Psychology of loneliness: new research 9781536129014, 1536129011

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PSYCHOLOGY OF EMOTIONS, MOTIVATIONS AND ACTIONS

PSYCHOLOGY OF LONELINESS NEW RESEARCH

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PSYCHOLOGY OF EMOTIONS, MOTIVATIONS AND ACTIONS

PSYCHOLOGY OF LONELINESS NEW RESEARCH

LÁZÁR RUDOLF EDITOR

Copyright © 2017 by Nova Science Publishers, Inc. All rights reserved. No part of this book may be reproduced, stored in a retrieval system or transmitted in any form or by any means: electronic, electrostatic, magnetic, tape, mechanical photocopying, recording or otherwise without the written permission of the Publisher. We have partnered with Copyright Clearance Center to make it easy for you to obtain permissions to reuse content from this publication. Simply navigate to this publication’s page on Nova’s website and locate the “Get Permission” button below the title description. This button is linked directly to the title’s permission page on copyright.com. Alternatively, you can visit copyright.com and search by title, ISBN, or ISSN. For further questions about using the service on copyright.com, please contact: Copyright Clearance Center Phone: +1-(978) 750-8400 Fax: +1-(978) 750-4470 E-mail: [email protected].

NOTICE TO THE READER The Publisher has taken reasonable care in the preparation of this book, but makes no expressed or implied warranty of any kind and assumes no responsibility for any errors or omissions. No liability is assumed for incidental or consequential damages in connection with or arising out of information contained in this book. The Publisher shall not be liable for any special, consequential, or exemplary damages resulting, in whole or in part, from the readers’ use of, or reliance upon, this material. Any parts of this book based on government reports are so indicated and copyright is claimed for those parts to the extent applicable to compilations of such works. Independent verification should be sought for any data, advice or recommendations contained in this book. In addition, no responsibility is assumed by the publisher for any injury and/or damage to persons or property arising from any methods, products, instructions, ideas or otherwise contained in this publication. This publication is designed to provide accurate and authoritative information with regard to the subject matter covered herein. It is sold with the clear understanding that the Publisher is not engaged in rendering legal or any other professional services. If legal or any other expert assistance is required, the services of a competent person should be sought. FROM A DECLARATION OF PARTICIPANTS JOINTLY ADOPTED BY A COMMITTEE OF THE AMERICAN BAR ASSOCIATION AND A COMMITTEE OF PUBLISHERS. Additional color graphics may be available in the e-book version of this book.

Library of Congress Cataloging-in-Publication Data ISBN: H%RRN

Published by Nova Science Publishers, Inc. † New York

CONTENTS Preface Chapter 1

Chapter 2

vii The Veteran's Loneliness: Emergence, Facets, and Implications for Intervention Jacob Y. Stein Loneliness and Preference for Solitude among Older Adults Aya Toyoshima

Chapter 3

Loneliness and Suicide Rebecca L. Kauten, Jessica M. LaCroix, Amber M. Fox and Marjan Ghahramanlou-Holloway

Chapter 4

Social, Interpersonal and Emotional Antecedents of Loneliness Leehu Zysberg

Chapter 5

Index

Loneliness Among Romanian Immigrants Living in Portugal Félix Neto and Maria da Conceição Pinto

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37 67

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123 141

PREFACE In this compilation, the authors begin by discussing veterans' loneliness post-war, delineating this experience's developmental course and the underlying relational deficits at its infrastructure throughout that course. The authors also compare the characteristics of this loneliness to those of other types of loneliness, highlighting the necessity of understanding the veteran's experience as a specific form of loneliness. Next, developmental change in elderly people linked to loneliness and preference for solitude are examined through findings of recent studies, and reconsidering loneliness and the positive aspects of solitude. Preference for solitude is similarly examined. One chapter examines loneliness and suicide through Aaron Beck’s cognitive behavioral theory and largely through Erik Erickson’s theory of psychosocial development. Intervention strategies to address loneliness and suicide are studied, and recommendations for clinical practice and future areas of study are presented. Lastly, a study is presented focusing on determinants of loneliness among Romanian migrants living in Portugal. The goal of the study was to answer two questions: “(1) What influences do acculturation problems have on loneliness? (2) What influences does adaptation to the society of settlement have on loneliness?” Chapter 1 - Veterans' loneliness may persist decades after the war and may be detrimental, particularly when deployment has been traumatic.

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Indeed, mitigating loneliness via social support may be essential for alleviating war-induced posttraumatic stress disorder (PTSD). Nevertheless, rarely has veterans' loneliness been empirically investigated, and its unique features have never been systematically delineated. Since experiences of loneliness vary qualitatively, and these variations may have implications regarding the kind of support and clinical intervention necessary for their amelioration, understanding its nature may be critical. The current chapter fills this gap by delineating this experience's developmental course and the underlying relational deficits at its infrastructure throughout that course. Based on veterans' accounts and extant multidisciplinary literature, the veteran's loneliness is traced from enlistment, through deployment, war, and homecoming. An experiential loneliness bound to the “veteran identity” is depicted, and the significance of transitions between social contexts and experiential worlds is underscored. Comparing the characteristics of this loneliness to those of other types of loneliness the chapter highlights the necessity of understanding the veteran's experience as a specific form of loneliness, with implications for intervention, both clinical and societal. The chapter therefore concludes with implications for practitioners and social support networks, as well as desirable directions for future research. Chapter 2 - Older adults tend to find it difficult to engage in social activities, as their social environments can be adversely affected as a result of negative life events such as bereavements, retirement, and the loss of physical function. Such individuals also find it difficult to develop new close relationships in later life. Further, the ratio of time spent alone tends to increase with age, with studies showing that older adults spend 48% of their daily lives engaging in solitary activities. However, although there are some negative factors that enhance loneliness in later life, the levels of loneliness reported by older adults are not as high as those reported by other age groups, which is a somewhat paradoxical finding. Geropsychological studies have determined that older adults manage the consequences of failure and loss using two strategies: primary control strategies and secondary control strategies. Primary control strategies refer to individuals’ attempts to change the external world to fit their personal

Preface

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needs and desires, while secondary control strategies concern individuals’ inner emotions and involve their efforts to influence their own preferences. As primary control strategies can be costly, older adults are more likely to rely on secondary control strategies. Thus, it is possible that older adults use secondary control to change their preferences and adapt to the new limitations to their social activities. Meanwhile, preference for solitude, which relates to a high level of competency in terms of spending time alone (e.g., feeling positive emotions in such a situation), may be another important factor in this regard. In this chapter, developmental change in elderly people in relation to loneliness and preference for solitude are reviewed; this is achieved by examining the findings of recent studies, and reconsidering loneliness and the positive aspects of solitude. Chapter 3 - Loneliness has been conceptualized both as an objective state of physical alienation and a subjective state of distress due to feeling alone. The construct of loneliness has been empirically linked with a variety of mental health conditions including depression, hopelessness, suicide ideation, and/or suicide-related behaviors. This chapter examines loneliness and suicide through Aaron Beck’s cognitive behavioral theory and largely through Erik Erickson’s theory of psychosocial development. More specifically, the authors review how ambivalence resulting from competing drives of connectedness, authenticity, and self-protection may contribute to loneliness and explore manifestations of loneliness and suicidality during childhood, adolescence, young adulthood, middle adulthood, and older adulthood. Intervention strategies to address loneliness in the context of suicide are explored, and recommendations for clinical practice and future areas of empirical inquiry are presented. Chapter 4 - While the literature is replete with evidence and theory regarding the emotional consequences of loneliness and the challenges they pose to individuals, there is still not enough evidence examining the emotional antecedents of the phenomenon. This chapter reviews the existing literature on emotional antecedents of loneliness, dwells on recent evidence linking loneliness and certain underlying emotional mechanisms and presents an integrative model to guide research and future practice in diverse settings.

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Chapter 5 - This study approaches the determinants of loneliness among Romanian migrants living in Portugal. Two research questions guided the study: (1) What influences do acculturation problems have on loneliness? (2) What influences does adaptation to the society of settlement have on loneliness? The sample of this research consisted of 181 Romanian immigrants living in Portugal (49% females). The average duration of stay in Portugal was 9 years. Loneliness was measured by the ULS-6. In addition, other scales were used to assess Portuguese language proficiency, perceived discrimination, sociocultural adaptation, multicultural ideology, psychological problems and self-esteem. Results showed that both indicators of acculturation problems and of adaptation significantly predicted loneliness. Implications of the findings for future research are discussed.

In: Psychology of Loneliness Editor: Lázár Rudolf

ISBN: 978-1-53612-900-7 © 2017 Nova Science Publishers, Inc.

Chapter 1

THE VETERAN'S LONELINESS: EMERGENCE, FACETS, AND IMPLICATIONS FOR INTERVENTION Jacob Y. Stein*, PhD Bob Shapell School of Social Work, Tel Aviv University, Tel Aviv, Israel I-CORE Research Center for Mass Trauma, Tel Aviv University, Tel Aviv, Israel

ABSTRACT Veterans' loneliness may persist decades after the war and may be detrimental, particularly when deployment has been traumatic. Indeed, mitigating loneliness via social support may be essential for alleviating war-induced posttraumatic stress disorder (PTSD). Nevertheless, rarely has veterans' loneliness been empirically investigated, and its unique features have never been systematically delineated. Since experiences of

* Corresponding Author address: Jacob Y. Stein, I-CORE Research Center for Mass Trauma, Bob Shapell School of Social Work, Tel Aviv University, 69978 Tel Aviv, Israel. Email: [email protected].

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Jacob Y. Stein loneliness vary qualitatively, and these variations may have implications regarding the kind of support and clinical intervention necessary for their amelioration, understanding its nature may be critical. The current chapter fills this gap by delineating this experience's developmental course and the underlying relational deficits at its infrastructure throughout that course. Based on veterans' accounts and extant multidisciplinary literature, the veteran's loneliness is traced from enlistment, through deployment, war, and homecoming. An experiential loneliness bound to the “veteran identity” is depicted, and the significance of transitions between social contexts and experiential worlds is underscored. Comparing the characteristics of this loneliness to those of other types of loneliness the chapter highlights the necessity of understanding the veteran's experience as a specific form of loneliness, with implications for intervention, both clinical and societal. The chapter therefore concludes with implications for practitioners and social support networks, as well as desirable directions for future research.

Keywords: loneliness, veterans, identity, experiential loneliness, trauma

INTRODUCTION In a recent evocative article that appeared in the veteran-issues online magazine US Defense Watch, former U.S Army Intelligence officer and veteran of the Gulf War, Ray Starmann (2015), asserted the following: Millions of vets are and have been successful in all endeavors. They are doctors, lawyers, business people and a thousand other professions. Not all have PTSD; not all are the troubled, brooding, street corner homeless guy, although they exist and need help desperately. No matter how successful a vet might be materially, more often than not, vets are often alone, mentally and spiritually each day and for the rest of their lives.

Starmann had written his article as the 2015 Veterans Day was approaching, so as to provide a glimpse at the solitary world of the veteran. However, for those unfamiliar with the veteran experience, the solitary world of veterans depicted by Starmann may seem striking, perplexing and

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enigmatic. The enigma is accentuated when this solitary reality is contrasted with the ostensible embracing welcome that many civilians offer their nation's returning veterans, and more so in cases wherein veterans evince an apparently successful reintegration into society, as portrayed by Starmann. Thus, as one reads Starmann's depiction of the veteran's isolation, one may come to wonder: what is it that is so critically lacking in veterans' social networks? What is it that renders them so alone? Moreover, how does this loneliness materialize? And how might it best be addressed and ameliorated? These are the questions that are at the center of the current chapter. It is important to address these questions and unravel the enigma for several reasons. First, because loneliness is an emotional state that may entail extreme torment and suffering, and as such shares common features with physical pain (e.g., MacDonald & Leary, 2005). Additionally, loneliness may be extremely detrimental, as it precipitates impediments to physical and mental health, hindered well-being and premature mortality (S. Cacioppo, Grippo, London, Goossens, L., & Cacioppo, 2015). Even more alarming is the evidence that loneliness plays a pivotal role in suicide behaviors (Van Orden et al., 2010). At a time when veteran suicides are spiking (e.g., Kang et al., 2015), veteran loneliness is an issue that must be understood to the core, and efficient means for its amelioration are to be sought with utmost urgency. Finally, understanding veterans' loneliness may be informative in that it sheds light on the processes that occur in the various social networks in which these individuals are situated, both military and civilian. In the current chapter I then strive to delineate both the characteristics of the veteran's loneliness, and the manner in which it unfolds from the time of enlistment to the veteran's return to civilian life. Towards this end, in the preparation of this chapter an "insider's perspective" of the experience was sought, and a rich description of the experience is put forth below. The ultimate objective of the current chapter is to inform mental health professionals, as well as supporting figures within veterans' close social networks, as to the manner in which the loneliness under scrutiny may best be addressed. Indeed, understanding the lonely aspect of being a

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veteran may be of immense value also for those who care for the returning veteran, first and foremost family and friends (Lyons, 2007). At the outset, however, the nature and multifariousness of loneliness must be addressed, for it is these that mandate the discernment of one type of loneliness from other types.

Loneliness – Its Nature and Relation to Recovery from Trauma Loneliness may be conceptualized as the epitome of relational deficit within a given social configuration. From a cognitive perspective, loneliness is conceptualized as a perceived discrepancy between an individual’s desired social relations and those that he or she currently inhabits (Peplau & Perlman, 1982; Russell, Cutrona, McRae, & Gomez, 2012). As such, loneliness is, by definition, a subjective rather than objective experience of isolation. Moreover, it is invariably experienced as unpleasant as opposed to neutral or positive modes of isolation, such as aloneness or solitude (Gotesky, 1965). However, loneliness is anything but a unified experience (e.g., Hawkley, Browne, & Cacioppo, 2005; Rokach, 1988), and is in fact a term that lends itself to diverse, although conceptually related, phenomena (Stein & Tuval-Mashiach, 2015b). According to Stein and Tuval-Mashiach (2015b), experiences of loneliness may be qualitatively discerned from one another by examining the characteristics of one or more of seven elements that constitute every experience of loneliness: a) the experiencing subject (e.g., the lonely person's age, gender, personality), b) the relationship within which the experience transpires (e.g., familial, social, romantic), c) the Other with whom the relationship is formed (e.g., friends, intimate partner, oneself as an Other), d) the relational needs that are to be fulfilled in the relationship and the relational expectations it fosters (e.g., belongingness, intimacy, love, attention), e) the discrepancy between desired and attained relatedness (e.g., intensity or severity), f) the manner in which the person experiences him or herself as isolated (e.g., socially isolated, emotionally isolated), and g) the quality or intensity of the painful affective state that

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constitutes the experience of loneliness (e.g., depression, hollowness, forsakenness). Loneliness in this respect is polymorphic. The social isolation of an ostracized adolescent yearning for friends and the emotional isolation of a widow longing for her lost companion, are both forms of loneliness albeit a very different from of loneliness (Weiss, 1973), as is the existential isolation demarcated by philosophers (e.g., Mijuskovic, 2015) and existential psychologists (e.g., Ettema, Derksen, & van Leeuwen, 2010; Moustakas, 1961; Yalom, 1980). These phenomena all share a mutual core, but are nonetheless associated with different psychosocial deficits. Therefore, it is argued, they may require different interventions for their amelioration. Conversely, recent research indicates that the loneliness of active duty soldiers is likewise contextually-bound, and must be understood somewhat differently than the loneliness that is prevalent among civilians (J. T. Cacioppo et al., 2016). Ultimately, the alleviation of loneliness may be achieved by addressing the person's maladaptive perceptions or social tendencies (Masi, Chen, Hawkley, & Cacioppo, 2011), or otherwise by environmental changes that entail the adequate provision of relational provisions and apt social support. Arguably, providing the necessary support and facilitating healing highly depend on the identification of the relevant relational needs of the lonely person and the relationships within which these must be realized (Dykstra, 1993). From a motivation-oriented evolutionary perspective, loneliness is understood primarily as a transient phenomenon that, although may include an initial phase of withdrawal, eventually motivates individuals to seek reconnection (Qualter et al., 2015). Understanding personal inclinations towards either withdrawal or reconnection then depends on understanding of the underlying foundations of the individual's experience of loneliness. These realizations become pertinent when one takes into consideration that veterans must often also cope with the traumatizing aspects of war. War entails numerous stressors, including a constant threat of annihilation, ubiquitous death, incessant anxiety, exhaustion, deprivation, moral conflicts, guilt, homesickness and the loss of friends (e.g., Nash, 2007). These, for many veterans, may result in prolonged torment and

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anguish that manifest as combat stress injuries (Figley & Nash, 2007), most conspicuous of which is posttraumatic stress disorder (PTSD; e.g., Fulton et al., 2015). Nevertheless, phenomena that have been identified as antonymic to loneliness (e.g., reconnection, reintegration, social support), may play a pivotal role in the process of recovering from trauma (Herman, 1992) as well as in mitigating the development of PTSD (e.g., Brewin, Andrews, & Valentine, 2000). Studies have found that perceived social support was implicated in less loneliness and PTSD among veterans both cross-sectionally and longitudinally throughout the course of 20 years after the war (Karstoft, Armour, Elklit, & Solomon, 2013; Solomon, Bensimon, Greene, Horesh, & Ein-Dor, 2015). Moreover, Solomon, Waysman and Mikulincer (1990) found that in the case of post-war PTSD support may be protective only if it indeed manages to alleviate loneliness. Notwithstanding, it would seem that any information addressing the nature and developmental course of veterans' loneliness may not to be found in one organized source in the trauma literature, but rather must be aggregated piecemeal from various sources.

Loneliness-Focused Trauma Literature: A Gap Delineated Trauma has long been recognized as one of many potential antecedents of loneliness (Rokach, 1989). In the specific domain of war related trauma, there are volumes replete with allusions to post-war isolation and its concomitants. Such allusions appear in interdisciplinary works raging across psychology and psychiatry (e.g., Caplan, 2011; Figley & Leventman, 1980; Herman, 1992; Lifton, 1973), sociology (e.g., Schuetz, 1945; Waller, 1944), and philosophy (Sherman, 2015). Adding to this rich literature are non-academic monographs written by veterans (e.g., Johnson, 2010; Paulson & Krippner, 2004), letters written by veterans (Gill, 2011), and literary memoirs (e.g., Hynes, 1996). When loneliness has indeed been examined systematically, it was found among veterans several decades after their traumatic war experiences. Kuwert, Knaevelsrud, and Pietrzak, (2014), for instance,

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found that among older veterans in the US, 44% reported feeling lonely at least some of the time, and of these, over 10% reported feeling lonely most of the time. Similarly, comparing veterans who sustained a psychiatric breakdown in the heat of battle – a phenomenon known as combat stress reaction (CSR) – with veterans who did not, Solomon et al. (2015) found that the CSR casualties evinced steady high rates of loneliness throughout 20 years after their war experiences, whereas non-CSR veterans' loneliness decresed throughout the years. Furthermore, Solomon and her colleagues found that the baseline severity of PTSD symptomatology was crosssectionally positively associated with loneliness, suggesting that loneliness may play a role in posttraumatic psychopathology. Indeed, "feelings of detachment or estrangement from others" (but not loneliness) have been incorporated in the recent edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5; American Psychiatric Association [APA], 2013, p. 272) as possible constituents of PTSD. Regardless of the above indications that war-induced trauma may result in loneliness, and despite the fact that loneliness has been recognized as a clinically pertinent issue (S. Cacioppo et al., 2015); it remains the case that systematic loneliness-focused investigations with traumatized populations are scant. Indeed, most of the aforementioned literature, with the exception of the few studies cited above, consists of anthologies and monographs rather than peer-reviewed studies. Moreover, if this literature has referred to veterans' loneliness, it has done so mainly in passing or by alluding to related terms from the vast loneliness nomenclature (e.g., isolation, estrangement, alienation). This paucity is indicated, for instance, in the fact that none of the trauma encyclopedias that were published in the past decade (Doctor & Shiromoto, 2010; Figley, 2012; Reyes, Elhai, & Ford, 2008) have allocated an entry for loneliness. As part of this investigative dearth, to date, there exists no systematic investigation as to the manner in which veterans' post-war loneliness transpires, and no delineation of the course in which it unfolds and manifests itself. Due to this gap in the literature, attempts to explain why veterans' loneliness lingers for decades after the war, as well as attempts to trace it to its origins, remain largely speculative and tentative. Filling this gap, in the

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current chapter I trace the experience back to its origins. This explication will facilitate a deeper understanding of veterans' motivations to reconnect or otherwise further withdraw in various social contexts, as well as promote the devising of apt clinical and supportive practices.

