Loneliness and psychosis in clinical practice

In practice, clinical psychologists typically focus on diagnosing and treating specific mental health conditions. As a consequence, the social needs and priorities of clients have often been down-played or treated as secondary considerations. However, this approach is rapidly changing as accumulating evidence shows that loneliness—the distressing feeling that our social relationships are not meeting our needs – has substantial negative impacts on mental and physical health and recovery.

We know that loneliness is major problem in the general community. Estimates of prevalence vary, depending on the particular measure used and the time frame assessed, but suggest that around 25-35% of people report often feeling lonely.

For people with psychotic disorders the situation is much worse. Recent studies suggest that the prevalence of loneliness is much higher. In fact, the annual rate of loneliness in people with schizophrenia and related psychotic disorders appears to be around 2.3 times higher than in the general population and linked to a range of adverse effects on physical health, cognitive functioning and symptoms of mental illness (e.g. Badcock et al., 2015; Chau et al., 2019). In addition, according to a national survey of psychosis in Australia, loneliness was found to be one of the top challenges in daily life for people with psychosis (second only to financial problems) (Morgan et al., 2017). Yet, outdated notions that individuals with schizophrenia, or other psychotic disorders, do not desire social interaction due to asociality or anhedonia, coupled with social stigma, often persist and may mean that loneliness continues to fly under the radar of treating clinicians, hampering client recovery.

In our recently published study in Clinical Psychology: Science and Practice (Badcock, Adery and Park, 2020) we examined the literature on loneliness in adolescents and adults with psychotic disorders to provide  practitioners with a foundation for clinical practice. We reviewed the concept of loneliness in psychosis, and how it differs from related constructs, reflected on the importance of negative attitudes about loneliness and psychosis in the recovery journey, examined the causes, correlates and consequences of feeling lonely for people with psychotic disorders and critically assessed common measurement tools and treatment options. Some of the key findings are highlighted below.

Given the prevalence and impact of loneliness in individuals with schizophrenia and other psychotic disorders, it is of utmost importance to recognize and address their social needs. Self-report assessment tools such as The UCLA Loneliness Scale (UCLA-LS-20; Russell, 1996; Russell et al., 1980) may be administered during clinical intake to inform treatment planning. An abbreviated UCLA Loneliness Scale (UCLA-LS-8; Hawkley et al., 2005) consists of the 8 highest-loading items of the UCLA-LS-20 and is suitable for use when limited time or attention span may be considerations. Other tools allow for parsing emotional from social distress, and loneliness from isolation (Emotional/Social Loneliness Inventory; Vincenzi & Grabosky, 1987). Existential loneliness (a more global feeling of disconnect from the environment and reality) may further characterize client’s difficulties and can introduce therapeutic discussions or treatment goals (Existential Isolation Scale; Pinel et al., 2004).

What reduces loneliness?  Social affiliation, secure attachment, social bonding and social engagement are all likely to reduce loneliness, but no evidence-based intervention has been established to specifically address the loneliness of individuals with psychosis (Lim & Gleeson, 2014). However, there are several promising developments such as group exercises, games and activities to cultivate connectedness, social engagement and “shared subjective experience”. Some group activities such as choral singing may be very effective in enhancing connectedness, with a unique “ice-breaker effect” in promoting faster group cohesion (Pearce et al., 2015). In individuals with psychosis, group singing has been shown to reduce loneliness  (Adery, 2019). These findings suggest that low-burden, low cost, and flexibility of group singing may offer an ideal intervention strategy for schizophrenia. Clearly, more work needs to be done to fill the need-treatment gap.

Our focus on loneliness is particularly timely in the context of COVID19. The impact of the pandemic extends well beyond the illness itself, with sharp increases already reported in anxiety, stress and social isolation. People with pre-existing problems with loneliness will be hardest hit by the social restrictions introduced to slow virus transmission and the skills and expertise of clinical psychologists are in high demand. However, whilst currently available resources will help clinicians respond right now to reduce loneliness in psychosis, the knowledge gained from practice-based evidence could go a long way to improving interventions for the future.

Discussion Questions

  • What might be the benefit of routinely asking people with psychosis if they feel lonely?
  • What are the mechanisms linking loneliness to poor mental and physical health in people with or without psychosis?
  • How might we utilize increased awareness of the widespread impacts of loneliness to reduce stigma and improve related treatment?

