Gayer-Anderson et al., 2013). However, there has been a dearth of rigorous studies exploring the relationship between loneliness and psychosis, and a theoretical framework has been proposed focusing on the experience of loneliness in the spectrum of psychosis and its impact on recovery and mental health (Lim et al., 2018).

Most studies exploring psychosis have explored social network size and reciprocity quantitatively (Michalska da Rocha et al., 2017), which has been helpful in illuminating a robust relationship between loneliness and psychosis. Qualitative studies exploring the experiences of those with schizophrenia spectrum disorders can also offer a unique opportunity to elucidate the lived experience of a psychological disorder, which is useful in informing the development of preventative and therapeutic interventions. This is particularly when the researchers take an ‘emic approach’ to “elicit descriptions of loneliness that are not bound to definitions proposed by researchers”.

In the current paper, Ludwig et al. (2022) aim to deconstruct which aspects of psychosis may impact the feeling of loneliness (frequency levels and severity), as well as how people with a diagnosis of psychosis manage their loneliness.

Loneliness can influence the negative symptoms of psychosis, mental health comorbidities and feelings of self-worth.

Methods

Participants were recruited from the Schizophrenia Treatment and Evaluation Program (STEP) outpatient services based in North Carolina. The vulnerability of participants was taken into consideration and people were included if they had no inpatient hospitalisations for the past three months, had a diagnosis of psychotic disorder and were receiving treatment in the clinics.

The interview guide was informed by recent literature on loneliness in psychosis and the involvement of a specialist consultant and an expert loneliness researcher. The guide included perspectives and personal accounts about loneliness and situations where these feelings had been more prominent, as well as symptoms that may exacerbate the experience of loneliness.

A thematic analysis was used to examine the interviews and identify themes. A combination of inductive and deductive analytic approaches was used, while the researchers discussed in-depth the coding framework and emerging themes.

Results

In total, 16 participants diagnosed with schizophrenia spectrum disorders engaged in semi-structured qualitative interviews about loneliness. The following themes were identified:

Physical barriers to adequate social engagement or community involvement

• Physical barriers were defined as the structural aspects that contributed to loneliness (tangible/intangible and social/no social obstacles). For example, people discussed their financial situation (i.e., unemployment/benefits) and difficulties with transportation (i.e., not driving) which prolonged the time spent in isolation and their sense of embarrassment.
• On the other hand, recreation and work were described to be protective activities; work-related activities or running errands during the day provided a sense of intrinsic purpose but also a way of making others aware of one’s meaningful contribution to society.

Patterns of social contact that contribute to lonely feelings

• This theme explored the participants’ social context and the ways in which their relationships contributed to feelings of loneliness (i.e., quantity, quality, type of social interaction, and stability of relationships). Individuals shared increased feelings of loneliness when they believed their social contact was infrequent, and their relationships lacked intimacy, encouragement and reciprocated appreciation.
• Psychosis was deemed to play a role in creating conflict in relationships to the point where individuals felt that their efforts to continue and amend relationships were futile.
• Interestingly, several individuals expressed a desire to engage with those outside of their peer community and family (i.e., ‘normative’ relationships) hoping that they will have more meaningful conversations.
• The cause of loneliness was also attributed to the absence of a romantic partner with whom one could develop an intimate bond, although people discussed barriers around personal insecurities or lack of experience with dating.

Psychological variables

• Participants expressed their internal experience of loneliness and the association with other psychological symptoms, such as temporary and chronic thoughts and emotions, and attitudes.
• Negative emotional states were described, whilst paranoia was the most frequently reported psychotic symptom associated with loneliness across interviewees.
• For others, social anhedonia and social anxiety surrounding the formation of social plans were barriers to forming social connections.
• The perception that their experiences could not be understood by others contributed to a deeply-rooted internalised stigma which led to self-perceptions of ‘abnormality’.

Coping strategies to manage loneliness

• Interviewees said that the ways they coped with these feelings of loneliness included actionable behaviours and self-talk. Many commented on the benefits of therapeutic techniques such as accepting emotions, journaling, distraction, prayer and cognitive restructuring.
• While participants expressed apprehension about talking to their friends or family about being lonely; worrying that they may be perceived as ‘needy’, most reported that sharing their experience with a trusted person was the most effective coping strategy.
• Some of the recommendations of support included the creation of a ‘safe place’ to discuss lonely experiences with therapists, group-based psychotherapy focused on goal-setting, as well as organised recreational activities and support groups for dating. One participant also shared the potential of artificial intelligence (i.e., having a robot to share feelings).

The experience of loneliness among people with psychosis was associated with practical and emotional barriers for social engagement and interactions.

Conclusions

The authors concluded that people diagnosed with schizophrenia spectrum disorders experience significant impacts of loneliness in their social life and interactions, as well as their psychological functioning, such as changes in their psychotic symptoms and other mental health difficulties. Reading how participants manage and cope with these lonely feelings really highlights the need for effective coping mechanisms and therapeutic pathways that target loneliness in this clinical population.