Gaining Entrance to the Experience The bulk of the current chapter is an attempt to grant readers an entrance into the veteran's experience of loneliness and its phenomenology. This endeavor is engaged below in two complementary manners: (a) via veterans' narrative explications and (b) via the vast extant literature relating to veterans' war and post-war experiences. Narratives are most informative when attempting to understand the unfolding of human experience, particularly that of loneliness, from an insider's perspective (Wood, 1986). This is because narratives consist of rich accounts wherein experiences (e.g., war and homecoming) are temporally concatenated in a plot, and are linked to the characters (i.e., self and Others) and meanings (e.g., deficient relational needs and expectations) that are most pertinent from the narrator's perspective (e.g., Polkinghorne, 1988). Moreover, it is within narrative that phenomena may receive the title "loneliness," thus indicating that the phenomena under inspection are indeed construed as such by the persons who have experienced them (Wood, 1986). Veterans' oral and printed accounts are ubiquitous these days, and many of these reveal experiences entailing a state of painful isolation (i.e., loneliness). At the center of the current chapter stand two such exemplary accounts. Both accounts were chosen for their rich explicatory nature, and because their authors do not present the accounts as personal narratives per se, but rather strive to explain the loneliness of a veteran qua veteran to an outsider (i.e., a non-veteran, a civilian). The original authors have given their permission to use the accounts in the current project. The first account is one shared by a Vietnam veteran, L.V. The narrative was sent to me by L.V via e-mail correspondence (August, 20, 2015) in response to my inquiry concerning the experience of post-war loneliness. Complementing

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L.V's account is Starmann's (2015) aforementioned piece, entitled The Solitary World of the Vet. Starmann's article was purposively chosen also because its publication enabled many other veterans to react to the depiction it offers. Veterans responding to Starmann's article, whether on the US Defense Watch site, where it had originally appeared, or on social media (i.e., Facebook), where it was shared several thousand times, have all confirmed that Starmann's articulate depiction is faithful to their own experience, thus confirming that the account is anything but idiosyncratic. Below, the discussion of L.V's and Starmann's accounts will be grounded in extant literature. Undeniably, neither such literature nor the veterans' narratives indicate the prevalence of the phenomena under scrutiny. To the best of my knowledge, quantitative epidemiological studies seeking to establish such prevalence have not yet been conducted. Nevertheless, recognizing the common factors among narratives and extant literature serves to further demonstrate that these phenomena transcend the idiographic accounts, and are readily transferable to other veterans in more diverse post-war realities. L.V's and Starmann's accounts are therefore discussed not only as private cases but also and primarily as exemplars of the lonely-veteran experience.

THE VETERANS' LONELINESS In order to gain a fuller understanding of veterans' post-war loneliness it may be beneficial to trace their experiences from the time of enlistment and deployment, through their war experiences, and finally to the post-war era from the initial time of homecoming to the more protracted civilian life wherein the loneliness at hand consolidates. Veterans' relational ties, the characteristics of their social networks, and their social connections and detachments throughout this temporal-experiential course vary considerably, and with them vary their experiences of loneliness.

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Enlistment, Deployment and Homesickness As he set out to explain what it is that the veteran's loneliness entails and where and when it is fashioned, L.V noted the following: Being lonely is very difficult for humans; we have always been around a lot of other people and engaged in the act of living with and interacting with others from the day we are born. We have sought love, sought to be "included" and sought the approval of those with whom we interact. Then as a young man, in my case, we leave those with whom we have made an integral part of our life and go away, alone and to unfamiliar places. We then share the most basic of human emotions with others who are in a situation similar to ours. We begin to bond because of this shared "lonesome for home and family and longtime friends feeling." We get close as a group, then experience horrors that we have never experienced before; most are so basically alien to what we have ever known or could have dreamed. The greater the threat, the horror, the pain we feel, the closer we become.

A primary goal in the initial phase of military training (i.e., boot camp) is the socialization of new recruits by stripping them of their civilian identity and instilling a military identity in its stead (Van Gennep, 1960). The transition into military life therefore entails a transition from the familiar, and perhaps typically caring, environment of one's family to the foreign military regime of the military. Thus, of great significance in adjusting to such transitions are the relationships in the soldier's family of origin prior to enlistment. Families that foster social growth and competence may in time facilitate closeness in the new social network of the military unit (Shulman, Levy-Shiff, & Scharf, 2000). At this preliminary point of transition, however, loneliness may become manifest first and foremost in the form of homesickness, implicated in the need for a familiar relational bond such as the family or friends left back home. This homesickness may be one of the first challenges soldiers must face right at the outset of their service (e.g., Flach, De Jager, & Van de Ven, 2000). It may exacerbate at times of deployment when the geographical distance

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complements and amplifies the sense of detachment from one's home, parents, spouse, and children. However, there is something much more profound in this transition, and it is underscored by the particular significance of the relationships formed among the members of the combat unit. Combat soldiers bond, in part, by undergoing shared experiences. The newly acquired social network becomes tighter and more significant as its members undergo mutual trials and tribulations. In this respect, the aforementioned homesickness is not only one of the warriors' shared experiences, but may, in fact, serve as a catalyst in the unit's bonding process thereafter (Waller, 1944). Such bonding, if attained, may fill the relational deficit created at the time of enlistment when the new recruit leaves home and all that it entails, but may later hinder the renewed entry into civilian society (Demers, 2011). Indeed, researchers recently found that for active-duty soldiers the experience of loneliness is more closely related to their bonds within the unit than to their relations with their actual families (J. T. Cacioppo et al., 2016). This finding makes perfect sense when the unit's cohesion is considered. Traversing into the war environment, it would seem that the soldiers' shared experiences become more extreme and tormenting, and as they do, the comrades' bond becomes tighter. In this shared fate, interdependence may be established among the members of the combat unit, resulting in a cohesion that may be indispensable for survival (Adler & Castro, 2013). Overcoming extreme hardship togehter may enable the overcoming of soldiers' initial loneliness and facilitate the forging of a comradery that must hold in circumstances of life and death on the battlefield. Fostering resilience in the face of potential threats to social ties (i.e., social resilience) may then be pertinent among soldiers (J. T. Cacioppo, Reis, & Zautra, 2011), and has therefore begun to attract researchers' attention (J. T. Cacioppo, Adler, et al., 2015). From an evolutionary perspective, animals and humans alike depend on companionship and mutual protection and assistance for their survival (J. T. Cacioppo, Cacioppo, et al., 2015). Loneliness then signals that there is a need to strengthen such bonds. This becomes even more pertinent at

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times of actual threat. During war, the lack of unit cohesiveness may be a catalyst for the mental breakdown on the battlefield (Dasberg, 1976; Solomon, 1993), and may result in subsequent PTSD after the shooting ends (Brailey, Vasterling, Proctor, Constans, & Friedman, 2007). Acknowledging the intensity of the soldiers' bond may be crucial for understanding the emergence and severity of the loneliness that veterans experience upon homecoming.

Homecoming, Experiential Loneliness and Communicative Isolation Eventually, the war ends and the unit, which has since become family, is dispersed. L.V makes note of this transition explicitly: Then, one day it is over. We know we will never see most of this “new” family again. We know that many of those who still have to stay and endure the horrors, will never actually leave. . . . This is traumatic to most, but not as much as finding out that when you do return, nobody has a clue what you have been through, or even who you have now become. You are alone, really alone.

The sense of being alone may then manifest itself as soon as the veteran returns home. Homecoming has been extremely difficult in this sense for veterans in the time when Homer wrote the Iliad and Odyssey (Shay, 1994, 2002), as it has been after the World Wars (e.g., Shuetz, 1945), after Vietnam (e.g., Figley & Leventman, 1980), or following the wars in Iraq and Afghanistan (e.g., Ahern et al., 2015; Caplan, 2011). Postwar loneliness to a great extent revolves around the loss of shared experiences. Upon homecoming, the world's population becomes bifurcated in the veteran's eyes: civilians on the one side, and veterans on the other (e.g., Ahern et al., 2015; Stein & Tuval-Mashiach, 2015a; Waller, 1944). The former do not share the war and post-war experiences and are thus incapable of understanding the returning veteran, and the latter are

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capable of listening and understanding but are usually not around to do so. Linking the above notions together, Starmann (2015) notes the following: Many vets experienced and saw and heard and did things unimaginable to the average person. They also lived a daily camaraderie that cannot be repeated in the civilian world. In fact, many vets spend the rest of their lives seeking the same esprit de corps that simply is absent from their civilian lives and jobs. They long to spend just 15 minutes back with the best friends they ever had, friends that are scattered to every corner of the earth, and some to the afterlife itself. Vets are haunted by visions of horror and death, by guilt of somehow surviving and living the good life, when some they knew are gone. They strangely wish sometimes that they were back in those dreadful circumstances, not to experience the dirt and horror and terror and noise and violence again, but to be with the only people a vet really knows, other vets.

Veterans may practically miss being around those who have shared the experiences that have made them who they are. For many, the end of the war puts an end to their aspiration to feel ultimately connected. It leaves them very much alone with their experiences in a civilian world oblivious to the meaning of the experiences they have endured during their deployments. Seeking a conceptual understanding of this form of isolation, Stein and Tuval-Mashiach (2015a) suggest that the loneliness at hand may be best characterized as loneliness of experiential isolation or in short, experiential loneliness (p. 127). Conversely, Wood (1986) terms this facet of loneliness failed intersubjectivity, denoting the person's unfulfilled desire for interpersonal connection on the subjective level. The psychological underpinnings of such phenomena are multifaceted. Bearing subjective experiences alone undermines the human need for shared inner realities. We all need to sense that others experience, feel, think, evaluate, and altogether view the world as we do (Echterhoff, Higgins and Levine, 2009). In part, this is what motivates people to tell stories of those experiences. That said, typically, people assume that those who have undergone the same experiences as them are most capable of understanding how they felt in these experiences; and at times, that only

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such individuals can do so (e.g., Hodges, Kiel, Kramer, Veach, & Villanueva, 2010). This persuasion, which may be pivotal in determining sources of emotional support and stress following stressful life events (Suitor, Keeton, & Pillemer, 1995), seems to lie in the substructure of veterans' post-war loneliness. At times, this feeling is exacerbated by the realization that others do not want to listen or otherwise are not really interested in understanding, thus ultimately culminating in the devastating feeling that no one really cares. In her analysis, for instance, Sherman (2015) notes in that for the veteran who needs others to really listen, the words "thank you for your service!" may be experienced as hollow lipservice, for they come instead of a sincere interest in that which the veteran had undergone during the war and since he or she has returned. Turning to L.V's explication of what this lonely experience entails, the personal meaning of such an experiential loneliness begins to emerge: The lonely feelings become enmeshed with feelings of helplessness and the scars of experiences that you never find a way to flush from your mind. You can write a superb study that many will read in curiosity or awe or for understanding. But I do not believe it is possible to explain or understand the type of deep, black loneliness that emerges in the context of or aftermath of combat and the later return to a world with those who have no such basis of experience or understanding. And for most, this is simply a subject not discussed. It is a very different kind of loneliness than simply missing a girl friend or family members. It is much more pervasive. You can go visit family and friends, [but] you cannot solve the loneliness issues that arise from horrific traumatic experiences that only others who have similar experiences can ever understand.

In these assertions, L.V practically deemed my current endeavor in this chapter all but a futile attempt to communicate the experience at hand, and he is certainly not alone in these sentiments. From the veterans' perspective, his or her post-war loneliness may be experienced as a perpetual, incommunicable, and irrevocable loneliness, explicitly differentiated from any other kind of more quotidian forms of loneliness. Words fail extreme loneliness (Fromm-Reichmann, 1959/1990), and they

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fail the experiences incorporated in the gestalt we recognize as “war.” This phenomenon may be referred to as communicative isolation, wherein one is severed from society by the constraints of language. Thus, veterans may feel experientially isolated in regards to their loneliness just as they are in regards to the combat experiences they bear, and which have given rise to this loneliness that they now experience. The failure of language in this sense is twofold. First, the lonely veteran learns that words cannot adequately communicate to civilians the ineffable war experience. Alfred Schütz notes in this respect that, When the soldier returns and starts to speak – if he starts to speak at all – he is bewildered to see that his listeners, even the sympathetic ones, do not understand the uniqueness of these individual experiences which have rendered him another man. (Schuetz, 1945, p. 374)

Starmannn (2015) expounds on this communicative barrier: A problem with the solitary world of the vet is that the vet has a hard time explaining what he or she did to those who didn’t serve. Some vets want to talk, but they have no outlet. . . . Part of this taciturn mentality is that vets speak another language, a strange and archaic language of their past. How do you talk to civilians about “fire for effect” or “grid 7310” or “shake and bake” or “frag orders” or “10 days and a wake up” or a thousand and one other terms that are mystifying to the real world? You can't.

But it is much more than the technicalities of military routines that is incommunicable. The whole gamut of experiences one endures in battle are fundamentally different from civilians' mundane experiences – the loss of friends, the looming death, the incessant sense of threat and uncertainty, the struggle with the forces of nature and the perniciousness and brutality of human actions – all of these words are hollow representations of the experiences they attempt to represent. Thus silence emerges, for, as Wittgenstein (1921/2002, p. 89) famously noted “What we cannot speak about we must pass over in silence.”

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The second linguistic barrier, indeed the Janusian face of the extreme nature of war, concerns the realization that for the veteran, civilian language has also changed its meaning. As Waller notes, “the words which mean so much to the civilian mean very little to the soldier” (Waller, 1944, p. 32). Words such as “pain,” “loss,” “friendship,” “responsibility,” “honor,” “loyalty,” “impossible,” and many others which are common stock in civilian discourse may have all changed their meanings for veterans who have encountered these in their most extreme forms. Such communicative barriers may once again lead to silence and withdrawal, as the veteran presupposes the emergence of misunderstanding a priori. These withdrawals permeate and impede several relational domains, including family, friends and society as a whole (Lyons, 2007). To exemplify, in their investigation of reintegration problems among veterans retuning from Iraq and Afghanistan Sayer et al. (2010) found that the leading challenges for reintegration are all interpersonal (e.g., dealing with strangers, making new friends, keeping up nonmilitary friendships, belonging in “civilian” society). More to the point, at the top of the list for most veterans in the study was the challenge of confiding or sharing personal thoughts and feelings with others.

Civilian Life, the Veteran Identity, and Experiential Alienation Evidently, the sense of loneliness at hand is rooted in emotional transitions which are only partially congruent with physical transitions: from home to the military, from training to war, and from war back home. Perhaps more than any other experience during one's military service, war ultimately changes the combatant's identity (e.g., Gill, 2011). In fact, participation in war is the primary factor which constitutes the combat veteran's identity as such. It is this altered identity that civilians typically underappreciate. Starmann (2015) notes that, “Civilians must understand that for a vet nothing is ever the same again.” Schütz complements this realization by noting that the returning veteran “is not the same man who

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left. He is neither the same for himself nor for those who await his return” (Schuetz, 1945, p.375). Emphasizing the critical junctions wherein emotional transitions occur, L.V brought his account to a close with a summarizing statement that encapsulates all that has already been said, and reveals most explicitly the unmet relational needs encompassed in the veteran's experientially lonely state: In an abbreviated sense, being lonely is fighting for acceptance in your original world, being ripped away and then enduring the same process in a new world but under horrific circumstances, then returning to your original world only to discover that you are not understood, do not belong there the same way you did before, and the new world you have just left no longer exists, leaving you alone. Even when there are still the trappings of the world you once knew, they are no more, and there is no one to comfortably talk with about these things, so you keep these feelings inside and withdraw into them unless distracted by work or some crisis or some event powerful enough to draw your mind away from simply feeling like you no longer belong, anywhere really.

Of immense importance here is yet another long standing fundamental human need, the need to belong (Baumeister & Leary, 1995; Gere & MacDonald, 2010). Aside from the compromised need to be understood, veterans also forfeit this form of connection, and thus feel further detached from society. The returning veteran's sense of being “a stranger among strangers” (Schuetz, 1945, p. 369), his or her experiential alienation, so to speak, once again underscores the existence of the aforementioned two populations, veterans and civilians, who are separated by an unshared and incommensurable experiential background. Such alienation was highlighted recently among UK veterans who sustained psychological injuries during combat (Brewin, Garnett, & Andrews, 2011). The researchers argue that this alienation was the most pressing issue relating to their mental health and suicidal behaviors. Participants in several related qualitative studies (Ahern et al., 2015; Brewin et al., 2011; Demers, 2011; R. T. Smith & True, 2014; Stein, 2017; Stein & Tuval-Mashiach, 2015a),

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repeatedly noted that it is this alienation, in part, that drives veterans to withdraw from civilians, family included, on the one hand; and at the same time seek the companionship of other veterans, “brothers in arms” and experiential partners. From the lonely veterans' perspective, only a network consisting of such experiential partners may assuage their loneliness, and only among them they truly belong (e.g., Ahern et al., 2015). In this respect, the veteran's loneliness is highly bound to their veteran identity as they are required to make the transition into a civilian identity that is altogether unfamiliar to them and undesired (R. T. Smith & True, 2014). This alienation is a signature feature of the veteran's loneliness, for it is anchored in the alteration of veterans' world views. The shattering of basic world views, particularly assumptions concerning self-worth and world benevolence, have been associated with the human reaction to trauma (Janoff-Bulman, 1992). As Brewin et al. (2011) suggest the alteration of such world views may be significant when concerning the alienation at hand in that it keeps the veteran from sharing civilians' preconceptions and hinders reintegration. However, the crux of this alteration in prior perspective may be missed when examined via a-relational categories such as "perception of the world" and "perception of the self". Rather, it may be more informative to view these changes as an alteration in the perception of self in relation to the world, particularly that of veterans versus civilians. As one of the participants in Brewin and colleagues' study (2011) noted, “our lives are completely alien to civilian lives. I think it always will be a them-and-us situation” (p. 1737). Civilians do not typically construct their identities as contrasted to veterans' identities, but the opposite is often true: veterans define themselves in contrast to civilians. In a parallel vein, increasing attention is being devoted in the US to the emergence of a civilian-military gap. Several domains have been underscored wherein military personnel find that they endorse significantly different views from the civilian population (e.g., Rahbek-Clemmensen et al., 2012; Szayana, McCarthy, Sollinger, Demaine, Marquis, & Steele, 2007). Veterans' loneliness, and particularly their sense of experiential alienation, is closely related to this gap. Nevertheless, to the best of my knowledge, these have never been explicitly considered in this context.

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Undeniably, the reception of the returning veteran by society may contribute immensely to this sense of estrangement. Unwelcoming, hostile, rejecting or ostracizing receptions may be the worst in this sense (e.g., after the Vietnam War; e.g., Figley & Leventman, 1980; Lifton, 1973). However, the reception does not have to be a hostile one for experiential isolation to transpire (Caplan, 2011). In fact, for the veteran, the vagaries of civilian life may be construed as the antithesis of war, and civilians leading their lives as usual, may be held in contempt and “guilty” of being apathetic to the war. As some veterans note, “We’ve been at war while the country has been at the mall” (Sherman, 2015, p. 1). It is the experiential chasm that opens up between veterans and civilians that matters. Furthermore, the sensation that civilians are stigmatic about veterans' posttraumatic reactions may exacerbate the latter's sense of alienation (e.g., Caplan, 2011; Brewin et al., 2011). Such stigmas may motivate veterans to eschew any inclination to reconnect and reintegrate, thus jeopardizing the formation and reestablishment of adaptive civilian networks. The veteran's experiential loneliness is also implicated in what may be referred to as an internal-external discrepancy, wherein veterans wish that others would share their experiences, and at the same time feel that their subjectivities must remain confined within the boundaries of their bodies. Due to shame or fear of society's judgmental gaze and stigmatization, veterans, at times, invest tremendous efforts in zealously safeguarding their experiences deep within and simultaneously put on a facade as if all is well. It is in this respect that L.V noted that, “you keep these feelings inside and withdraw into them.” The result is often a lack of much needed authentic expression, silence, withdrawal, and isolation. The loneliness at hand is then not about the perceived presence or absence of other people or even about the relation with civilians per se. Rather it is about others' capacity to relate to certain experiences. Indeed, as loneliness is considered to be a subjective rather than objective sense of isolation, it is emphasized in the literature that one may feel extremely lonely even when in a crowd (e.g., Peplau & Perlman, 1982). As if echoing this realization, L.V noted of his own lonely experience that, “I have been in large crowds of people at social events and not felt the presence of a single person.”

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Ultimately withdrawing into the confinements of the self, and fearing the stigma of mental injury results in the reluctance to seek help (e.g., Hoge et al., 2004; Kim, Britt, Klocko, Riviere, & Adler, 2011). Refraining from help-seeking then adds another layer to the veteran's stratified experience of loneliness.

The Conviction of Being Alone in Coping Approaching his final conclusion, Starmann (2015) notes the following: All of this adds to the solitary world of the vet. Some are better at handling life afterwards than others. Some don’t seem affected at all, but they are. They just hide it. Some never return to normal. But, what is normal to a vet anymore?