Reference Article

Badcock, J.C., Adery, L.H. and Park, S. Loneliness in psychosis: A practical review and critique for clinicians. Clinical Psychology: Science and Practice, Accepted April, 2020.

Author Bios

Professor Johanna Badcock is a Fellow of the Association for Psychological Science, Research Director of Perth Voices Clinic (Western Australia) and Adjunct Professor in the School of Psychological Science, University of Western Australia.

Dr. Laura Adery is a Postdoctoral Scholar and Clinical Instructor in the Department of Psychiatry at the University of California, Los Angeles.

Sohee Park is the Gertrude Conaway Vanderbilt Professor of Psychology at Vanderbilt University in the U.S.  She is a Fellow of the Association for Psychological Science and serves on the Board of Directors of the Schizophrenia International Research Society.

References

Adery, L. L. (2019). Better Together: Effects and Treatments of Loneliness and Social Isolation Across the Schizophrenia Spectrum. (Publication Number etd: 05042019-005238.) Vanderbilt University].

Badcock, J. C., Shah, S., Mackinnon, A., Stain, H. J., Galletly, C., Jablensky, A., & Morgan, V. A. (2015). Loneliness in psychotic disorders and its association with cognitive function and symptom profile. Schizophrenia Research, 169(1-3), 268-273. https://doi.org/10.1016/j.schres.2015.10.027

Chau, A. K. C., Zhu, C., & So, S. H. (2019). Loneliness and the psychosis continuum: a meta-analysis on positive psychotic experiences and a meta-analysis on negative psychotic experiences. International Review of Psychiatry, 1-20. https://doi.org/10.1080/09540261.2019.1636005

Hawkley, L. C., Browne, M. W., & Cacioppo, J. T. (2005). How Can I Connect With Thee?: Let Me Count the Ways. Psychological Science, 16(10), 798-804. https://doi.org/10.1111/j.1467-9280.2005.01617.x

Lim, M. H., & Gleeson, J. F. (2014). Social connectedness across the psychosis spectrum: Current issues and future directions for interventions in loneliness [Opinion]. Front Psychiatry, 5. https://doi.org/10.3389/fpsyt.2014.00154

Morgan, V. A., Waterreus, A., Carr, V., Castle, D., Cohen, M., Harvey, C., Galletly, C., Mackinnon, A., McGorry, P., McGrath, J. J., Neil, A. L., Saw, S., Badcock, J. C., Foley, D. L., Waghorn, G., Coker, S., & Jablensky, A. (2017). Responding to challenges for people with psychotic illness: Updated evidence from the Survey of High Impact Psychosis. Australian and New Zealand Journal of Psychiatry, 51(2), 124-140. https://doi.org/10.1177/0004867416679738

Pearce, E., Launay, J., & Dunbar, R. I. (2015). The ice-breaker effect: singing mediates fast social bonding. R Soc Open Sci, 2(10), 150221. https://doi.org/10.1098/rsos.150221

Pinel, E. C., Long, A. E., Landau, M. J., & Pyszczynski, T. (2004). I-Sharing, the Problem of Existential Isolation, and Their Implications for Interpersonal and Intergroup Phenomena. In Handbook of Experimental Existential Psychology. (pp. 352-368). Guilford Press.

Russell, D. W. (1996). UCLA Loneliness Scale (Version 3): reliability, validity, and factor structure. Journal of Personality Assessment, 66(1), 20-40. https://doi.org/10.1207/s15327752jpa6601_2

Russell, D. W., Peplau, L. A., & Cutrona, C. E. (1980). The revised UCLA Loneliness Scale: concurrent and discriminant validity evidence. Journal of Personality and Social Psychology, 39(3), 472-480. https://doi.org/10.1037//0022-3514.39.3.472

Vincenzi, H., & Grabosky, F. (1987). Measuring the Emotional Social Aspects of Loneliness and Isolation. Journal of Social Behavior and Personality, 2(2), 257-270. <Go to ISI>://WOS:A1987J463800027

Pearce, E., Launay, J., & Dunbar, R. I. (2015). The ice-breaker effect: singing mediates fast social bonding. R Soc Open Sci, 2(10), 150221. doi:10.1098/rsos.150221

Russell, D. W. (1996). UCLA Loneliness Scale (Version 3): reliability, validity, and factor structure. Journal of Personality Assessment, 66(1), 20-40. doi:10.1207/s15327752jpa6601_2

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