This study emphasises that psychosocial support targeting loneliness in people with psychosis needs more attention.

Strengths and limitations

The authors provide an in-depth view of people’s experience of loneliness and the structural, emotional and environmental barriers they may face in forming and/or establishing relationships. Through their detailed methodology, it is evident that the authors followed several steps to ensure their research is important, relevant and applicable to current clinical practice. We appreciated the involvement of research consultants and experts in the field, however, it would have been even more valuable to involve people with lived experience.

Moreover, the study took place in the United States, a country with limited public healthcare provision and a different mental health system from the UK. Therefore, this raises questions on whether the results can be interpreted cross-culturally for people with different societal structures, cultural norms, resource availability and situational factors. The adults in the sample were aged between 30-50 years old. However, it is increasingly becoming known that loneliness is a major problem in young adults. It would be interesting to replicate the study in younger individuals earlier in the course of their illness. Lastly, individuals with infrequent experiences of loneliness were excluded; hence, it is not known whether these experiences are common to individuals with psychosis who have intermittent or infrequent feelings of loneliness.

The lack of experts by experience involvement in the design of the study is a real limitation.

Implications for practice

The association between loneliness, negative cognitions, and emotions indicate that cognitive behavioural therapy techniques focused on the ‘here and now’, such as cognitive restructuring and exposure, may be helpful to enhance satisfaction from in-person social interactions. This may be particularly helpful for people with psychosis to navigate fears of rejection and facilitate a connection with individuals outside their close social circles. It would be interesting to explore how these techniques might alter neural sensitivity to social reward and increase social motivation.

The study also revealed that individuals with psychosis yearn for relational intimacy. This finding underlines the need to enhance people’s confidence in building and sustaining healthy romantic relationships (i.e., dating skills and psychoeducation). Interventions could focus on strengthening relationships within existing social circles, whilst at the same time helping individuals to identify ways to form new meaningful relationships.

Clinicians working within secondary care or early intervention in psychosis services could use the qualitative findings from this study to inform their practice in the following ways:

• Initiate conversations around feelings of loneliness and assess the impact of this experience on their daily functioning, quality of life and therapeutic progress
• Map activities of interest and hopes of social interactions and signpost to available community resources (i.e., social or activity groups, community-based interventions)
• Help to build skills that could support social interaction
• Invite the involvement of significant others to reduce feelings of loneliness (i.e., indirect interventions to improve people’s quality of life).

Clinicians working with people with psychosis can provide a safe environment to explore feelings of loneliness and build skills useful in social interactions.

Statement of interest

No conflicts of interest with the paper. Both bloggers have a research interest in feelings of loneliness.

Links

Primary paper

Kelsey A. Ludwig, Benjamin Brandrett, Michelle H. Lim, Paul Mihas & David L. Penn (2022) Lived experience of loneliness in psychosis: A qualitative approach, Journal of Mental Health, 31:4, 543-550, DOI: 10.1080/09638237.2021.2022622

Other references

Lim, M. H., Gleeson, J. F., Rodebaugh, T. L., Eres, R., Long, K. M., Casey, K., … & Penn, D. L. (2020). A pilot digital intervention targeting loneliness in young people with psychosis. Social psychiatry and psychiatric epidemiology, 55, 877-889.

Morgan, V. A., Waterreus, A., Carr, V., Castle, D., Cohen, M., Harvey, C., … & Jablensky, A. (2017). Responding to challenges for people with psychotic illness: Updated evidence from the Survey of High Impact Psychosis. Australian & New Zealand Journal of Psychiatry, 51(2), 124-140.

Stain, H. J., Galletly, C. A., Clark, S., Wilson, J., Killen, E. A., Anthes, L., … & Harvey, C. (2012). Understanding the social costs of psychosis: the experience of adults affected by psychosis identified within the second Australian National Survey of Psychosis. Australian & New Zealand Journal of Psychiatry, 46(9), 879-889.

Sündermann, O., Onwumere, J., Kane, F., Morgan, C., & Kuipers, E. (2014). Social networks and support in first-episode psychosis: exploring the role of loneliness and anxiety. Social psychiatry and psychiatric epidemiology, 49, 359-366.

Petitte, T., Mallow, J., Barnes, E., Petrone, A., Barr, T., & Theeke, L. (2015). A systematic review of loneliness and common chronic physical conditions in adults. The open psychology journal, 8(Suppl 2), 113.

Gayer-Anderson, C., & Morgan, C. (2013). Social networks, support and early psychosis: a systematic review. Epidemiology and psychiatric sciences, 22(2), 131-146.

Lim, M. H., Gleeson, J. F., Alvarez-Jimenez, M., & Penn, D. L. (2018). Loneliness in psychosis: a systematic review. Social psychiatry and psychiatric epidemiology, 53, 221-238.

Michalska da Rocha, B., Rhodes, S., Vasilopoulou, E., & Hutton, P. (2018). Loneliness in psychosis: a meta-analytical review. Schizophrenia bulletin, 44(1), 114-125.

Photo credits