The veteran's loneliness is a stratified experience in which multiple facets accumulate and create a taxing experiential gestalt. The past and present emotional turmoil that veterans bear within, the lack of communicative capacities and opportunities for sharing within an understanding environment, all amass and give rise to a fifth element, being alone in coping. As the different facets of experiential loneliness accumulate, veterans may be convinced that they have no other choice but to cope alone with the collateral damage of the war. When this conviction creeps into veterans' minds they become exposed to a whole new gamut of relational deficits, once again painting the loneliness at hand in new colors. Here loneliness is demarcated by the need for support in the form of assistance and guidance, and often also for therapy. Indeed, this sense of being alone in coping may be part and parcel of what veterans mean when they speak of being alone (Stein, 2017). Certainly this is the facet of loneliness which agencies such as the VA and veteran emergency hotlines refer to when they reach out to veterans and proclaim “you are not alone!”

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Notably, coping alone may refer to coping with anything and everything, from the transition to civilian life and adaptation to it, to the emotional baggage from the war (e.g., guilt, loss), and up to the psychiatric symptoms endured on the battlefield (e.g., CSR; Solomon, 1993) or thereafter (e.g., PTSD). Interestingly, however, both L.V's and Starmann's accounts do not refer to psychopathology, neither CSR nor PTSD. The isolated states they share are purportedly representatives of the experience of (nearly) anyone who has been to war and lived to tell the tale. As Hynes' (1996) acclaimed titled reads, they represent The Soldier's Tale. As such, their accounts do not indicate the additional experiential isolation which may characterize coping with mental injuries or mental illnesses. Indeed, the complexity of reintegration and the experiential isolation it entails are challenging for veterans and may warrant counseling also when they are relatively healthy (Castro, Kintzle, & Hassa, 2015). It stands to reason, however, that veterans' experiential loneliness may be exacerbated as their emotional trials and tribulations intensify, and particularly when these manifest themselves in psychiatric pathology (Solomon et al., 2015). This is evident, for instance, in Dasberg's (1976) depiction of the loneliness associated with CSR. Accordingly, treading so closely to death's grasp, an overwhelming vulnerability and existential fear may render these combat soldiers ultimately lonely and forsaken. In this mental state, any sense of belonging and cohesion is torn apart at the seams as the soldier anticipates his or her approaching annihilation. The realization that one must inevitably face death alone is a conviction that one can hardly shake off, and hence it is suggested that it lingers on also after the shooting is long over (Solomon et al., 2015). Taking into account the aforementioned civilian-military gap, it is not surprising that remaining alone in coping is exacerbated by a lack of trust in civilians (e.g., Kubany, Gino, Denny, & Torigoe, 1994), and particularly in the care system (e.g., Hoge et al., 2004). As psychiatrist Jonathan Shay notes, combat “destroys the capacity for social trust” (Shay, 1994, p. 33) because it shatters the illusion that people are basically benevolent and good (Janoff-Bulman, 1992). This distrust is directed at one and all, and may also play a role in veterans' sense of loneliness. Distrust in people is

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magnified when care systems such as the Veterans Health Administration (VHA) fail to deliver safe, effective, patient-centered care (Kizer & Jha, 2014). The lack of provision of apt care by those who are most responsible for the veteran's well-being, those who have sent him or her to the war, may be experienced as institutional betrayals (C. T. Smith & Freyd, 2014), thus worsening the psychological toll of war. As studies show, the more people believe they can trust others, the less isolated and lonely they tend to feel over time (Rotenberg et al., 2010). Thus, the distrust that may characterize the veteran's post-war experience may also contribute to feeling alone in coping. Moreover, compared to the trust that veterans afford each other during and after combat – trust that is considered as “unparalleled” (Nash, 2007, p. 25) – this new experience of distrust and the resulting predicament of having to cope alone, may mark the end product of a trajectory leading from the “brotherhood of veterans” to a lonely civil detachment.

DISCUSSION Ultimately, understanding the veteran's loneliness may facilitate apt interventions and reconnection, as well as direct future research. I will address these aspects in relation to the multifaceted experience of loneliness depicted above.

Implications for Intervention and Reconnection As clinicians consider implications for intervention, the first aspects to be addressed are the unique as well as the similar features that the veteran's loneliness shares with other forms of loneliness. The loneliness at hand in its experientially-bound core is different from other forms of loneliness (e.g., lack of friends, lack of intimate partner, social exclusion or ostracism, existential solipsism). Undeniably, the constituents of this experiential loneliness (i.e., failed intersubjectivity, experiential alienation,

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communicative isolation, the internal-external discrepancy, and the sense of having to cope alone with the aftermath of adversity) may all be shared by any that have undergone emotional, psychological, or physical adversities, traumatic or otherwise. As such, much like trauma itself, these experiences may be part and parcel of the human condition (Moustakas, 1961; Stolorow, 2007), and may concern any who wish to diminish the trauma victim's loneliness by being an intersubjectively attuned “relational home” in which severe emotional pain can be held (Stolorow, 2007, p. 10). The special character of the veteran's post-war loneliness, however, may be unique also within the more delimited context of traumatic experiences. This special character lies in the twofold relation it bears to the interpersonal context wherein it transpires. First, as noted above, veterans' identities as veterans form in contrast to the “civilian” identity, which they may eschew (e.g., Smith & True, 2014). Concomitantly, their loneliness also forms in relation to society at large, and their relational deficits often concern society as a whole. Such construal may be expected in collective or national traumas wherein society presumably plays a role in welcoming and ambracing the traumatized person after the trauma is over. Secondly, veterans' loneliness transpires against the backdrop of the closely-knit, experientiallyconnected, group of comrades. As noted, loneliness invariably manifests itself as a perceived discrepancy between the person's desired and current relational connections (Peplau & Perlman, 1982), and the severity of any experience of loneliness is intensified as this discrepancy grows (Russell et al., 2012). For veterans, this discrepancy is amplified by the intensity of the bond they have come to know under the extreme conditions of war, as well as their conviction that this type of relationship can never be achieved outside of the military. In this respect, veterans may be different from other trauma victims (e.g., rape victims, disaster victims) in that they have an alternative society (i.e., fellow veterans) to which they may compare their sense of experiential connection and disconnection. Thus, I would argue from a prospective and preventive point of view, that as veterans approach the time of discharge, they may benefit from apt preparation that includes forewarnings concerning the encounter with this

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experiential gap and manners in which it may be adaptively approached (e.g., Hoge, 2010). Veterans should be informed prior to discharge of the plausible inclination to reproach civilian society, to withdraw into their veteran-self, and shun at civilians' expressions of interest. Concomitantly, veterans may be taught how they might foster more adaptive approaches. The specific features of the loneliness at hand, however, must also be accounted for in interventions that strive to facilitate active reconnection and reintegration after homecoming. Ultimately, since the veteran's loneliness may be closely tied to the “veteran identity” and to the experiences constituting that identity, the focus of intervention must be on assisting veterans in finding their place within newly acquired civilian social networks while retaining their veteran identities – once a warrior always a warrior (Hoge, 2010). This may be done in two complementary avenues. On the one hand, intervention must provide veterans with the necessary tools to bridge the experiential gap they experience. They must find a way to challenge the conviction that society is dichotomously bifurcated into civilians and veterans. On the other hand, society as a whole, and particularly veterans' proximate social support networks, must also work to minimize this gap. This line of thoughts calls into question the mainstream approach to loneliness reduction interventions. Loneliness is typically treated in the literature in the terms of perceived social isolation (e.g., S. Cacioppo et al., 2015). Concomitantly, several effective interventions have been underscored by the literature. These include a) altering maladaptive social cognitions, b) increasing opportunities for social interaction, c) improving social skills, and d) facilitating social support (Masi et al., 2011). According to Masi and his colleagues, interventions seeking to alter maladaptive social cognitions are slightly but significantly more effective than other interventions. This intervention typically aims to teach lonely individuals to identify automatic negative thoughts about themselves (e.g., likability, attractiveness) and their social environment and regard them as hypotheses to be tested rather than consolidated facts.

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The first conclusion to be drawn from the current chapter must be that the alleviation of veterans' loneliness may necessitate either abandoning these alternative approaches to loneliness reduction or otherwise adapting them to its unique features. Altering one's perception of his or her selfworth or likability, or otherwise simply seeking to meet new people or learning how to better engage them will not do. Rather, when seeking to increase social support, for instance, the support needed may be that of a sincere attempt to understand veterans' war and post-war experiences. Clinicians, family members and friends who wish to understand the veteran could, for example, get better acquainted with the war experience by reading descriptions of it by those who have experienced it. In this respect, Litz, Lebowitz, Gray and Nash (2016) argue that clinicians must get familiar with the military culture and the warrior ethos, as well as the particular meaning that the war had for the veteran, prior to their attempts to remedy the aftermath of veterans' traumatic experiences. In a similar vein, support providers might wish to get acquainted with veterans' perspectives concerning the aftermath of war. An alternative or complementary route may be educating oneself by consulting the more scientific literature (e.g., Lyons, 2007). Clinicians would do best to facilitate and encourage such psycho-education. It is noteworthy, however, that making an effort to understand the veteran's experience would ideally be a societal endeavor rather than a task bestowed solely upon veterans' families or friends. What is ultimately needed is the cultivation of a society that is committed to listening to veterans' stories and that would be caring enough to seek to understand their war and postwar experiences (Caplan, 2011; Sherman, 2015). As Sherman (2015, p. 40) asserts, “healing after war is a nation’s work.” In this respect, Starmann (2015) brought the address to an end by stating the following: So, this Veterans’ Day, if you see a vet sitting by themselves at a restaurant or on a train or shopping at the grocery store alone, take a moment to speak with them. Take them out of their solitary world for a moment. You’ll be happy you did.

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From the other side of the equation, veterans themselves may also work to minimize the aforementioned experiential gap. When addressing social skills, veterans may benefit from learning to communicate their experiences so as to breach their communicative barriers. In their attempts to overcome linguistic barriers at times of disclosure, veterans may learn to utilize several linguistic devices that might bring the experience to life and vivify it so as to have their audiences connect to the experience on an experiential level (Stein & Tuval-Mashiach, 2017). Furthermore, addressing maladaptive social cognitions, veterans must learn to trust that others will apprehend these disclosures to the best of their capacity. They may also benefit from challenging the conviction that they and the civilian population are inherently different. Undeniably, when considering opportunities for positive social interactions it may be argued that other veterans may be the most apt for the task of reestablishing experiential-connection. This is because veterans already share the war and post-war experiences. This may enable an immediate connection both via veterans' mutual experientially isolated states and the shared experiences lying in the infrastructure of these lonely states. This realization has already inspired several veteran-to-veteran peer support initiatives (e.g., Greden et al., 2010) aiming, among other things, at reducing fear of stigma, increasing veterans' willingness to seek therapy for PTSD and ultimately put an end to their insistence to cope alone. Forming a collective story together may encourage veterans to feel less alone with their own plight and everyday challenges, find once again the comradery they had during their time of service, and ultimately drive them to seek help (Caddick, Phoenix, & Smith, 2015; Hundt, Robinson, Arney, Stanley, & Cully, 2015). Indeed, some veterans tell their stories particularly to further this end (e.g., Johnson, 2010; Paulson & Krippner, 2004). Notwithstanding, the investigation of these interventions is at its preliminary stages. Thus, while several benefits of peer-support interventions have been documented (e.g., the facilitation of support and experiential belongingness), and while their employment has attracted attention in governmental institutions such as the Department of Veteran Affairs (VA; Chinman et al., 2008), their effectiveness in lowering PTSD

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symptomatology remains undetermined and necessitates further research. Hopefully, adhering to any of the suggested intervention routes above may motivate veterans to reconnect in some way, and cease remaining alone with their experiences.

Limitations and Future Directions The developmental course of the veteran's loneliness delineated above is limited in several manners that must be acknowledged. For one, there are undeniably individual differences in veterans' reactions to war and their social resilience thereafter. Moreover, the above relates solely to Western veterans' experiences, primarily ranging from the World Wars (e.g., Schuetz, 1945; Waller, 1944) to the present (e.g., Ahern, 2015), and only among men. The examination of other cultures and societies, as well as the investigation of women veterans' experiences, may reveal somewhat different courses in which the veteran's loneliness develops and manifests. Of primary interest may be societies which differ in respect to norms of disclosure and sharing of war experiences, or societies wherein civilianmilitary gaps may be expected to be less prominent. These may include, for instance, societies wherein military enlistment is conscription based (e.g., Israel). Nevertheless, as scholars (e.g., Schuetz, 1945; Shay, 1994, 2002) trace such phenomena back to the time of Homer (9th century B.C.), it would seem that many aspects of this loneliness may be universally associated with the warrior's homecoming experience. Second, in the current explication the prominence of experiential loneliness has been underscored, and it has been suggested that it is this form of isolation rather than other forms which veterans might most readily experience after their participation in war. Nevertheless, there currently exists no quantitative study wherein the prevalence of this phenomenon has been empirically investigated. Naturally, veterans may experience other forms of loneliness, and certainly not all veterans experience experiential loneliness even when they do experience experiential isolation. Either they do not perceive their isolation as

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loneliness or otherwise are not bothered by it. Future research should establish such prevalences. Finally, several factors may contribute to the manifestation of veterans' unenviable experience of loneliness. These may include the manifestation of PTSD or CSR (Dasberg, 1976; Solomon et al., 2015), dissociation from the self (DePrince & Freyd, 2007), the kind of support one receives upon return (Solomon et al., 1990), individual trait differences concerning the need for social sharing, institutional betrayals upon homecoming (e.g., C. T. Smith & Freyd, 2014), and cultural norms, to name but a few. The investigation of these and other factors should be pursued in future research. The first step must be the creation of a valid measurement of experiential loneliness. Once the experience is better investigated, and its characteristics become common knowledge, it may be hoped that veterans will feel a little bit less alone.

REFERENCES Adler, A. B., & Castro, C. A. (2013). The occupational mental health model for the military. Military Behavioral Health, 1, 1–11. Ahern, J., Worthen, M., Masters, J., Lippman, S. A., Ozer, E. J., & Moos, R. (2015). The challenges of Afghanistan and Iraq veterans’ transition from military to civilian life and approaches to reconnection. PloS one, 10(7), e0128599. American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: Author. Baumeister, R. F., & Leary, M. R. (1995). The need to belong: desire for interpersonal attachments as a fundamental human motivation. Psychological Bulletin, 117(3), 497-529. Brailey, K., Vasterling, J. J., Proctor, S. P., Constans, J. I., & Friedman, M. J. (2007). PTSD symptoms, life events, and unit cohesion in U.S. Soldiers: Baseline findings from the neurocognition deployment health study. Journal of Traumatic Stress, 20(4),495−503.

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Brewin, C. R., Andrews, B., & Valentine, J. D. (2000). Meta-analysis of risk factors for posttraumatic stress disorder in trauma-exposed adults. Journal of Consulting and Clinical Psychology, 68(5), 748-766. Brewin, C. R., Garnett, R., & Andrews, B. (2011). Trauma, identity and mental health in UK military veterans. Psychological Medicine, 41(08), 1733-1740. Cacioppo, J. T., Adler, A. B., Lester, P. B., McGurk, D., Thomas, J. L., Chen, H. Y., & Cacioppo, S. (2015). Building social resilience in soldiers: A double dissociative randomized controlled study. Journal of Personality and Social Psychology, 109(1), 90-105. Cacioppo, J. T., Cacioppo, S., Cole, S. W., Capitanio, J. P., Goossens, L., & Boomsma, D. I. (2015). Loneliness across phylogeny and a call for comparative studies and animal models. Perspectives on Psychological Science, 10(2), 202-212. Cacioppo, J. T., Cacioppo, S., Adler, A. B., Lester, P. B., Mcgurk, D., Thomas, J. L. & Chen, H. Y. (2016). The cultural context of loneliness: Risk factors in active duty soldiers. Journal of Social and Clinical Psychology, 35, 865-882. Cacicoppo. J. T., Reis, H. T., & Zautra, A. J. (2011). Social resilience: The value of social fitness with an application to the military. American Psychologist, 66(1), 43–51. Cacioppo, S., Grippo, A. J., London, S., Goossens, L., & Cacioppo, J. T. (2015). Loneliness: Clinical import and interventions. Perspectives on Psychological Science, 10(2), 238-249. Caddick, N., Phoenix, C., & Smith, B. (2015). Collective stories and wellbeing: Using a dialogical narrative approach to understand peer relationships among combat veterans experiencing post-traumatic stress disorder. Journal of Health Psychology, 20(3), 286-299. Caplan, P. J. (2011). When Johnny and Jane come marching home: How all of us can help veterans. Cambridge, MA: MIT press. Castro, C. A., Kintzle, S., & Hassan, A. M. (2015). The combat veteran paradox: Paradoxes and dilemmas encountered with reintegrating combat veterans and the agencies that support them. Traumatology, 21(4), 299-310.

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Chinman, M., Lucksted, A., Gresen, R., Davis, M., Losonczy, M., Sussner, B., & Martone, L. (2008). Early experiences of employing consumerproviders in the VA. Psychiatric Services, 59, 1315–1321, Dasberg, H. (1976). Belonging and loneliness in relation to mental breakdown in battle: With some remarks on treatment. Israel Annals of Psychiatry & Related Disciplines, 14, 307–321. Demers, A. (2011). When veterans return: The role of community in reintegration. Journal of Loss and Trauma, 16(2), 160-179. DePrince, A. P., & Freyd, J. J. (2007). Trauma-induced dissociation. In M. J. Friedman, T. M. Keane & P. A. Resick (Eds.), Handbook of PTSD: Science and practice (pp. 135-150). New York, NY: The Guilford Press. Doctor, R. M., & Shiromoto, F. N. (2010). The encyclopedia of trauma and traumatic stress disorders. New York, NY: Infobase Publishing. Dykstra, P. A. (1993). The differential availability of relationships and the provision and effectiveness of support to older adults. Journal of Social and Personal Relationships, 10, 355–370. Echterhoff, G, Higgins, E. T. & Levine, J. M. (2009). Shared reality: Experiencing commonality with others’ inner states about the world. Perspectives on Psychological Science, 4(5), 496–521. Ettema, E. J., Derksen, L. D., & van Leeuwen, E. (2010). Existential loneliness and end-of-life care: A systematic review. Theoretical Medicine and Bioethics, 31(2), 141-169. Figley, C. R. (2012). Encyclopedia of trauma: An interdisciplinary guide. Thousand Oaks, CA: SAGE Publications. Figley, C. R., & Nash, W. P. (Eds.) (2007). Combat stress injury: Theory, research and management. New York, NY: Routledge. Flach, A., De Jager, M. L., & Van de Ven, C. P. H. W. (2000). Fight or flight? The drop-out phenomenon during initial military training: Homesickness. Proceedings of the 42nd Annual Conference of the International Military Testing Association (pp. 181-187), Edinburgh, UK Fromm-Reichmann, F. (1990). Loneliness. Contemporary Psychoanalysis, 26, 305–329. (Original work published 1959).

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Fulton, J. J., Calhoun, P. S., Wagner, H. R., Schry, A. R., Hair, L. P., Feeling, N., . . . Beckham, J. C. (2015). The prevalence of posttraumatic stress disorder in Operation Enduring Freedom/ Operation Iraqi Freedom (OEF/OIF) Veterans: A meta-analysis. Journal of Anxiety Disorders, 31(0), 98-107. Gere, J., & MacDonald, G. (2010). An update of the empirical case for the need to belong. Journal of Individual Psychology, 66(1), 93-115. Gill, D. C. (2010). How we are changed by war: Study of letters and diaries from colonial conflicts to Operation Iraqi Freedom. New York, NY: Routledge. Gotesky, R. (1965). Aloneliness, loneliness, isolation, solitude. In J. Edie (Ed.), An invitation to phenomenology: Studies in the philosophy of experience (pp. 211-239). Chicago: Quadrangle Books. Greden, J. F., Valenstein, M., Spinner, J., Blow, A., Gorman, L. A., Dalack, G. W., ... & Kees, M. (2010). Buddy‐to‐Buddy, a citizen soldier peer support program to counteract stigma, PTSD, depression, and suicide. Annals of the New York Academy of Sciences, 1208(1), 90-97. Hawkley, L. C., Browne, M. W., & Cacioppo, J. T. (2005). How can I connect with thee? Let me count the ways. Psychological Science, 16, 798–804. Herman, J. L. (1992). Trauma and recovery. New York: Basic Books. Hodges, S. D., Kiel, K. J., Kramer, A. D., Veach, D., & Villanueva, B. R. (2010). Giving birth to empathy: The effects of similar experience on empathic accuracy, empathic concern, and perceived empathy. Personality and Social Psychology Bulletin, 36(3), 398-409. Hoge, C. W. (2010). Once a warrior always a warrior: Navigating the transition from combat to home—including combat stress, PTSD, and mTBI. Guilford, CT: Globe Pequot Press. Hoge, C. W., Castro, C. A., Messer, S. C., McGurk, D., Cotting, D. I., & Koffman, R. L. (2004). Combat duty in Iraq and Afghanistan, mental health problems, and barriers to care. New England Journal of Medicine, 351(1), 13-22.

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Hundt, N. E., Robinson, A., Arney, J., Stanley, M. A., & Cully, J. A. (2015). Veterans' perspectives on benefits and drawbacks of peer support for posttraumatic stress disorder. Military Medicine, 180(8), 851-856. Hynes, S. L. (1997) The soldiers’ tale: Bearing witness to modern war. New York, NY: Penguin. Janoff-Bulman, R. (1992). Shattered assumptions: Towards a new psychology of trauma. New York, NY: Free Press. Johnson, J. D. (2010). Combat trauma: A personal look at long-term consequences. Lanham, MD: Rowman & Littlefield Publishers. Kang, H. K., Bullman, T. A., Smolenski, D. J., Skopp, N. A., Gahm, G. A., & Reger, M. A. (2015). Suicide risk among 1.3 million veterans who were on active duty during the Iraq and Afghanistan wars. Annals of Epidemiology, 25(2), 96-100. Karstoft, K. I., Armour, C., Elklit, A., & Solomon, Z. (2013). Long-term trajectories of posttraumatic stress disorder in veterans: The role of social resources. The Journal of Clinical Psychiatry, 74(12), 11631168. Kim, P. Y., Britt, T. W., Klocko, R. P., Riviere, L. A., & Adler, A. B. (2011). Stigma, negative attitudes about treatment, and utilization of mental health care among soldiers. Military Psychology, 23(1), 65. Kizer, K. W., & Jha, A. K. (2014). Restoring trust in VA health care. New England Journal of Medicine, 371(4), 295-297. Kubany, E. S., Gino, A., Denny, N. R., & Torigoe, R. Y. (1994). Relationship of cynical hostility and PTSD among Vietnam veterans. Journal of Traumatic Stress, 7(1), 21-31. Kuwert, P., Knaevelsrud, C., & Pietrzak, R. H. (2014). Loneliness among older veterans in the United States: results from the National Health and Resilience in Veterans Study. The American Journal of Geriatric Psychiatry, 22(6), 564-569. Lifton, R. J. (1973). Home from the war: Vietnam veterans: Neither victims nor executioners. Oxford, England: Simon & Schuster.

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Litz, B. T., Lebowitz, L., Gray, M. J., & Nash, W. P. (2016). Adaptive disclosure: A new treatment for military trauma, loss, and moral injury. New York, NY: The Guilford Press. Lyons, J. A. (2007). The returning warrior: Advice for families and friends. In C. R. Figley, & W. P. Nash (Eds.), Combat stress injury: Theory, research and management (pp. 311-324). New York, NY: Routledge. MacDonald, G., & Leary, M. R. (2005). Why does social exclusion hurt? The relationship between social and physical pain. Psychological Bulletin, 131(2), 202-223. Masi, C. M., Chen, H., Hawkley, L. C., & Cacioppo, J. T. (2011). A metaanalysis of interventions to reduce loneliness. Personality and Social Psychology Review, 15, 219–266. doi:10.1177/1088868310377394. Moustakas, C. E. (1961). Loneliness. Englewood Cliffs, NJ: Prentice-Hall. Mijuskovic, B. L. (2015). Feeling lonesome: The philosophy and psychology of loneliness. Santa Barbara, CA: Preager. Nash, W. P. (2007). The stressors of war. In C. R. Figley, & W. P. Nash (Eds.), Combat stress injury: Theory, research and management (pp. 11-31). London, England: Routledge. Paulson, D. S., & Krippner, S. (2004). Haunted by combat: Understanding PTSD in war veterans, including women, reservists, and those coming back from Iraq. Westport, CT: Praeger Security International. Peplau, L. A., & Perlman, D. (Eds.) (1982). Loneliness: A sourcebook of current theory, research and therapy. New York, NY: Wiley. Polkinghorne, D. E. (1988). Narrative knowing and the human sciences. Albany: State University of New York Press. Qualter, P., Vanhalst, J., Harris, R., Van Roekel, E., Lodder, G., Bangee, M., Verhagen, M. (2015). Loneliness across the life span. Perspectives on Psychological Science, 10(2), 250–264. Rahbek-Clemmensen, J., Archer, E. M., Barr, J., Belkin, A., Guerrero, M., Hall, C., & Swain, K. E. (2012). Conceptualizing the Civil–Military Gap A Research Note. Armed Forces & Society, 38(4), 669-678. Reyes, G., Elhai, J. D., & Ford, J. D. (2008). The encyclopedia of psychological trauma. Hoboken, NJ: John Wiley and Sons.

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Rokach, A. (1988). The experience of loneliness: A tri-level model. The Journal of Psychology, 122(6), 531-543. Rokach, A. (1989). Antecedents of loneliness: A factorial analysis. The Journal of Psychology, 123(4), 369-384. Rotenberg, K. J., Addis, N., Betts, L. R., Corrigan, A., Fox, C., Hobson, Z., Boulton, M. J. (2010). The relation between trust beliefs and loneliness during early childhood, middle childhood, and adulthood. Personality and Social Psychology Bulletin, 36, 1086 –1100. Russell, D. W., Cutrona, C. E., McRae, C., & Gomez, M. (2012). Is loneliness the same as being alone? The Journal of Psychology, 146(12), 7-22. Sayer, N. A., Noorbaloochi, S., Frazier, P., Carlson, K., Gravely, A., & Murdoch, M. (2010). Reintegration problems and treatment interests among Iraq and Afghanistan combat veterans receiving VA medical care. Psychiatric Services, 61(6), 589-597. Schuetz, A. (1945). The homecomer. American Journal of Sociology, 50, 369-376. Shay, J. (1994). Achilles in Vietnam: Combat trauma and the undoing of character. New York, NY: Scribner. Shay, J. (2002). Odysseus in America: Combat trauma and the trials of homecoming. New York, NY: Scribner. Sherman, N. (2015). Afterwar: Healing the moral wounds of our soldiers. New York, NY: Oxford University Press. Shulman, S., Levy-Shiff, R., & Scharf, M. (2000). Family relationships, leaving home, and adjustment to military service. Journal of Psychology, 134, 392-400. Smith, C. P., & Freyd, J. J. (2014). Institutional betrayal. American Psychologist, 69(6), 575-587. Smith, R. T., & True, G. (2014). Warring identities: Identity conflict and the mental distress of American veterans of the wars in Iraq and Afghanistan. Society and Mental Health, 4, 147–161. Solomon, Z. (1993) Combat stress reaction: The enduring toll of war. New York, NY: Springer Science+Business Media.

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Solomon, Z., Bensimon, M., Greene, T., Horesh, D., & Ein-Dor, T. (2015). Loneliness trajectories: The role of posttraumatic symptoms and social support. Journal of Loss and Trauma, 20(1), 1-21. Solomon, Z., Waysman, M., & Mikulincer, M. (1990). Family functioning, perceived social support, and combat-related psychopathology: The moderating role of loneliness. The Journal of Social and Clinical Psychology, 9, 456–472. Starmann, R. (2015, November 8). The solitary world of a vet. US Defense Watch, Retrieved from http://usdefensewatch.com/2015/11/thesolitary-world-of-a-vet/. Stein, J. Y. (2017). The meaning of “loneliness” to traumatized veterans: A semiotic investigation of veterans' written narratives. Manuscript submitted for publication. Stein, J. Y., & Tuval-Mashiach, R. (2015a). Loneliness and isolation in life-stories of Israeli veterans of combat and captivity. Psychological Trauma: Theory, Research, Practice, and Policy, 7(2), 122-130. Stein, J. Y., & Tuval-Mashiach, R. (2015b). The social construction of loneliness: An integrative conceptualization. Journal of Constructivist Psychology, 28(3), 210-227. Stein, J. Y., & Tuval-Mashiach, R. (2017). Narrating for affective empathy: Verbal discursive devices that elicit an experiential connection in war-related trauma narratives. Israel Studies in Language and Society, 10, 175-199. Stolorow, R. D. (2007). Trauma and human existence: Autobiographical, psychoanalytic, and philosophical reflections. New York, NY: The Analytic Press. Suitor, J. J., Keeton, S., & Pillemer, K. (1995). When experience counts: The effects of experiential and structurSal similarity on patterns of support and interpersonal stress. Social Forces, 73(4), 1573-1588. Szayana, T. S., McCarthy, K. F., Sollinger, J. M., Demaine, L. J., Marquis, J. P., & Steele, B. (2007). The civil-military gap in the United States: Does it exist, why, and does it matter? Arlington, VA: RAND Corporation.

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In: Psychology of Loneliness Editor: Lázár Rudolf

ISBN: 978-1-53612-900-7 © 2017 Nova Science Publishers, Inc.

Chapter 2

LONELINESS AND PREFERENCE FOR SOLITUDE AMONG OLDER ADULTS Aya Toyoshima, PhD* Graduate School of Human Sciences, Osaka University, Suita City, Japan

ABSTRACT Older adults tend to find it difficult to engage in social activities, as their social environments can be adversely affected as a result of negative life events such as bereavements, retirement, and the loss of physical function. Such individuals also find it difficult to develop new close relationships in later life. Further, the ratio of time spent alone tends to increase with age, with studies showing that older adults spend 48% of their daily lives engaging in solitary activities. However, although there are some negative factors that enhance loneliness in later life, the levels of loneliness reported by older adults are not as high as those reported by other age groups, which is a somewhat paradoxical finding. Geropsychological studies have determined that older adults manage the consequences of failure and loss using two strategies: primary control strategies and secondary control strategies. Primary control strategies *

Corresponding author: Email: [email protected].

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Aya Toyoshima refer to individuals’ attempts to change the external world to fit their personal needs and desires, while secondary control strategies concern individuals’ inner emotions and involve their efforts to influence their own preferences. As primary control strategies can be costly, older adults are more likely to rely on secondary control strategies. Thus, it is possible that older adults use secondary control to change their preferences and adapt to the new limitations to their social activities. Meanwhile, preference for solitude, which relates to a high level of competency in terms of spending time alone (e.g., feeling positive emotions in such a situation), may be another important factor in this regard. In this chapter, developmental change in elderly people in relation to loneliness and preference for solitude are reviewed; this is achieved by examining the findings of recent studies, and reconsidering loneliness and the positive aspects of solitude.

Keywords: preference for solitude, loneliness, subjective well-being, older adults

1. INTRODUCTION Research into the loneliness experienced by older adults is important for promoting general well-being, especially considering the rapidly aging populations in many countries around the world. In fact, as a result of this rapid increase in population age, the problems faced by lonely elderly people are now gaining a great deal of academic attention, especially in Asian countries. Focusing on Japan, the number of older adults living alone has increased dramatically, from 17.3% in 1995 to 22% in 2005, and it is estimated that approximately 25% of older adults in Japan currently live alone (Cabinet Office, Government of Japan, 2015). The main cause of this situation is the increased prevalence of nuclear families in the country, which has resulted in some older adults living alone, without social interaction with neighbors; thus, older adults often die alone in their homes, a phenomenon known as “kodoku-shi” (solitary death).

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1.1. Loneliness and Social Isolation Before beginning an in-depth analysis of loneliness among older adults, it would be beneficial to describe the difference between “loneliness” and “social isolation.” Since the research of Weiss (1973) and Perlman and Peplau (1981), which are regarded as the first studies of loneliness, loneliness has become an important research topic in the fields of personality and social psychology; specifically, Perlman and Peplau (1981) defined loneliness as “the unpleasant experience that occurs when a person’s network of social relations is deficient in some important way, either quantitatively or qualitatively” (p. 31). More recently, however, loneliness researchers have determined loneliness to be a subjective perception of social isolation or negative emotional experience, and a condition that is distinguishable from objective social isolation (Cacioppo & Hawkley, 2009; Cornwell & Waite, 2009). One of the most widely used (e.g., Lasgaard, 2007; Toyoshima & Sato, 2017; Wilson, Cutts, Lees, Mapungwana, & Maunganidze, 1992) instruments for assessing loneliness is the UCLA Loneliness Scale (Russell, 1996); examples of the items of this scale include: “how often do you feel that you lack companionship?” and “how often do you feel part of a group of friends?” This instrument is popular because, while some items in this scale inquire into social relationships with others, others focus on whether individuals perceive their social relationships negatively. In contrast, social isolation refers to a situation in which a person lacks social contacts. Gierveld and Havens (2004) suggested that “social isolation relates to the objective characteristics of a situation and refers to the absence of relationships with other people” (p. 110). Specifically, sociologists and geropsychologists assess social isolation by analyzing an individual’s social activities, the members of their social networks, and their frequency of contact with family members, neighbors, and friends (Victor, Cambler, & Bond, 2009). In fact, there are numerous indicators of social isolation: living alone, having a small social network, low participation in social activities, and a perceived lack of social support

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(Berkman & Syme 1979; Dean, Matt, & Wood, 1992; Hawkley, Masi, Berry, & Cacioppo, 2006; Krause 1987; Thoits & Hewitt, 2001). Previous studies have found it difficult to distinguish concepts of loneliness from those of social isolation, mainly because researchers have varying definitions of these concepts. Moreover, in pathological terms, loneliness and social isolation have been referred to as negative aspects of the social relationships of older adults; in conceptual gerontology, preventing these social diseases tends to be a priority, despite the lack of a clear definition of the concepts (Victor, Cambler, & Bond, 2009). Although loneliness relates to an individual’s subjective perception, a lack of social relationships, similar to social isolation, can also cause this emotion. This is a primary reason people tend to confuse the concepts of loneliness and social isolation. Loneliness is a possible outcome when individuals find themselves having a small number of relationships (Gierveld & Havens, 2004); however, it is important to note that people who are socially isolated do not always feel lonely, and that people can feel lonely even when staying with others in groups or colonies. Consequently, in this chapter, to avoid confusion with social isolation, the author describes “loneliness” as a subjective perception featuring negative emotion. The cognitive discrepancy model of loneliness (Thibaut & Kelley, 1959) explains the psychological process through which an individual develops a comparison level for his or her entire network of social relationships. Such a comparison level can be thought of as representing the quantity or quality of social contact desired by a person. Russell, Cutrona, McRae, and Gomez (2012) examined relationships between desired and actual social contact and loneliness, and found that people who reported identical levels of desired and actual social contact showed the lowest levels of loneliness. Further, they also found that loneliness increases as the actual number of close friends exceeds the ideal number; therefore, it is possible that people feel lonely when they have more social contacts than they desire, despite the fact that they are not socially isolated.

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1.2. Effects of Loneliness on Physical Health and Cognitive Function It has become widely known that loneliness influences physical health; for example, it has been reported that loneliness is linked to high blood pressure (Cacioppo et al., 2000) and sleep problems (Hawkley, Preacher, & Cacioppo, 2011; Pressman, Cohen, Miller, Barkin, Rabin, & Treanor, 2005). However, this seems to be a more severe problem for older adults than younger generations, as the negative impacts of loneliness on health have been regularly shown in studies on older adults (blood pressure; Hawkley et al., 2006; poor sleep quality: McHugh & Lawlor, 2013; Stafford, Bendayan, Tymoszuk, & Kuh, 2017). Interestingly, studies have also found that loneliness is a strong predictor of mortality (Berkman & Syme, 1979; Patterson & Veenstra, 2010; Shiovitz-Ezra & Ayalon, 2010), with higher rates of mortality being reported among isolated older adults (Luo & Waite, 2014; Perissinotto, Cenzer, & Covinsky, 2012). For example, Holt-Lunstad, Smith, Baker, Harris, and Stephenson (2015) conducted a meta-analysis to examine the effect of loneliness as a risk factor for mortality, and reported that loneliness predicts mortality, and that it has a similarly strong influence in this regard as that of social isolation and living alone. The psychological definition of loneliness is that it is a subjective perception that has a serious impact on health in later life. Several studies have found loneliness and the experience of negative emotions to have impacts on health over long-term periods, although some of the studies that have produced this finding tend to mix the definitions of loneliness and social isolation, and more research is needed to obtain a definitive conclusion in this regard (Ong, Uchino, & Wethington, 2016). The association between loneliness and cognitive function has also been analyzed, and these studies have found that loneliness negatively influences cognitive function (e.g., Cacioppo & Cacioppo, 2014; Zhong, Chen, Tu, & Conwell, 2017) and is a risk factor of dementia. In an experimental study, Cacioppo and Hawkley (2009) suggested that perceived social isolation, which they included as part of the concept of

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loneliness, is related to poorer cognitive performance and faster cognitive decline. Thus, as a risk factor of dementia, it is possible that loneliness has an interactive relationship with confounding factors such as social activity, personality traits, and physical health. In summary, in this section, the author introduced the effect of loneliness on physical health and cognitive function, which is an important topic concerning older adults and impacts their ability to enhance their health and enjoy a successful aging process. From the evidence provided in this section, it is clear that loneliness must be treated as an evil that should be excluded from aging societies.

1.3. Psychological Factors of Loneliness From a psychological perspective, social psychologists have suggested that maintaining and forming social relationships play important roles in regard to one’s subjective well-being. However, being isolated from social groups and experiencing conditions in which one cannot mix with groups represent crisis states. Experiencing such situations causes us to feel negative emotions (i.e., loneliness), which prompts us to try to undo our isolation from society (Cacioppo & Patrick, 2008). Some researchers have treated loneliness as a means of measuring negative aspects of subjective well-being (e.g., Toyoshima, Martin, Sato, & Poon, 2017; Windle & Woods, 2004); furthermore, loneliness has also been associated with depression (Cacioppo, Hawkley, & Thisted, 2010; Koenig, Isaacs, & Schwartz, 1994), low self-esteem (Schultz & Moore, 1988), and aggression (Crick & Grotpeter, 1995; Diamant & Windholz, 1981). It is particularly difficult to distinguish between loneliness and depressive symptoms because both concepts concern negative emotions, and feeling lonely is a symptom of many mood disorders. However, loneliness has been found to be a significant predictor of changes in depressive symptoms (Cacioppo, Hawkley, & Thisted, 2010).

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Loneliness has also been associated with suicidal ideation and behavior (Barnow, Linden, & Freyberger, 2004; Goldsmith, Pellmar, Kleinman, & Bunney, 2002; Waern, Rubenowitz, & Wilhelmson, 2003), and analysis of psychological processes can explain why individual social perception has such a strong effect on people’s decisions concerning their own lives. Although it is distressing that feeling lonely can force people to kill themselves, most people who feel lonely and/or loneliness do not commit suicide. Further, such a risk of suicidal ideation is low when we only experience loneliness in brief episodes during our daily lives; however, such ideation becomes severe when people feel loneliness for long periods, as it can develop into depressive symptoms (Cacioppo & Patrick, 2008). Thus, experiencing severe levels of loneliness has the possibility to create depressive feelings that develop into suicidal ideation. There is no direct connection between feeling lonely in daily life and depressive symptoms and suicide; however, there are individual differences between people in terms of sensitivity to loneliness, personality, family structure, and frequency of feeling lonely, meaning the same event could impact some people more severely than others. Thus, considering that severe and longterm loneliness can be a risk factor of depressive symptoms and suicide, this shows that the loneliness people regularly feel in daily life generally equates to severe loneliness. In other words, there are a number of levels between the loneliness that occurs in daily social life and the severe loneliness that enhances the risk of depression, suicide, and even dementia. The above illustrates that studies have shown that feeling loneliness is a risk factor for many health problems, including physical and mental health issues. This is not surprising, because loneliness relates to undesirable experiences and negative emotions. Innumerable studies have reported on the negative impact of loneliness on our physical and mental health, and these findings clearly show the importance of maintaining subjective well-being in older adults. It is easy to imagine that older adults face an increased risk of loneliness and require interventions to decrease loneliness; thus, in aging societies, the problem of loneliness for older adults represents a large obstacle to enhancing their health and subjective well-being.

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2. AGING PARADOX OF LONELINESS In the previous section, the author described the negative impact of loneliness on older adults and emphasized the importance of loneliness studies in aging societies. However, some studies have reported that older adults show lower levels of loneliness than younger generations. This phenomenon also extends to studies concerning the prevalence of issues relating to developmental changes and social factors. Thus, in this section, in an attempt to understand loneliness among older adults from a geropsychological viewpoint, the author reviews methods of explaining this paradoxical phenomenon.

2.1. Periods of Time Spent Alone Increase with Age Being isolated from social groups and spending time alone can be regarded as crisis states related to feeling lonely. As people age, time spent alone increases and time spent engaging in social activities decreases. In other words, in comparison to younger adults, older adults spend less time with others (Carstensen, 2001; Cornwell, 2015; Larson, Zuzanek, & Mannell, 1986) and less time engaging with their personal networks (Cornwell, 2015; Horgas, Wilms, & Baltes, 1998). The ratio of time spent alone tends to universally increase with age, regardless of whether the person in question is living alone or with a family, with one study showing that while younger adults spend 29% of their time engaging in solitary activities, this increases to as much as 48% among retired, older adults (Larson, 1990). Furthermore, it has also been found that the variety of activities that older and younger adults engage in differs. (Marcum, 2013). In later life, people tend to focus on relationships with people they feel close to (spouse, children, close friends, etc.) and neglect creating new relationships with others; moreover, they also have relatively less diverse and more family-centric networks (Antonucci & Akiyama, 1987). Socioemotional selectivity theory (Carstensen, 2006) suggests that older adults invest a great deal in maintaining close

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relationships and prefer to maintain emotions that are as positive as possible; this is thought to be because older adults feel that they have a more limited future than younger adults. The decreasing of engagement in these social activities with age becomes a risk factor for frequently feeling lonely. There are other risk factors concerning enhanced loneliness in later life. For example, a lack of companionship has been found to be closely related with loneliness (Blau, 1961; Lowenthal & Haven, 1968), and older adults also tend to experience the bereavements of close friends more often than younger adults, which also has a negative impact. Moreover, the inability to control their personal environments can also cause loneliness in older adults (Averill, 1973; Schulz, 1976); for example, retirement and the change of lifestyle it brings is a critical stage for older adults. In such situations, people are forced to adapt to a drastic change in their lifestyle, one that they have never experienced before. Another possible trigger of loneliness is declining physical and mental health. In later life, people experience a number of negative life events, such as the bereavement of friends and family members, undesired retirement, and decreasing health, and these are regarded as risk factors of feeling lonely (Perlman & Peplau, 1981). Indeed, the quantity of social interactions does not always enhance subjective well-being in older adults, possibly due to the limitations on social interactions that arise with age. In essence, older adults tend to find it difficult to maintain social interaction with others when their social environments are changed by life events such as bereavements, and they also find it difficult to create new social relationships.

2.2. Loneliness does not always Increase with Age Interestingly, while the amount of time spent alone increases as one ages (e.g., Larson, 1990), for adults aged 65–75 (young-elderly) the level of loneliness does not rise in conjunction with this increase (e.g., Sörensen & Pinquart, 2002). Specifically, for middle-aged adults and young-old, the

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level of loneliness appears to remain stable, while for the oldest elderly, those aged over 80, higher levels of loneliness are commonly found (Sörensen & Pinquart, 2002). In other words, the results of the metaanalysis conducted by Sörensen and Pinquart (2002) suggest that loneliness does not increase with age. Further, other studies have supported this finding by suggesting that loneliness decreases from middle to older age (Cacioppo et al., 2010). A possible reason for this is that the sources of loneliness differ between life stages; for example, in early childhood, a lack of peer friendship is the main source of loneliness, while romantic relationships are valued more highly during younger adulthood (Qualter et al., 2015). However, it should also be noted that sources of loneliness are perceived differently depending on one’s age and culture (Rokach & Neto, 2005). While studies in various countries have reported that the loneliness scores for young- old, do not exceed those for children and younger adults (Toyoshima & Sato, 2017; Yang & Victor, 2011), there are some issues in regard to methodology and participants that impact these results; nevertheless, all such studies agree that, with age, the number of social activities decreases and the risk of loneliness increases. There are three challenges to explaining this paradoxical phenomenon; that is, that older adults tend to report lower levels of loneliness than expected. The first is the methodological challenge. Many loneliness scales have been developed. For example, the de Jong Gierveld Loneliness Scale (Gierveld & Tilburg, 2006) and the Social-Emotional Loneliness Scale for Adults (DiTomasso, Brannen, & Best, 2004) are widely used. Thus, the results of previous studies have been affected by the researchers’ choice of scale. This also causes a problem in regard to the validity and reliability of using multi-generation data, which occurs when the researchers compare loneliness between older adults and various other age groups (Penning, Liu, & Chou, 2014). The second challenge is similar to the first, and relates to the fact that triggers and sources of loneliness differ between age groups (Qualter et al., 2015). Finally, the third challenge concerns the possibility that for older adults the association between social activity and loneliness is weaker than for younger adults. This means that the psychological

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process that relates to engaging in social activities and its effects on loneliness changes with age. The first and second challenges can be addressed by conducting a meta-analysis and reviewing the articles of numerous previous studies. In fact, some researchers are currently attempting to negotiate these challenges. However, for the third challenge, reviewing geropsychological studies and theories are necessary. The first and second inform us that loneliness studies have inherent methodological problems; however, the phenomenon that older adults tend to report a lower level of loneliness than younger adults may be true, nevertheless. Consequently, considering this third issue, in this chapter the author will review some geropsychological theories that have been posed as possible explanations for the change in loneliness with increasing age.

2.3. Aging Paradox in Social Relationships In this work, the author refers to the phenomenon of the level of loneliness failing to increase with age, despite the risk factors and triggers of loneliness concurrently rising, as the “aging paradox of loneliness.” Previous geropsychological studies have reported on this aging paradox, wherein older adults’ subjective well-being is sustained despite experiencing various losses such as a decline in physical functions (Gondo et al., 2006; Löckenhoff & Carstensen, 2004; Mroczek & Kolarz, 1998). The effect of aging on the relationship between social activities and loneliness is paradoxical, as negative life events occur more frequently in later life (such as the bereavement of close friends, the loss of social rules with retirement, a reduction in the size of social networks, the limitation of social activities, and increased difficulty creating new social networks and social roles), but loneliness does not increase with age. The aging paradox of loneliness is a framework concerning the concept of loneliness and how it effects the social aspect of aging individuals. Specifically, this paradox means that researchers focusing on

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the psycho-social aspect of aging have not been able to clearly identify the negative effects in later life. A factor of the aging paradox of loneliness is that loneliness has a stronger association with the quality of social relationships than the quantity of such relationships (Hawkley et al., 2003; Heinrich & Gullone, 2006). Further, the effect the quantity of social relationships and the reduction of social networks have on loneliness is not direct (Hawkley, Burleson, Berntson, & Cacioppo, 2003; Sörensen & Pinquart, 2002). As mentioned earlier, loneliness is a subjective perception of social isolation that is distinguished from objective social isolation (Cacioppo & Hawkley, 2009; Cornwell & Waite, 2015); however, social isolation is objective and can be a trigger for loneliness. The negative impacts that objective triggers that occur as a result of age have on loneliness and subjective well-being have been found to be weaker than expected (Figure 1). Life event E.g., Bereavement of friends Undesired retirement Objective variables

Decreasing social activities

Loneliness Subjective variables

Subjective well-being Note: The white arrow signifies that the negative effect of objective triggers on loneliness is weaker than expected. Figure 1. Aging paradox of loneliness.

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3. THEORETICAL FRAMEWORK OF THE AGING PARADOX Further discussion and theoretical models are required to explain the paradoxical phenomenon of loneliness among older adults. One reason for this is that psychological studies examining psychological concepts of loneliness and gerontological studies examining the relationship between social activities and subjective well-being have been conducted independently of each other. Consequently, in this section, some psychology and gerontology theories are discussed in an attempt to explain the effect of age on loneliness and social relationships.

3.1. Attachment Styles of Emotional Loneliness At an early stage of loneliness research, researchers regarded attachment style (Bowlby, 1969) to be an important factor in this regard (e.g., Weiss, 1973). In particular, Weiss (1998) suggested that two kinds of loneliness exist: social loneliness and emotional loneliness. Social loneliness is defined as a lack of social relationships in group environments, such as in work and school, while emotional loneliness relates to a lack of relationships with caregivers, such as partners or parents. In other words, the former relates to a person’s social network (e.g., their number of friends) and the latter is influenced by whether the person has a partner or is married. Weiss (1973), considering these attachment styles and loneliness, specifically stated that the development of relationships between parents and children in childhood influences loneliness during young adolescence. Attachment styles are classified using the situation procedures developed by Ainsworth, Blehar, Waters, and Wall (1978). Some studies have reported that the attachment style adopted in childhood affects levels of loneliness in adult life (DiTommaso, Brannen-McNulty, & Best, 2004; DiTommaso, Brannen-McNulty, Ross, & Burgess, 2003). Secure type (type B of Ainsworth et al.’s (1978) three main attachment styles) children who develop stable attachment with their caregivers tend to report lower

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levels of loneliness than other types, and to develop social skills and personalities that allow them to develop close relationships with others after young adolescence. In particular, emotional loneliness is lower in the secure type and higher in the avoidant type (type A: children who tend to avoid interaction with caregivers and strangers). Thus, it can be claimed that attachment style developed during childhood remains stable throughout adolescence (Kirkpatrick & Hazan, 1994) and is related to loneliness (Conger, Cui, Bryant, & Elder, 2000). Mickelson, Kessler, and Shaver (1997) examined the difference age makes in regard to attachment style, assessing the attachment styles of participants using the Adult Attachment Interview (Main, Kaplan, & Cassidy, 1985). By comparing the association between emotional loneliness and attachment styles, they found that the prevalence of avoidant type (dismissing of detached) decreased with age. Further, Kafetsios and Sideridis (2006) also reported that the association between loneliness and the tendency to be the avoidant type was weaker in older adults than in younger adults. Therefore, the reasons older adults report lower levels of loneliness than younger adults may relate to the scarcity of the avoidant type among older adults and the weakness of association between loneliness and attachment style in later life. Thus, there is a possibility that attachment style relates to the aging paradox of loneliness, although this cannot be confirmed because the studies mentioned above are cross-sectional and do not specifically identify the effect of aging on attachment style. However, attachment theory cannot explain the developmental change in loneliness after middle-age. Specifically, differences in attachment styles and association with loneliness do not explain why older adults report lower levels of loneliness than expected. For example, the bereavement of parents, and other persons with whom a close attachment is formed, tend to occur after middle-age. These life events undoubtedly enhance emotional loneliness; however, levels of loneliness do not show a related increase at this point. Attachment theory cannot provide an explanation for this paradox. Moreover, attachment theory is unable to explain the social loneliness that occurs as a result of a reduction in social

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networks and the loss of social relationships caused by negative life events such as retirement. Instead, attachment theory focuses on relationships in childhood and is suitable for providing an understanding of the types of emotional loneliness that may exist in later life. Thus, to provide an understanding of social loneliness in later life, other gerontological theories that focus on related changes in social networks and social activities must be considered.

3.2. Selective Optimization with Compensation Selective Optimization with Compensation (SOC; Baltes & Baltes, 1990; Baltes, Dittmann-Kohli, & Dixion, 1984) is a gerontological theory concerning successful aging. SOC theory relates to a framework of adaptive development that can be employed in response to the losses that occur during aging, meaning that people use this to maximize gains and minimize losses in regard to their aging processes. Specifically, this entails that, in later life, older adults prioritize certain goals over others (lossbased selection), perform the most suitable actions for accomplishing each goal (optimize), and compensate for their loss of resources, such as their decreasing physical and mental functions, by exploiting other available resources. To interpret the aging paradox of loneliness in terms of SOC theory, this would mean that, in order to maintain their social relationships, older adults use a strategy of focusing on relationships with closely related and familiar persons and people with whom they can connect easily with when they encounter difficulties. For young-elderly who are retired, contact with people in valued relationships (e.g., contact with children in parental relationships, and contact with partners in marital relationships) has been found to enhance subjective well-being and positive self-concepts (Nakahara, 2013). Meanwhile, older adults, who face limitations on their social activity, tend to focus on more important relationships; i.e., with people with whom they are close. Therefore, it is the quality of social relationships and social activities that influences subjective well-being in

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later life, not the size of a person’s social network or the degree of social activities they engage in. Further, older adults have been found to use SOC strategies to restrain loneliness triggers, particularly those concerning social loneliness; social loneliness relates to social networks and social relationships, and older adults tend to experience changes in this aspect as a result of negative life events. Heckhausen and Schulz (1993, 1995) suggested that older adults select goals, strive to attain those goals, and manage the consequences of failure and loss as a result of age using two strategies: primary control strategies and secondary control strategies. Primary control strategies refer to individuals’ attempts to change the external world to fit their personal needs and desires; an example would be the investment of time and effort to maintain a close personal relationship. In contrast, secondary control strategies target individuals’ inner world and involve their efforts to influence their own motivations, emotions, and mental representations; an example of such a strategy would be making efforts to care about the loss of social relationships. Older adults are more likely to rely on secondary control strategies because of the limitations they experience in terms of creating new social relationships. Further, there is also the possibility that older adults increase their use of secondary control strategies and their recognition of the merits of solitude during their adaptation to the social limitations that come with age. Thus, primary control strategies cause a decrease in social activities, while secondary control strategies influence the negative impact of decreasing social activities as a result of age (Figure 2).

4. PREFERENCE FOR SOLITUDE Preference for solitude (PS), a psychological concept in social psychology, may be an important factor in regard to the aging paradox of loneliness. PS refers to the degree to which a person prefers to be alone or

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the level of competency in spending time alone (Burger, 1995); those who have a high PS tend to choose to be alone, which suggests that they regard the time they spend alone as positive. While SOC theory suggests that a reason older adults do not report higher levels of loneliness than younger adults is that they use primary control strategy to adapt to their decreasing social relationships and activities, on the other hand, PS relates to secondary control strategy and can be useful for measuring changes in an individual’s inner perception. An increase in loneliness is considered an undesirable state of being, and spending time alone has been raised as one of the causes of this increase. However, some studies have mentioned some positive aspects to being alone, such as the fact that solitude increases creativity (Storr, 1988), or that it is necessary to maintain privacy (Bates, 1964). Further, there are cases where isolating oneself is used as a coping mechanism for heavy stress (Heinrich & Gullone, 2006). The main problem relating to solitude is that it entails a lack of social support, but several studies have found positive aspects (Burger, 1995; Long & Averill, 2003); Leary, Herbst and McCrary (2003) found that a group with high PS preferred activities that could be conducted alone, as spending time alone functioned as a pause in social activities for them. Burger (1995) concluded that differences between individuals regarding PS is an important factor in determining whether solitude is a positive condition for particular persons. PS is a preference indicator that shows whether one prefers the condition of being alone, and it can also be considered as “competency spending time alone” (Long, Seburn, Averill, & More, 2003). Those who have high PS choose independently to be alone, they tend to regard time spent alone as positive. Long et al. (2003) divided solitude into three factors: “Inner-directed” (characterized by selfdiscovery and inner peace), “Outer-directed” (characterized by intimacy and spirituality), and “Loneliness.” In particular, inner-directed solitude is especially beneficial from an emotional standpoint, as it has been found to be associated with low depression and high self-esteem.

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Time spent alone can be divided into two classes: relational and nonrelational. Relational links to the positive aspects of solitude; specifically, inner-directed and outer-directed factors. Meanwhile, non-relational links to the negative aspects; that is, feeling isolated and lonely (Averill & Sundararajan, 2014). A person with a high PS tends to be active when they are alone and to feel positive when spending time alone, even though their social activities are decreased. For such people, being alone allows them to contemplate and increase their intellectual activities and creativity, meaning PSS can positively influence one’s subjective well-being (Burger, 1995). When older adults face a crisis, such as through a negative life event, loneliness is enhanced, and some people adapt to such an event by changing their inner perception. For example, older adults tend not to desire a large-scale social network when they are prevented from going outside as a result of decreasing physical function. As mentioned above, a person with a higher PS tends to be “relational” when they spend time alone and to value staying alone (Long & Averill, 2003); this may influence certain older adults’ increasing use of secondary control strategies and their recognition of the merits of solitude during their adaptation to the social limitations that come with age. Thus, considering this theoretical background, it can be said that developmental changes relating to PSS are indicators of changes in the value of social interactions with others caused as a result of the adoption of secondary control strategies. There is a degree of evidence supporting the theory that older adults tend to have different levels of preference in comparison to younger generations. For example, Toyoshima and Sato (2017) examined whether PS promotes emotional well-being in older adults and college students; their results showed that older adults reported both a higher level of PSS and a lower level of negative emotion than the college students. Further, Pauly, Lay, Nater, Scott, and Hoppmann (2016) reported that temporary solitude is linked to more favorable mental health in older adults. Thus, it can be concluded that temporarily spending time alone is an experience that is not necessarily negative and may become more positive with aging.

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Life event E.g., Bereavement of friends Undesired retirement Objective variables

Decreasing social activities

Primary control strategy Secondary control strategy

Loneliness Subjective variables

Subjective well-being

Figure 2. The theoretical model of the aging paradox of loneliness.

5. AVENUES OF RESEARCH FOR FUTURE STUDIES PSS is a psychological factor that explains the aging paradox of loneliness; however, further study is required on this topic. In this chapter, the author showed that loneliness among older adults is an important topic in aging societies, and also discussed an interesting phenomenon, the aging paradox of loneliness, which concerns the finding that older adults report lower levels of loneliness than expected. This final section describes avenues of research for future studies concerning the developmental changes associated with PSS. First, a behavioral model is required to differentiate between those who are at risk of developing loneliness and those who are not. A challenge here is that it is difficult to identify when a person requires help in regard to their loneliness, because loneliness is a subjective perception. Further, socially isolated older adults do not always feel lonely. When such individuals desire to remain alone and do not wish to receive support, there

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is little that a caregiver can do. PS is a preference and psychological factor and does not relate to whether a person wants to be isolated or if they are taking risks by isolating themselves. Consequently, to identify whether the person is unhealthy and exposed to risk, a definition or assessment tool that measures behavior would be effective. Distinguishing between positive solitary behavior and negative solitary behavior is important to define the existence of loneliness. To develop such an assessment tool, examining the daily activities of older adults with high levels of PS and who maintain subjective well-being is necessary. Second, interventions for isolated older adults with high levels of PS are urgently required. Some social isolated older adults who prefer to be alone tend to avoid receiving support from others. Some existing intervention programs for social isolation focus on enhancing social communication and developing new relationships with others; however, isolated older adults with higher PS may be passive towards participating in these interventions and social activities, even though they are exposed to risk and are the primary targets of the program. It is important to determine the interest of such people in order to convince them to participate in intervention programs. Finally, understanding how older adults overcome loneliness and adapt to decreasing social relationships would be useful for providing effective information for younger generations. Intrinsically, many younger adults report feeling lonely and are exposed to a high risk of loneliness. Researchers and politicians tend to focus on isolated older adults; however, younger generations should be set as the main targets in regard to initiatives that address the problem of loneliness. The strategies and behaviors that older adults employ to maintain their subjective well-being may also apply to other age groups who are distressed concerning their social relationships with others.

ACKNOWLEDGMENTS The concept of this article is based on the author’s doctoral thesis: “Toyoshima, A. (2015). Kodoku kan no aging paradox to taisyo horyaku ni

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kansuru kenkyu. Doctoral Thesis, Graduate School of Human Sciences, Osaka University, Japan” (in Japanese). To conduct this study, I received advice from Professor Shinichi Sato and Associate Professor Yasuyuki Gondo from Graduate School of Human Sciences, Osaka University, and I would like to express my sincere gratitude to them for their assistance. Further, I would like to thank Editage (www.editage.jp) for English language editing.

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from a British birth cohort study. Journal of Psychosomatic Research, 98, 1-9. Storr, A. (1988). Solitude, London: Flamingo. Thibaut, J. W. & Kelley, H. H. (1959). The social psychology of groups. New York, Willey. Thoits, P. A. & Hewitt, L. N. (2001). Volunteer work and well-being. Journal of Health and Social Behavior, 42, 115–131. Tijhuis, M. A. R., Gierveld, D. J. D., Feskens, E. J. M. & Kromhout, D. (1999). Changes in and factors related to loneliness in older men. The Zutphen Elderly Study. Age and Ageing, 28(5), 491–495. Toyoshima, A., Martin, P., Sato, S. & Poon, L. W. (2017). The relationship between vision impairment and well‐being among centenarians: findings from the Georgia Centenarian Study. International Journal of Geriatric Psychiatry, Online First. Toyoshima, A. & Sato, S. (2017). Examination of the relationship between preference for solitude and emotional well-being after controlling for the effect of loneliness. Osaka Human Sciences, 2, 171–183. Victor, C., Scambler, S. & Bond, J. (2009). The social world of older people: understanding loneliness and social isolation in later life (growing older), Maidenhead, England, Open University Press. Waern, M., Rubenowitz, E. & Wilhelmson, K. (2003). Predictors of suiside in the old elderly. Gerontology, 49, 328–334. Weiss, R. S. (1998). A taxonomy of relationships. Journal of social and personal relationships, 15(5), 671-683. Weiss, R. S. (1973). Loneliness: The experience of emotional and social isolation. Cambridge, MA: MIT Press. Wilson, D., Cutts, J., Lees, I., Mapungwana, S. & Maunganidze, L. (1992). Psychometric properties of the revised UCLA Loneliness Scale and two short-form measures of loneliness in Zimbabwe. Journal of Personality Assessment, 59, 72–81. Windle, G. & Woods, R, T. (2004). Variations in subjective wellbeing: the mediating role of a psychological resource. Ageing and Society, 24, 582–602.

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Yang, K. & Victor, C. (2011). Age and loneliness in 25 European nations. Ageing and Society, 31(8), 1368–1388. Zhong, B. L., Chen, S. L., Tu, X. & Conwell, Y. (2017). Loneliness and cognitive function in older adults: Findings from the Chinese Longitudinal Healthy Longevity Survey. The Journals of Gerontology: Series B, 72(1), 120-128.

In: Psychology of Loneliness Editor: Lázár Rudolf

ISBN: 978-1-53612-900-7 © 2017 Nova Science Publishers, Inc.

Chapter 3

LONELINESS AND SUICIDE Rebecca L. Kauten, PhD, Jessica M. LaCroix, PhD, Amber M. Fox and Marjan Ghahramanlou-Holloway, PhD F. Edward Hébert School of Medicine, Uniformed Services University of the Health Sciences. Bethesda, Maryland

ABSTRACT Loneliness has been conceptualized both as an objective state of physical alienation and a subjective state of distress due to feeling alone. The construct of loneliness has been empirically linked with a variety of mental health conditions including depression, hopelessness, suicide ideation, and/or suicide-related behaviors. This chapter examines loneliness and suicide through Aaron Beck’s cognitive behavioral theory 

Corresponding Author: Marjan Ghahramanlou-Holloway, Ph.D. Associate Professor, Department of Medical and Clinical Psychology; Psychiatry. Director, Suicide Care, Prevention, and Research (CPR) Initiative. F. Edward Hébert School of Medicine. Uniformed Services University of the Health Sciences. 4301 Jones Bridge Road, Room B3046. Bethesda, Maryland 20814-4799. Telephone: 301-295-3271. Fax: 301-295-3034. Email: [email protected]. Additional email: [email protected].

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Rebecca L. Kauten, Jessica M. LaCroix, Amber M. Fox et al. and largely through Erik Erickson’s theory of psychosocial development. More specifically, we review how ambivalence resulting from competing drives of connectedness, authenticity, and self-protection may contribute to loneliness and explore manifestations of loneliness and suicidality during childhood, adolescence, young adulthood, middle adulthood, and older adulthood. Intervention strategies to address loneliness in the context of suicide are explored, and recommendations for clinical practice and future areas of empirical inquiry are presented.

INTRODUCTION Conceptualizations of loneliness tend to differentiate between “subjective” and “objective” loneliness. Subjective loneliness relates to feeling alone and socially isolated (Russell, Peplau, & Cutrona, 1980), while objective loneliness involves physical alienation such as living alone or not having friends (Stravynski & Boyer, 2001). Subjective and objective experiences of loneliness are somewhat analogous to emotional and social typologies of loneliness, the former associated with lack of intimacy and attachment and the latter associated with lack of a social network (Russell, Cutrona, Rose, & Yurko, 1984; Weiss, 1973). Loneliness has also been defined as the “unpleasant experience that occurs when a person’s network of social relationships is significantly deficient in either quality or quantity” (Perlman & Peplau, 1984, p. 15). Loneliness is thus described as (1) a perceived discrepancy between one’s needs or desires for social contact and one’s actual social contact, (2) a subjective rather than objective experience, and (3) as distressing. Feelings of loneliness may vary over a period of hours as evidenced by a study capturing one’s experience via ecological momentary assessments (Kleiman et al., 2017). Furthermore, loneliness may be more or less distressing at various developmental time points due to differences in context and desire for social relationships. Distress due to loneliness can therefore contribute to various mental health issues across the lifespan including depression, hopelessness, suicide ideation, and/or suicide behavior (Chang et al., 2017; Kleiman et al., 2017; Lasgaard, Goossens, & Elkit, 2011; Stravynski & Boyer, 2001).

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THE NEED TO BELONG Human beings have a fundamental need to belong (Baumeister & Leary, 1995; Maslow, 1943). Intimacy demands are critical and represent the layer of essential needs beyond physiological and safety requirements (Maslow, 1943). Belongingness is more than a desire; it has been presented as a necessary ingredient for a fulfilling life (Heinrich & Gullone, 2006) and evolutionarily advantageous (Baumeister & Leary, 1995). It also demands reciprocal support; providing social support to others is a critical component of belonging (Cacioppo, Grippo, London, Goossens, & Cacioppo, 2015). Failure to meet the need to belong can inhibit self-esteem and self-actualization (Maslow, 1943) and can contribute to loneliness, which when experienced at intense levels, can lead to depression and suicidal thoughts (Chang et al., 2017; Kleiman et al., 2017; Lasgaard et al., 2011). The interpersonal-psychological theory of suicide highlights the importance of belongingness in one’s desire to live or die (Joiner, 2005; 2009; Joiner, Brown, & Wingate, 2005). Perceived burdensomeness and thwarted belongingness are key factors that influence one’s decision to attempt suicide. Perceived burdensomeness is defined by the belief that one’s existence is a burden on those around him or her, e.g., “I think my death would be a relief to the people in my life” (Van Orden, Witte, Cukrowicz, & Joiner, 2012). This concept is distinct from Perlman and Peplau’s (1984) conceptualization of loneliness, i.e., a perceived discrepancy between one’s needs or desires for social contact and one’s actual social contact. In contrast, thwarted belongingness reflects a sense of social alienation and a feeling that one does not belong to a larger group, e.g., “I often feel like an outsider in social gatherings” (Joiner, 2005; Van Orden et al., 2010), and is more similar to loneliness (Kleiman et al., 2017). Nonetheless, the link between thwarted belongingness, loneliness, and suicide is inconsistent, perhaps due to measurement discrepancies (c.f., Joiner & Rudd, 1996; Stravynski & Boyer, 2001; Van Orden et al., 2008).

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A COGNITIVE BEHAVIORAL CONCEPTUALIZATION OF LONELINESS The cognitive behavioral model delineates that thoughts, feelings, and behaviors are interrelated and influence one another. Any one of the component facets – cognition, emotion, or action – has the capacity to influence the others. The cognitive behavioral model is useful in conceptualizing loneliness (c.f., Heinrich & Gullone, 2006). First, the definition of loneliness described above depends on the cognitive perception of a mismatch between the social relationships one has and the social relationships one needs or wants (Perlman & Peplau, 1984), and lonely individuals may distort their cognitive perceptions of the world. For instance, lonely people may view social interactions through a negative filter (Ernst & Cacioppo, 1999), or perceive the world as more threatening than people who are not lonely (Hawkley et al., 2003). Lonely people also often think poorly of themselves (i.e., have low self-esteem) (Peplau, Miceli, & Morasch, 1982) and may think they are a burden to others, e.g., “I think I make things worse for the people in my life” (Van Orden et al., 2012). Lonely people may employ selective attention and attend exclusively to evidence that supports a lack of closeness and willingness of family and friends to provide emotional help. In addition to the inability to recognize support being offered by others, individuals in a depressive state may be unable to evoke memories of supportive others while in crisis (Adler & Buie, 1979). Loneliness, though distinct from depression, has been shown to increase the likelihood of depression (Cacioppo et al., 2015). Thus, a lonely person may have depressive thoughts, characterized by negative cognitions about the self (e.g., “I am not good company. Who would want to spend time with me?”), the world (e.g., “No one in the world cares for me”), and the future (e.g., “I will always be alone”) (Beck, 1970). These thoughts, in turn, may perpetuate feelings of loneliness. Affectively, loneliness involves a subjective feeling of distress. Many lonely people experience feelings associated with desperation (e.g.,

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panicked, helpless, hopeless), depression (e.g., sad, empty, alienated), impatient boredom (e.g., bored, uneasy, angry), and self-depreciation (e.g., unattractive, ashamed, insecure) (Rubenstein & Shaver, 1982). Finally, as a result of negative thoughts and emotions, lonely people may behave in a passive and ineffective manner (e.g., may be shy, avoid engagement with others). Lonely people may also be stigmatized, derogated, and avoided, which in turn may perpetuate their loneliness (Ernst & Cacioppo, 1999). Loneliness has also been linked with insomnia, though the relation becomes insignificant when accounting for depression (Hom et al., 2017). Insomnia, a symptom of depression, may enhance one’s feelings of loneliness. When someone is awake in the middle of the night, they have more time to dwell on their state of alone-ness. If the cycle of intrusive negative thoughts, overwhelming negative feelings, and social withdrawal continues, an individual’s loneliness may contribute to psychopathology and beget depression, hopelessness, and thoughts of suicide.

LONELINESS AND SUICIDE ACROSS THE LIFESPAN Erik Erikson’s (1963) theory of psychosocial development emphasizes completion of relational milestones in order to successfully and adaptively progress through life. From developing trust in others to cultivating intimacy within relationships to fully accepting the people within one’s life, the focus of Erikson’s psychosocial model of development centers on overcoming interpersonal challenges. For an individual to successfully progress through Erikson’s model, the individual must achieve social effectiveness throughout each developmental stage. Failure to successfully complete the tasks demanded by each psychosocial stage generally leads to isolation and, likely, loneliness (e.g., mistrust, shame, guilt, inferiority, role confusion, isolation, stagnation, and despair). This loneliness manifests uniquely at various developmental time points and is influenced by age, maturity, contextual demands, experience, and more. Each stage may thus give rise to particular manifestations of loneliness that may then be

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associated with suicidal thoughts and behaviors within each developmental stage.

Childhood: Birth to 12 Years Erikson’s first stage of psychosocial development lasts from birth to about 18 months. Interpersonal reliance on others begins at birth when the infant encounters the psychosocial crisis of trust versus mistrust. Here, the infant learns whether or not he or she can trust others. Infants who are cared for consistently and reliably will develop a sense of trust that will form the basis of future relationships. Successful completion of this stage leads to hope – when additional needs arise, the individual will have hope that those needs will be met. Conversely, if this stage is not successfully completed, the individual will move on with the fear that his or her needs will not be met. Mistrust and fear may contribute to anxiety and insecurity – and eventually a sense of loneliness. The second psychosocial stage lasts from about 18 months to 3 years. Here, the crisis presented is autonomy versus shame and doubt. During this stage, the child tests his or her limits and develops a sense of autonomy and confidence, ideally with the support of caregivers who allow the child to make and learn from mistakes. Successful completion of this stage leads to individuals who are supported and encouraged – to build confidence. Conversely, if this second stage is not successfully completed, the individual will feel ashamed and doubt his or her abilities. Shame and doubt may contribute to poor self-esteem and heightened dependence. The crisis of initiative versus guilt characterizes the third stage, which lasts from ages 3 to 5 years. During this stage, the child experiments with interpersonal play with peers. The child also begins to take initiative and ask questions. Success during this stage results in purpose; individuals will develop a sense of comfort and competence in interpersonal relationships, while criticism and restriction during this stage leads to guilt and lack of initiative.

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The final stage of childhood stage involves the crisis of industry versus inferiority and lasts until the child is 12 years old. During this stage, the child seeks acceptance from authority members (e.g., teachers) and peers by displaying competency and adhering to societal standards. The child relies on his or her sense of autonomy and encouragement from others in order to successfully complete this stage, the result of which is feeling competent and industrious. When the individual is not encouraged or is restricted, he or she will feel inferior compared to others. It is evident in this fourth stage that Erikson meant for the stages to be completed sequentially; they build upon one another, and failure to successfully complete an early stage can lead to difficulties in later stages. However, researchers have also argued that the progression through the stages is not necessarily linear, and individuals may decompensate backward through the stages at any time (Whilbourne, Zuschlag, Elliot, & Waterman, 1992). Research related to loneliness and suicide in childhood is scant, and there is no available evidence-based treatment that is specifically targeted at managing suicidal ideation and urges in youth. However, it seems as though both maternal depression and low perceived parental support emerge as factors influencing childhood suicidal ideation and urges (Anderson, Keyes, & Jobes, 2016; Sarkar et al., 2010; Whalen, DixonGordon, Belden, Barch, & Luby, 2015). Both of these factors are linked to insecure attachment (Teti, Gelfand, Messinger, & Isabella, 1995; Yan, Han, Tang, & Zhang, 2017). Insecurely attached children tend to become upset regardless of whether or not the parent is present in the strange situation paradigm (Ainsworth & Bowlby, 1991). The fact that these children are not comforted even when the parent is present suggests a lack of reliable attachment and could represent that the child’s needs, namely those for connection, are not being met at home. Furthermore, insecure attachment patterns tend to extend to peer relationships, and individuals displaying such patterns are often faced with peer rejection in early childhood, when these relationships are formative (Ernst & Cacioppo, 1999). In other words, lonely individuals are often rejected, which then perpetuates the lonely feelings. Lack of social support from peers and family lays the foundation for more feelings of loneliness.

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The loneliness that manifests in early childhood is related to suicidal behaviors in middle childhood (Schinka, VanDulmen, Bossarte, & Swahn, 2012). For prepubescent children ages 10 through 14, suicide is the third leading cause of death (Centers for Disease Control and Prevention, 2016). Overall, when one’s trust, autonomy, initiative, and industry are being developed in relation to others, the absence of meaningful social connection can be devastating.

Adolescence: 12 to 18 Years The four developmental stages found in childhood provide the foundation for the fifth stage, characterized by the psychosocial conflict of identity versus role confusion. This stage lasts through adolescence, from 12 to 18 years. In contrast to the focus of reliance on other people found in the childhood stages, individuals in the fifth stage are expected to connect with, rather than rely on others. During adolescence, the individual develops an identity that is inherently built in relation to other people. This stage is marked by recognition of one’s sexual orientation, falling in love, and experimenting with various interpersonal and occupational roles. Successful completion of this stage leads to fidelity – the individual is able to accept others and commit to others. Failure to complete this stage results in identity crisis or role confusion, a vague and shifting chameleon-like sense of self, and enhanced susceptibility to peer influence. Peer relationships become even more critical during adolescence, when teens are developing their identities in relation to others. Whereas childhood relationships are built on shared activities, adolescent relationships prioritize intimacy (Heinrich & Gullone, 2006). Lacking intimacy during adolescence contributes to feelings of loneliness and hinders identity formation. Additionally, adolescents spend a large portion of the week in school. Thus, a lack of social support is punctuated by the necessity of being in an inherently social location without feeling connected; the adolescent is not physically alone but may experience subjective feelings of loneliness.

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Up to 79% of individuals under 18 years old report occasional to frequent feelings of loneliness (Parlee, 1979). Although not all of these individuals later attempt suicide or even have suicidal thoughts, feeling lonely still has negative implications. Given the emphasis placed on relational effectiveness during adolescence (Erikson, 1963), a lack of connection could prime someone for loneliness. During adolescence, loneliness can be experienced on multiple levels: lack of supportive peer network, feelings of incongruence with peers, disconnection from parents, perceptions of being misunderstood, with the added weight of a general inability to see beyond the present moment. Additionally, chronically lonely adolescents have been found to be hypersensitive to social exclusion and hyposensitive to social inclusion. They also tend to attribute social exclusion to stable, internal factors and social inclusion to external factors, indicating a tendency to respond to situations in a way that perpetuates loneliness (Vanhalst et al., 2015). Minor difficulties often seem to be monumental and insurmountable during adolescence. Loneliness during this developmental period is associated with depression, which has been shown to account for the correlation between loneliness and suicide (Lasgaard et al., 2011; Schinka et al., 2012). Additionally, to the extent that gender differences exist in relation to loneliness, adolescent males tend to report greater levels of loneliness than do females (Heinrich & Gullone, 2006). Although females are more likely than males to have suicidal thoughts, males die by suicide almost four times more frequently than females, and suicide is the second leading cause of death among adolescents and young adults between the ages of 15 and 34 (Centers for Disease Control and Prevention, 2015; 2016). Further, the suicide rate among teens of both genders has been rising over the past decade, up 31% for males and doubling for females (Scutti, 2017). Addressing loneliness and social isolation could be an avenue of suicide prevention within this particular age group.

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Young Adulthood: 18 to 40 Years The sixth stage of psychosocial development is young adulthood, lasting from age 18 to 40 years. The conflict for this stage is intimacy versus isolation. During this period, individuals seek lasting relationships, including romantic relationships and long-term friendships. Successful completion of this stage leads to love. Failure to create intimate connections and fear of commitment leads to isolation, lack of connectedness, and can contribute to depression at this stage. Here again, it is apparent that failure to successfully complete previous stages can impact resolution of the intimacy versus isolation conflict. Mistrust, shame, doubt, guilt, feelings of inferiority, and identity crises can all negatively affect intimate relationships during young adulthood and hinder completion of this stage. The goals of young adulthood and each subsequent developmental stage build upon the sense of support and industry that were established during childhood. During young adulthood, individuals often settle into intimate romantic relationships, and they sometimes marry and start families. Additionally, young adulthood marks a period of work productivity during which networking and making connections is valuable for later professional growth. Young adulthood is also a period of significant change. Individuals enter and graduate from college, experiment with various relationships, and sample a variety of jobs. Within college, people choose their major, extracurricular activities, living situation, and friendships. Many young adults move out of parents’ homes to live on their own, which adds an element of physical isolation. Similar to adolescence, the social nature of the systems in which young adults operate almost necessitates interpersonal interaction. As a result, lacking social interaction is apparent and can be distressing. Situational changes, both dramatic and small, can influence one’s feelings of loneliness (Ernst & Cacioppo, 1999). The overwhelming nature of the change itself can be magnified when the individual does not have an adequate support system. Negative life events in particular can interact

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with loneliness and contribute to suicide risk above and beyond the individual effects of negative life events or loneliness (e.g., sexual assault, Chang et al., 2015). Furthermore, with the explosion of social media, constant momentary updates, and compulsory comparison through multiple portals, it is much easier to recognize when one is being excluded. It is not surprising, then, that when considering college students who reported a history of suicidal ideation, loneliness was often cited as a cause (Westefeld & Furr, 1987).

Middle Adulthood: 40 to 65 Years The seventh stage of psychosocial development, middle adulthood, lasts from age 40 to 65 years. The conflict inherent in this stage is generativity versus stagnation. In this stage, the individual strives to contribute to society in a useful way, and feeling connected to others as part of the broader society is a key motivator. Successful completion of this stage results in care for future generations and social institutions. However, stagnation results from feelings of uselessness and may be accompanied by social withdrawal as well as a variety of escapist behaviors including drug and alcohol use and infidelity. Middle age is characterized by a sense of stability compared with young adulthood. By middle adulthood, individuals generally have established social networks and have learned how to meet their needs for social interaction. Individuals in middle adulthood tend to be settled in marriages, friend groups, jobs, and have found routine in their daily lives (Ryff 1989; Tornstam, 1992; Wrzus, C., Hänel, Wagner, & Neyer, 2013). The stability that often comes with middle age may contribute to the decreased loneliness reported at this developmental stage (Pinquart & Sorensen, 2001). Additionally, feeling needed by others is key in this stage of development, and research has found that individuals who provide support to friends and family have fewer depressive symptoms and less stress (Fiori, & Denckla, 2012; Takizawa et al., 2006). In addition, individuals who feel needed are unlikely to perceive themselves as

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burdensome, a key risk factor for suicide ideation (Joiner, 2005). However, middle aged adults are likely to experience loneliness in the absence of others (Hawkley & Cacioppo, 2010), especially when stability in their social networks is disrupted. In situations that force isolation, like being diagnosed with a physical disability that inhibits social activity, living alone, going through divorce, or developing a life-threatening illness that forces unexpected loss of employment, middle aged adults experience increased loneliness (Lasgaard, Friis, & Shevlin, 2016), and perceived lack of social support is associated with depressive symptoms among this age group (Fiori, & Denckla, 2012). Although suicide is the second leading cause of death for adolescents and young adults, more people die by suicide in middle or late adulthood than in adolescence or young adulthood. In the U.S. in 2015, 16,490 people between the ages of 45 and 64 died by suicide compared with 12,438 people between the ages of 15 and 34 (Centers for Disease Control and Prevention, 2016). The suicide rate among adults between 45 and 64 years of age is 19.6 per 100,000 compared with a rate of 12.5 per 100,000 among adolescents and young adults between 15 and 24 years of age. Further, suicide rates among middle adults have been increasing, up from 13.5 per 100,000 in 2000 to 19.6 per 100,000 in 2015 (American Foundation for Suicide Prevention, 2017). Notably, between 1999 and 2015, rural White Americans between the ages of 45 and 54 had the highest increases in “despair deaths” (Case & Deaton, 2015), i.e., death due to suicide, poisoning, and liver disease, than any other group (Stein, Gennuso, Ugboaja, & Remington, 2017). This group experiences economic stress and hopelessness (e.g., stagnation) (Erikson, 1963) that contributes to dysfunction in relationships, poor social support, and escapist use of drugs and alcohol (Case & Deaton, 2017).

Old Age: 65 Years and Beyond The eighth and final stage of development is old age and lasts from age 65 to death. Integrity versus despair constitutes the final conflict in

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Erikson’s psychosocial development theory. According to Erikson (1980), integrity is “the acceptance of one’s own and only life cycle and of the people who have become significant to it as something that had to be and that, by necessity, permitted of no substitutions” (p. 104). To successfully complete this stage, the individual must find acceptance of his or her life, including acceptance and connection with the people in it, and develop a sense of control over what is to come. Failure to integrate one’s identity with one’s experiences leads to despair, regret, and contempt for other people. Loneliness seems to be felt more acutely in old age. Beyond age 65, one’s social circle and support system begins to shrink. Older adults are more likely to lose the close relationships of spouses, friends, and family to death, leaving older adults with a withering social network and fewer opportunities for social engagement (Pinquart & Sörensen, 2001). Older adults whose spouses pass away show some of the greatest increases in loneliness (Dykstra, van Tilburg, & de Jong-Gierveld, 2005). As adults continue through older adulthood, they are faced with declining physical health, death of loved ones, separation from family and friends, and consequently a degenerating ability to engage in social activities (Barlow, Liu, & Wrosch, 2015; Dykstra et al., 2005). Being unable to socialize with friends because either the individual or the individual’s friends are incapacitated decreases older adults’ ability to engage in social activity and increases their likelihood to experience more severe loneliness. In a society lacking significant institutional support and integrated activities, along with a growing reliance on novel and shifting technology, older adults may feel increasingly alienated and marginalized. Consequently, this group is particularly at risk for loneliness (Crocker, Clare, & Evans, 2006; Victor & Yang, 2012). During the period of old age, elderly adults may have several rights revoked. They may have driving privileges removed, could be placed in a nursing home where they have little opportunity to make their own decisions, and another person may be given guardianship or power of attorney over them. Accordingly, older adulthood is associated with conditions that decrease one’s ability to engage in social activity (Barlow,

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Liu, & Wrosch, 2015; Dykstra et al., 2005; Pinquart & Sörensen, 2001). This decreased social activity may be related to the feelings of loneliness experienced by older adults. With these circumstances, the older adult likely perceives little control over his or her own life and may develop a sense of perceived burdensomeness and/or thwarted belongingness as though their place in the world is narrowing. These individuals feel separated not only from individuals but also from the world at large. Quality of relationships becomes more valuable than quantity (Pinquart & Sorensen, 2001). In one particular qualitative investigation, several older adults who had attempted suicide provided their rationale for their decision (Crocker et al., 2006). Several themes emerged, including feelings of invisibility and a struggle to maintain control over their lives. When these individuals felt separated from and ignored by society and helpless to change their situation, they attempted suicide as a way of gaining control over some aspect of their lives. Very old adults have the second highest rate of suicide; adults aged 85 and older have a rate of 19.4 per 100,000 (American Foundation for Suicide Prevention, 2017). Ultimately, the sense of losing control is a key contributor to rationale for attempting suicide in older adults; it is also a factor that influences feelings of loneliness. Adults that feel they have control over their (social) lives and can influence their experience with personal effort tend to feel less lonely than those that believe that only external factors influence their reality (Newall, Chipperfield, Clifton, Perry, Swift, & Ruthig, 2009). Unfortunately, this control is often lost with age, and older adults living in nursing homes tend to be at higher risk for loneliness (Pinquart & Sorensen, 2001).

LONELINESS ACROSS THE LIFESPAN: CONTEXT AND CAVEATS Several factors are important to keep in mind when considering the manifestation of loneliness across Erikson’s developmental stages. First, it

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is helpful to conceptualize the relation between loneliness and suicide as part of the cognitive behavioral model. As mentioned above, cognitive behavioral theory posits that thoughts, feelings, and behaviors are interdependent. These factors can sometimes operate on a feedback loop, whereby thoughts result in feelings that drive behaviors, which in turn perpetuate and maintain the valence of the thoughts, feelings, and so on. For example, an adolescent or young adult may notice that they were not invited to a party that was photographed and broadcasted on social media and think, “I am being left out. I have no friends. I don’t fit in.” Consequently, the individual may feel lonely and isolated. The individual may shut down and refuse to share his or her thoughts or feelings, even within their intimate relationships. The individual may be hypervigilant to negative feedback and may notice that close friends and family did not acknowledge his or her withdrawal and mood change. As a result, the individual may think, “No one notices when I’m upset. I guess I really don’t have anyone that cares about me.” Consequently, the cycle of loneliness is maintained. Individuals who experience loneliness may then engage in behaviors that incite further rejection and loneliness per the selffulfilling prophecy (Merton, 1968). The second factor to keep in mind when considering the manifestation of loneliness across Erikson’s developmental stages is ambivalence toward other people. By ambivalence, we mean competing desires for (1) closeness with others, and (2) independence from others. This ambivalence is a result of competing drives: the drive for connectedness, the drive for authenticity, and the drive for self-protection. The drive for connectedness is that from which loneliness originally stems; individuals are compelled by an innate desire for intimacy, and they feel lonely when that need is not met. The drive for authenticity stems from Erikson’s sixth stage, identity versus role confusion. In this stage, individuals want to be accepted, but the drive for connectedness may be at odds with the drive for authenticity, and people may hide their true selves in order to be accepted. Alternately, the individual could prioritize authenticity, seeking the invitation for intimacy from others but ultimately choosing to be alone if that connectedness requires inauthenticity. Finally, and potentially most

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problematic, the drive for self-protection may serve as a defense mechanism against loneliness. If an individual perceives rejection from others, for instance, he or she may respond defensively and conclude that he or she does not in fact desire connection with others. The individual may adopt a mentality of rejecting others before they themselves can be rejected. It is thus possible to simultaneously want to be accepted by others while spurning advances of those who seek to connect with us. The third factor to consider while exploring loneliness in the context of Erikson’s stages is that within cultures that value independence and selfreliance, it can be difficult to acknowledge that it is sometimes necessary to rely on other people. When one does inevitably need support or assistance, he or she may be embarrassed and may perceive themselves as weak or ineffective, which can lead to self-hatred and suicidal ideation in extreme circumstances. For instance, one participant in our clinical trial of Post Admission Cognitive Therapy (PACT; Ghahramanlou-Holloway, Cox, & Greene, 2012; Ghahramanlou-Holloway, Neely, & Tucker, 2014) explained their thought processes while considering seeking help for suicidal thoughts: “They asked me if I wanted to talk on the phone with them, I really didn’t, because then at that point it’s personal, when you hear someone’s voice and their inflection and that kind of thing… If I had to talk to another person at those moments when I’m ready to kill myself, it would have been too much to emotionally bear.” The participant further explained that, “the issue that arose that prompted these thoughts alienated me from my family because I was too embarrassed to tell [them] what happened. So I think that’s what the difficult thing was in my situation … who do I turn to when I have something so embarrassing when all I have are very close peers.” Another participant reported that, “I don’t really reach out to people because I don’t feel like wanting to be burdensome to the other people, and I don’t want to disappoint them, and of course, in committing suicide, [that] would also be very disappointing.” These quotes illustrate the ambivalence individuals may feel due to simultaneous desires to connect with others and to remain self-reliant and illustrate the interconnectivity between loneliness, alienation, and suicidal thoughts.

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CLINICAL AND RESEARCH CONSIDERATIONS Understanding the phenomenon of loneliness as it relates to each of Erikson’s developmental stages helps to identify opportunities for intervention. Research shows that increased frequency of contact with others does not necessarily influence one’s perceptions of loneliness (Heinrich & Gullone, 2006). Rather, the quality of interactions is the key factor in ameliorating negative emotions (Ernst & Cacioppo, 1999). Intimacy is more critical than togetherness in altering one’s sensation of belonging. Still, belonging or shared experience can serve in some capacity to mitigate one’s sense of loneliness, though physical togetherness is merely the first step. A review of empirical studies evaluating the “Caring Letters Project,” a program in which brief letters are sent to patients after discharge from treatment, has shown that follow-up contacts help decrease repeated suicide attempts (Luxton, June, & Cometois, 2013). Perceiving that someone cares is a key element in managing loneliness and alleviating suicide risk. In clinical practice, it is best to unilaterally assess all patients for the experience of loneliness as a risk factor for suicide (Tucker, Pak, Neely, Tylor, Colborn, & Ghahramanlou-Holloway, 2015). Beyond an objective assessment, genuine interest should be paid to how individuals are coping with the challenges presented at each developmental stage. Adolescents, for instance, may be questioned about their peer groups, and young adults could be asked about the quality of their relationships, while keeping in mind that quality of these relationships is generally a better indicator of susceptibility to loneliness than is quantity. Understanding the experience of loneliness, through clinical dialogue as well as systematic assessment, is only the first step in the clinical care of individuals at risk for suicide. Evidence-based cognitive behavioral interventions for the prevention of suicide (e.g., Brown et al., 2005; Rudd et al., 2016) highlight the importance of social support in the prevention of suicide. We recommend that clinicians aim to decipher whether the individual is experiencing loneliness due to a lack of an existing social

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support network, due to a lack of skills in adequately utilizing an existing social support network, and/or due to beliefs that interfere with the appropriate usage of an existing social support network. For those who do not have an existing social support network, the role of the clinician is to serve as a collaborator in building the structure of a social support network (e.g., referring the individual for group therapy and connecting him or her to a peer mentor). For those who do not have the skills to engage in a social support network, the role of the clinician is to teach specific social skills (e.g., how to maintain eye-contact and initiate conversation) to enhance the likelihood of effective social interactions. For those who have interfering beliefs, the role of the clinician is to collaboratively, through Socratic questioning and guided discovery, help the individual restructure his or her cognitions and/or associated images (e.g., cognitive rehearsal for asking a person to dinner and responding adaptively to negative self-talk). In a meta-analysis of randomized control trials to address loneliness, cognitive-behavioral therapy to decrease negative social cognitions that perpetuate loneliness was found to have the largest effects, followed by building social support (Cacioppo et al., 2015). The cognitive approach allows the lonely person to understand that they can manage their loneliness. This concept is underscored by more recent research suggesting that future orientation, namely a perception that circumstances can improve, mitigates symptoms of depression and suicidal ideation (Chang et al., 2017). In terms of clinical research, investigators of randomized controlled trials on suicide prevention are encouraged to include measures on loneliness, thwarted belongingness, and social support – and to further examine these factors in relation to primary and secondary outcomes. Qualitative research to best understand the thoughts, emotions, and behaviors of individuals who experience loneliness preceding, during, and immediately following a suicidal crisis is much needed. For example, how is the experience of loneliness before attempting suicide different from the

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experience of loneliness after a suicide attempt? Finally, clinical observations indicate that individuals who report a sense of loneliness may rely on substances (e.g., alcohol) to self-medicate and to even bolster social confidence. Research on the link between the emotion of loneliness and various self-destructive behaviors such as excessive drinking is needed to best understand the trajectory and the mechanisms from suicidal thoughts to suicidal actions.

CONCLUSION The subjective and distressing experience of loneliness may manifest differently across the lifespan depending on psychosocial stage of development. Success in each of Erikson’s (1963) stages of development contributes to trust, autonomy, initiative, industry, identity, intimacy, generativity, and integrity, all of which are required to create and maintain healthy and fulfilling interpersonal relationships in order to meet the human need for belonging (Baumeister & Leary, 1995). Nonetheless, when the need for belonging is unmet or hampered by mistrust, shame, guilt, inferiority, role confusion, isolation, stagnation, and despair, the loneliness and alienation felt by individuals can contribute to depression, hopelessness (Erikson, 1963), thwarted belongingness, perceived burdensomeness (Joiner, 2005), and may ultimately give rise to suicidal thoughts and behaviors. Mental health providers are encouraged to assess individuals’ perceived adequacy of social support and explore the extent to which loneliness may contribute to feelings of thwarted belongingness and perceived burdensomeness. Attention should be paid to individuals’ developmental stage and the psychosocial and contextual factors that may facilitate and/or hinder successful completion of crises within stages. From this knowledge, clinicians may assess for and identify vulnerabilities in their clients that may contribute to suicide risk.

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Disclaimer: The opinions expressed are those of the authors and do not necessarily reflect the views of the Uniformed Services University of the Health Sciences or the Department of Defense. Disclosure of Funding: Support for writing and research related to this manuscript has been provided to Principal Investigator, Dr. Ghahramanlou-Holloway, by the Department of Defense, Congressionally Directed Medical Research Program (W81XWH-08-2-0172), Military Operational Medicine Research Program (W81XWH-11-2-0106), and the National Alliance for Research on Schizophrenia and Depression (15219). The authors report no financial relationships with commercial interests.

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In: Psychology of Loneliness Editor: Lázár Rudolf

ISBN: 978-1-53612-900-7 © 2017 Nova Science Publishers, Inc.

Chapter 4

SOCIAL, INTERPERSONAL AND EMOTIONAL ANTECEDENTS OF LONELINESS Leehu Zysberg, PhD Research Authority, Gordon College of Education, Haifa, Israel

ABSTRACT While the literature is replete with evidence and theory regarding the emotional consequences of loneliness and the challenges they pose to individuals, there is still not enough evidence examining the emotional antecedents of the phenomenon. This chapter reviews the existing literature on emotional antecedents of loneliness, dwells on recent evidence linking loneliness and certain underlying emotional mechanisms and presents an integrative model to guide research and future practice in diverse settings.

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INTRODUCTION As our world becomes more densely populated and as global travel, electronic communication and information become more accessible than ever, we seem to be lonelier than ever. A paradox, it seems but on a closer look – not at all. Loneliness, as a psychological and social phenomenon is not about actual interpersonal connections. Loneliness can be defined as an on-going, adverse subjective experience of discrepancy between individuals’ need for socialization and attachment, and their subjective perception of their actual condition in these respects. All definitions agree that the experience is inherently unpleasant, adverse and at times destructive. Most definitions point that the experience has little to do with a person’s ‘objective’ social standing or associations (Ernst & Cacioppo, 2000; Lasgaard et al., 2016; Peplau & Perlman, 1982). Loneliness is often related to as ‘the plague of the 21st century’ and is highly prevalent in western societies (Nyqvist et al., 2017; Ronka et al., 2013). A surprisingly high rate of individuals report experiencing loneliness in various stages in life, and though the experience is often transitory and time dependent numerous authors describe the experience of ‘chronic loneliness’ (Cramer & Barry, 1999) as a growing concern. As new evidence is slowly accumulating, there is a growing realization that chronic loneliness may become a new lifestyle or frame of mind that is typical of current social constructs, culture and social interactions (Pittman and Reich, 2016). Loneliness has been studied extensively – especially with respect to its consequences: the phenomenon has been associated with a broad range of negative outcomes on the individual and group levels. Thus, loneliness shows associations with emotional distress, depression, and lower academic achievement in younger age (Cacioppo et al., 2002; Glaser et al., 1985; Leary, 1990) as well as reduced immune function, higher risk of health hazards of opportunistic nature, and even mortality (Richard et al., 2016; Valtorta, et al., 2016) at older age. Loneliness seems to work its way to pathology in similar routes as described in the study of the outcomes of stress: through added burden on the individuals’ (and at times, the groups’)

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coping resources, and reserve capacity thus increasing the chance of pathology when facing challenge. Unlike stress though, Loneliness seems to have a two peak risk pattern across the life span: The literature suggests that individuals are most prone to experience loneliness around adolescence and around older age (retirement age or older) (Allen et al., 1993; Nyqvist et al., 2017). Less studied are the antecedents of psychological loneliness: What factors predict the subjective experience of loneliness? The literature is divided into a few domains of such antecedents: 1) “Objective factors” relating to life changes and choices – such as moving from one community to another, immigration, etc. that are associated with higher risk of experiencing loneliness, (2) General social factors associated with shifting trends in cultures, social norms and lifestyle – that associate with the experience of being alone and missing others’ company, (3) Aspects of interpersonal abilities, skills, and the nature of interpersonal interactions with others, and (4) Aspects of emotional regulation, emotional abilities and skills associated with increased risk of loneliness (Carr et al., 2017; Lesgaard et al., 2016). This chapter will offer an integrative view of the cultural, interpersonal and emotional antecedents of Loneliness and present emerging conclusions and trends suggested by the evidence in this field.

LONELINESS – DEFINITIONS AND CONCEPTUALIZATION Most individuals can understand and relate to the term ‘loneliness’ intuitively, however authors provided formal definitions of loneliness, relying on varying perspectives and theories. Peplau & Perlman (1982) provided an overview of common psychological definitions of loneliness. What does being lonely mean? Some authors believe the experience has an innate evolutionary function: From an evolutionary point of view being alone is a disadvantage, and a risk for thriving and survival, therefore we may be innately wired to feel alarmed, experience pain (if only emotional)

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whenever we perceive the lack of adequate social associations and support from our environment (Bowlby, 1973; Weiss, 1974). Others maintain that loneliness has a developmental value: Interactions with others are acknowledged as a key factor in human development. As such it has drawn a lot of attention from researchers examining the consequences of rejection, neglect, immigration and other early life experiences putting individuals at the risk of social confinement (e.g., Asher & Wheeler, 1985; Parker & Asher, 1993). Experiencing loneliness, though often cited as a developmental risk factor has also been mentioned as a motivational basis, a challenge that if successfully mitigated, serves future development and learning (Jung, Song and Vorderer, 2012; Moore & Schultz, 1983; Rokach & Brock, 1998). Another way to look at loneliness is from the point of view of motivation, expectancy and frustration: Life in any other field in our lives we form motivations aimed at achieving certain goals, set expectations and strive to achieve them – this process takes place in the social and interpersonal domains as well as any other (Asher Y Wheeler, 1985). When interpersonal expectations are not met (e.g: having many good friends, marriage, etc.) individuals experience frustration and stress that may account for the aversive aspect of feeling alone, or lonely. Moreover, loneliness, as any psychological experience, is probably mainly in our head: Studies found evidence that marginalized youths, who had only one contact they considered a friend, were already quite ‘immune’ to the adverse effects of loneliness (Cassidy & Asher, 1992; Ernst & Cacioppo, 2000). The way individuals construed, and interpreted their experiences seems to matter more in predicting adverse effects associated with loneliness than the actual social network available to them )e.g., Bogaerts, Vanheule, & Desmet, 2006). The classic literature on loneliness differentiates between two types of loneliness: Weiss (1974) defines two types of experiences under the ‘loneliness’ umbrella: 1) Emotional loneliness is the experience of lack of intimacy and trust in others. A person may be surrounded by others yet feel they have no one to trust, confide in and share personal experiences. (2) Social loneliness is the experience of lack of interpersonal associations, or

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an insufficient social network in both quantitative and qualitative terms (Russel, Catrona, Rose & Yurko, 1984). This typology evoked an impressive wave of empirical research and instrument development efforts, based on this dual-factor model. Another model, based on empirical analyses, suggested loneliness encompasses at least 5 content-realms of perceptions and feelings relating to: 1) Emotional distress, (2) social alienation, (3) growth and discovery, (4) isolation, and (5) self-alienation (Rokach, 1997). The model highlights the multi-tiered complex nature of the experience, including both adverse and positive, growth-related components (Rokach, 2007). The above-described models indicate the disagreement on the nature of the experience and the subjectivity of the psychological components involved in “what it means and what it feels like to be lonely.” The main experience acknowledged by all models is that of a psychological challenge, and at times: crisis.

Antecedents of Loneliness – What the Literature Teaches Us The study of the antecedents of loneliness is less prolific than in other aspects of the phenomenon. Studies, however, did attempt to map factors associated with loneliness and have come up with a broad range of content areas. Rokach (1997) identified 5 common causes of loneliness he named: 1) Personal inadequacies, (2) developmental challenges, (3) unfulfilling interpersonal relations, (4) relocation or social separation, and (5) social marginalization. These causes span the full range from innate, personal to financial and social factors.

The ‘So-Called-Objective’ Factors of Loneliness: The Role of Environments and Settings Despite the emphasis on psychological and social factors, sometimes the experience of loneliness stems simply from objective realities very

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typical of a modern, mobile world: The evidence suggests that separations from social networks such as family, communities, work organizations and educational institutions. Societies around the globe are characterized by increasing mobility: from work and career related shifts to immigration waves – individuals are torn out of their social networks constantly (Rokach, 2002; Savikko et al., 2005). living in rural areas as compared to cities and metropolises also associates with loneliness (in a manner somewhat contrary to common perception of cities as alienating settings, rural dwellers experience higher levels of loneliness, see Rokach, 2007; Savikko et al., 2005). Culture and politics may also play a role, with some evidence suggesting societies experiencing turmoil and change leave more room for uncertainty; the breakdown of social structured and hence put more people at risk of feeling lonely, among other things (e.g., Huntington, 2006).

Cultural Aspects: Are We Living within a ‘Culture of Loneliness’? Culture is a term loosely used in the literature to describe the amalgam of basic assumptions, ideologies and norms held by a given social group and guide its function (Lykes and Kemmelmeier, 2014; Rokach, 2007). Culture guides not only group level outcomes but sets the parameters for individual behavior, and more importantly in our case – interpersonal interaction patterns. Culture often serves practical needs of the community: from survival to maintaining order, economic viability and prosperity (Fiske and Taylor, 2013). Other factors, however, shape culture too, such as communication patterns and media, politics and perhaps most of all in recent years technology (Murphie and Potts, 2003). Technology seems to have shaped our world in so many ways and as technological progress only accelerates, authors can only imagine what future influences it may have on our society and the way we handle ourselves and others in interpersonal interaction. Possible scenarios range

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from utopian views of a prolific society supported by high technology to apocalyptic views of human society being ripped apart at the seams (Muller, 2016). Regardless of future scenarios, a look at how technology changed and reshaped culture and interpersonal interaction, if only in the last few decades, reveals an interesting trend that may have relevance to the subject at hand. Of special interest to us are advances in IT, communications (cellular and internet based) and the way they re-shaped social interaction patterns. The literature seems to agree the recent advances in communication technology have created a paradox: on one hand, we are more connected and available to others (and others to us) than ever before, response times have reached immediacy levels which are unprecedented. Social networks and bulletin boards connect individuals and groups across geographical and social borders. Real time technology allows work teams to work on projects from different corners of the globe. Data, information and knowledge are transferred faster than we could even imagine and are accessible, searchable and communicable to almost anyone (Lin and Atkin, 2014). On the other hand we meet face to face, and interact with other less than ever before. This trend is more noticeable among children and adolescents, individuals who are ‘technological natives’ and accept CT and IT more naturally and utilize it more effectively than adults who take more time to adapt to these changes (Best et al., 2014; Nesi et al., 2017). Not surprisingly the meager and relatively new evidence regarding the role of communication technology in loneliness among tech users, especially adolescents and young adults is painting a grim picture: Adolescents’ use of smartphone based communication and social apps was associated with reported loneliness and emotional distress (Bian and Leung, 2016). Recent studies report an increase in the incidence of computer addiction, typically bringing the phenomenon of psychological isolation to an extreme (Muñoz-Miralles, 2016). Additional evidence show an emerging picture of inverse association between social network and online communication applications usage and reported sense of loneliness, emotional distress and even depression (Salmela-Aro et al., 2017).

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The trend emerging from the literature is that of resorting to virtual interaction patterns that do not meet the basic need for direct and immediate interaction and attachment to and with others. The literature often mentions that consumers of social networks services see the interactions with others in such media as impersonal and shallow (Vaterlaus et al., 2016). Hence the above mentioned paradox: everconnected and at the same time, alone, and hungry for direct, more immediate association with others.

Interpersonal Factors: Interactions That Precede Loneliness This field of research is one of the least developed in this area of interest. Still, existing evidence, at times sporadic and imperfect, point in interesting directions. Morjano and colleagues (2017) for example suggest that certain relationship patterns with parents and siblings predict selfreported loneliness in young adults. Other studies link family relationship patterns in early life with adolescent and young adult loneliness (Johnson, Lavoie and Mahoney, 2001; Hurt, Hoza and Pelham, 2007). Peer relations in school age are also a major factor in determining the experience of loneliness: Parker and Asher (1991) showed how children’s evaluation of their friendship quality accounts for their self-rated loneliness. Boivin and colleagues (1995) showed how negative aspects of peer-relations such as victimization and rejection predict loneliness. The key here seems to be social support: Although it may be most visible at early age to adolescence, it is pointed out as an important buffer and protective factor in a broad range of settings: from social adjustment, to individual distress and mental health up to coping with chronic health conditions (Zysberg, 2017). Another recent study shows that along specific time-points in life the source and arena of interpersonal relationship and support matter: adolescents, for example, found peer support more satisfying than family support (Lee and Goldstein, 2016). Gur-Yaish and colleagues (2013) showed that older adults prefer instrumental support from professional aides rather than family or close friends, but prefer social

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support from family members. In other words – social support matters, but who provides it is sometimes important too. To better understand the role of interpersonal relationships and their protective role we should take a look at personal characteristics often associated with the above.

Personal Characteristics Research searches for factors associated with loneliness not only at the social-cultural level but also on the individual: Demographic characteristics associate with varying levels of loneliness: gender (being male), older age and lower socioeconomic status were associated with increased loneliness. Age, however shows an intriguing ‘anomaly’ whereas loneliness tends to peak around adolescence and older adulthood, for different reasons (Yang & Victor, 2011). Family structure also associates with loneliness. For example, widowed participants reported feeling lonelier than individuals living with their families (Savikko et al., 2005). Environment and settings seem to play a major role in triggering loneliness but given the subjective nature of the experience, the literature focused on personal attributes associated with it more than external factors. Rokach, among the more prolific authors on the subject suggested a 5-factor model to account for the subjective experience of loneliness. Out of these factors, 3 are personal in nature and include: developmental issues, social inadequacy, and inability to draw upon interpersonal relationships (e.g., Rokach, 1997). These factors hint at self-perception and personality as potential structures underlying these experiences. Indeed, the literature offers a lot of evidence to support the personality-loneliness association: Studies find relationships between traits under the ‘five factor model’ and Eysenck’s typology (among the most robust models of personality assessment) and aspects of loneliness, especially neuroticism and extraversion (or more accurately – the lack of it) (e.g., Saklofski et al., 1986). Current studies have linked personality traits to both the extent of the experience of loneliness and attitudes or judgments of this experience as more or less acceptable, much in line with the findings reported above (e.g., Teppers et al., 2013).

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Additional evidence link predispositions and behavioral patterns which are beyond the scope of personality trait typology but associate with interpersonal tendencies to interact with others: studies have identified perspective taking, social and communication skills as well as selfdisclosure, attribution style and even attachment style with the tendency to feel lonely (e.g., Bogaerts, Vanheule, & Desmet, 2006; Bruch et al., 1988). The consistent evidence associating personality and loneliness almost suggest the existence of a ‘lonely personality’ with very specific traits and predispositions, namely: tendencies toward lesser regulation of reactions, interpersonal relationships and lower proficiency in reading and processing information about the self and others. These points lead us to examine the emotional and emotional regulatory functions and their associations with loneliness.

Emotions, Emotional Regulation and Loneliness Is there an emotional code to loneliness? Though there is some work addressing emotional antecedents of loneliness, it is far less developed than the literature on the emotional consequences of loneliness. Here I will attempt to provide an emerging picture of emotional factors that may have a role in individuals’ likelihood of experiencing loneliness. Let us start with the building blocks of the model, or the basic psychological functions closely related with emotional experiences that show evidence of association with loneliness: Delay of gratification. The most Basic function of emotional management and regulation is perhaps the one involving postponing gratification or need fulfilment (Agarwal, 2014). The most basic of emotional regulation tasks and the most difficult to manage, it is also considered by many to be the very foundation upon which interpersonal associations and relations are built in terms of effective negotiations, effective conflict management and coping with needs within a complex interpersonal setting (Agarwal, 2014; Cacioppo et al., 2006; Dill &

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Anderson, 1999). Need satisfaction regulation or delay of gratification has been associated in psychological and educational research with life-long adjustment, mainly at the social and emotional levels: Mischel’s classic ‘marshmallow study’ exemplified how emotional regulation and delay of gratification serve as factors in psychological adjustment through the life cycle (Mischel et al., 2010). It is suggested that such abilities are pivotal in developing and maintaining meaningful interpersonal relationships, thus reducing the chance of experiencing loneliness in the long run. Emotional knowledge. The concept is often associated with two skills: 1) The naming or recognition of emotions in self and others and (2) Awareness of emotions as they are experienced by self and others (Stein & Levine, 1989). This concept represents a developmental task beginning at very early age and often associated with early experiences of deprivation and frustration (Garner & Power, 1996). Another developmental aspect associated with this concept is that of the development of Ego resources or perceptions associated with a sense of self: Anchored in the grand theories of such luminaries as Kohlberg, Sullivan and Erikson, the notion of ego development speaks of emerging selfhood, as a physical, perceptual, emotional and interpersonal anchor of psychological development (for a thorough review see: Hy Le & Loevinger, 2014). As individuals learn through on- going experiences since birth, both physical and interpersonal, they define their own and others’ boundaries, set perceptual frameworks and rudimentary perceptions that shape their world, and their relationships with themselves and others (e.g., Allen et al., 1994). Ample evidence associate Ego development, emotional reaction patterns and relationship patterns throughout the lifespan (e.g., Smetana et al., 2006). Though theory associates self and emotional knowledge with the nature and quality of social associations and studies have associated emotional knowledge (or the lack of it) with increased risk of loneliness especially at childhood and adolescence (e.g., Heintz et al., 2014), the evidence is however still preliminary and rudimentary. Future studies may

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further help explore the nature of emotional aspects of self-definition and self in general and their role in the experience of loneliness. Self-knowledge, internalizing vs externalizing. A coherent selfconcept as a basis for adept emotional processing and coping is an idea presented in the early days of psychological reasoning and research (Hobfoll & London, 1986). The healthy self-concept provides an infrastructure for better self-knowledge, and the ability to differentiate between what is “me” or “mine” and “not me or mine.” Such differentiation is taking place at multiple levels of our psyche, including perception, and emotional reactions to events (within and around us). Such structures may account for our tendency toward internalization (less expression or relief of tensions, attribution of life outcomes so characteristics of self) or externalization (more expressive style, attribution of life outcomes to others, or circumstances). These can be conceptualized as an attribution style or a personality-related pre-disposition, and are associated with loneliness in children and pre-adolescents (e.g., Heintz et al., 2014). Such patterns seem to show stability across the life-span (Fischer et al., 1984). Emotion-Regulation. Emotion regulation is a concept describing the extent to which and the strategies by which individuals control (not suppress!) emotional responses, and attune them to support adaptive behavior (see: Rubin et al., 1995). This is no mean feat, mind you: research shows that emotional reactions and experiences are primordial, automatic in nature and extremely hard to manage. Individuals dramatically vary on the extent to which they are capable of managing and regulating their emotions more than almost any other psychological attribute in adulthood (Gross and John, 2003). The literature is replete with evidence to the association of emotion regulation (or the lack of it) with a broad range of psychological and social pathologies ranging from depression to selfmutilation (Mikolajczak, Petrides, and Hurry, 2009). Less abundant is the literature on the positive effects of effective emotion regulation, but the picture painted by the evidence is quite clear and consistent: Emotion

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regulation is associated with lower chances of anxiety disorders, more effective communication and interpersonal relations (Goldin and Gross, 2010; Shiota et al., 2004). The literature positions emotion regulation as a major function underlying individuals’ social behavior and some of the basic building blocks of social networking, support and satisfaction with social relations. Emotion regulation can be addressed as a component of a larger scale, recent term presented in the literature: emotional intelligence. Emotional intelligence. Emotional intelligence is a relatively new concept addressing a century old issue – the role of emotions in reasoning and problem solving. Various definitions are presented in the current literature but all share the following assumptions on the concepts’ nature and significance in our context: 1) Emotions are a major and basic motive in our behavior, (2) Emotions can be utilized to encode information, better read situations and effectively manage interpersonal relations, and (3) Individuals vary extensively in how effective and capable they are in these fields of intra and inter-personal function (Boyatzis, Goleman, & Rhee, 2000). Emotional intelligence has been related to as an ability, a personality trait and an eclectic collection of non-cognitive skills and tendencies (Salovey & Grewal, 2005), and despite the use of various measures, evidence did show support of the concept’s role in everyday social and interpersonal settings and challenges. For our purpose here it does seem like individuals high in EI, manage interpersonal relationships more effectively, derive more pleasure form them and report less social distress (e.g., Petrides et al., 2006). A few studies have provided direct evidence to the role of EI in the experience of loneliness, among them Zysberg’s (2012, 2017) suggesting that EI provides a protective effect against feeling lonely, beyond what is accounted for by personal characteristics and personality traits in a sample of young adults. Austin and colleagues (2006) showed that EI is associated with a sense of social and interpersonal well-being (which can be described as the opposite of loneliness).

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From Culture through Society to the Individual Antecedents of Loneliness: An Emerging Model The evidence mentioned above provides the basis for an emerging model describing a functional hierarchy of the social-emotional factors associated with psychological loneliness. The model also addresses the intricate interactions between different levels of influence: from the cultural to the individual. Culture. The concept to frame the entire process or line of influences shaping the experience of loneliness start with culture. Cultural assumptions, values and norms set the stage to what is allowed and what not. Culture sets the basic parameters within which interpersonal and personal experiences take place and are interpreted. Characteristics such as individualism vs. collectivism, cohesiveness, hierarchy, norms of interpersonal communication, and identity are among the most influential cultural factors associated in the literature with social interactions. Social-Interpersonal. Social norms, community structure, the extent to which technology adoption is acceptable and appreciated, laws and norms regarding interpersonal communication and interaction, all set the stage and shape social interaction. In turn, social and interpersonal interaction, past and present seem to imprint themselves upon the individual and shape perceptions of quality and quantity of their associations with others, thus providing all the ‘psychological components’ of the perception of loneliness. A key concept emerging from the literature that may point to the underlying mechanisms at work here is that of social support: Helpful, attentive availability of others seems to have a strong influence on our wellbeing in general. Who provides that support and how may vary but the extent to which an individual can be confident in his or her expectation of attentive availability from others is a major player in this domain. Emotional. Emotional antecedents of loneliness seem to be the most confusing and the least studied of the above concepts. Perhaps due to the

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potential confusion between the emotional antecedents of loneliness and its emotional consequences. In other words: is depression (for example) an antecedent of loneliness or is it its outcome? Examining what is known in this field, a few concepts and processes can be identified as potential factors anticipating the emergence of loneliness in childhood, adolescence and early adulthood. Among those concepts are emotional temperament, emotion regulation, and emotional intelligence: these associate closely with individuals’ ability to manage emotional responses in a manner that is congruent with social demands, norms and expectations – thus fostering more effective interpersonal relations.

Figure 1. An emerging model of Social factors of psychological loneliness.

What’s Next? Recent developments in psychological theory and research provide us with new insights into the social and emotional antecedents of loneliness. While the literature provides enough evidence to paint the picture described above, ALL of the elements in the emerging model are still in progress in terms of how we understand them or apply them. Of special

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interest are those aspects that seem to rise in importance and relevance in recent years, namely: Cultural aspects, that seem to play a more complex role than we may think as immigration and global mobility makes almost any society on earth a mix of cultures, bringing together varying beliefs, norms and assumptions – how does this meeting of cultures influence perceived interactions and judgements of loneliness? Emotional antecedents of loneliness remain elusive, and recent addition to our tool box in the shape of the concept of emotional intelligence, among others, add to our ability to re-examine and explore what we know in this venue. Is emotional intelligence a potential that has a protective value when it comes to loneliness? And if so – can we intervene to ‘inoculate’ individuals against the adverse outcomes of being alone? Practitioners in the fields of education, sports and athletics, social workers working with immigrants, refugees, with children at risk, with families experiencing crisis – may embrace some of the insights offered here. The proposed model may help to both identify individual at high risk of experiencing loneliness in a manner that may pose risk to their wellbeing as well as intervene to ameliorate the adverse effects of the gap between individuals’ perceptions of the relationships they have and those they are wishing for.

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Vanhalst, J., Luyckx, K., & Goossens, L. (2014). Experiencing Loneliness in Adolescence: A Matter of Individual Characteristics, Negative Peer Experiences, or Both?. Social Development, 23(1), 100-118. Varghese, M. E., & Pistole, M. C. (2017). College Student Cyberbullying: Self‐ Esteem, Depression, Loneliness, and Attachment. Journal of College Counseling, 20(1), 7-21. Vaterlaus, J. M., Barnett, K., Roche, C., & Young, J. A. (2016). “Snapchat is more personal”: An exploratory study on Snapchat behaviors and young adult interpersonal relationships. Computers in Human Behavior, 62, 594-601. Vaux, A. (1988). Social and Emotional Loneliness The Role of Social and Personal Characteristics. Personality and Social Psychology Bulletin, 14(4), 722-734. Walęcka-Matyja, K. (2016). Psychological dimensions of relationships with siblings as predictors of loneliness of young adults. In Polskie Forum Psychologiczne (Vol. 4, No. XXI). Watson, J., & Nesdale, D. (2012). Rejection sensitivity, social withdrawal, and loneliness in young adults. Journal of Applied Social Psychology, 42(8), 1984-2005. Wildschut, T., Sedikides, C., & Cordaro, F. (2011). Self-regulatory interplay between negative and positive emotions: The case of loneliness and nostalgia. In Emotion regulation and well-being (pp. 6783). Springer New York. Wilson, R. S., Krueger, K. R., Arnold, S. E., Schneider, J. A., Kelly, J. F., Barnes, L. L., & Bennett, D. A. (2007). Loneliness and risk of Alzheimer disease. Archives of general psychiatry, 64(2), 234-240. Zysberg, L. (2012). Loneliness and emotional intelligence. The Journal of psychology, 146(1-2), 37-46. Zysberg, L. (2017) Emotional intelligence and health outcomes: toward an ecological model of well-being. NY: Nova.

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BIOGRAPHICAL SKETCH Leehu Zysberg Affiliation: Gordon College of Education Education: PhD in I/O psychology Business Address: 73 Tchernichowski st. Haifa Israel. Research and Professional Experience: Prof. Zysberg is interested in the study of emotions in everyday life, ranging from work, and education to community and family settings. Published numerous manuscripts and book chapter in diverse international forums, journals and conferences in these venues. Professional Appointments: Associate professor of psychology, Gordon College of education. Chair of the research authority. Publications from the Last 3 Years: 1. Zysberg, L. (2014). Emotional intelligence, personality, and gender as factors in disordered eating patterns. Journal of health psychology, 19(8), 1035-1042. 2. Zysberg, L., Kimhi, S., & Eshel, Y. (2013) Someone to watch over me: Exposure to war events and trust in the armed forces in Israel as factors in war-related stress. Medicine, War and Survival, 29:2, 140–154. 3. Zysberg, L. & Tell, E. (2013) Emotional Intelligence, Perceived control and eating disorders. SAGE Open July-September, 1–7. 4. Raz, S., Dan, O., Arad, H. & Zysberg, L. (2013) Behavioral and neural correlates of emotional intelligence: An event-relatedpotentials (ERP) Study. Brain Research, 1526, 44–53. 5. Zisberg, A., Van Son, C. R., & Zysberg, L. (2013, November). Immigrant Acculturation and Culture of Origin in Emotional

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Outcomes of Older Patients. In Gerontologist (Vol. 53, pp. 289290). Siegel, E. O., Young, H. M., Zysberg, L., & Santillan, V. (2014). Securing and Managing Nursing Home Resources: Director of Nursing Tactics. The Gerontologist, gnu003.* Raz, S., Dan,O & Zysberg, L. (2014) Neural correlates of emotional intelligence in a visual emotional oddball task: An ERP study. Brain and Cognition, 91, 79–86.* Zysberg, L., Yosel, T. B., & Goldman, M. (2015). Emotional intelligence and glycemic management among type I diabetes patients. Journal of health psychology, DOI: 1359105315596373.* Zysberg, L & Lang, T. (2015) Supporting parents of children with type 1 diabetes mellitus: Review of strategies. Patient Intelligence, 7, 21-31 [An invited review]. * Polischuk, K & Zysberg, L. (2016) Emotional intelligence, exposure to visual content on Facebook and body image in young adults. RAV GVANIM [Multi-colors- Hebrew], 15, 194–212. * Siegel, E. O. & Zysberg, L. (2016) Licensed nursing home administrator preparation and job variations. Annals of Long Term Care, 24:3, 28-36* Zysberg, L., Orenshtein, C., Gimmon, E., & Robinson, R. (2016). Emotional Intelligence, Personality, Stress, and Burnout Among Educators. International Journal of Stress Management. Advance online publication. http://dx.doi.org/10.1037/str0000028* Siegel, E. O., Zisberg, A., Bakerjian, D., & Zysberg, L. (2016). Nursing Home Administrator Quality Improvement Self-Efficacy Scale. Health care management review.* Zysberg, L. (2016) Diabetic management and emotional intelligence: an emerging direction in current research. Journal of Endocrinology and Diabetes, 3:1, 1–3. * Zysberg, L., Maskit, D., Reichman, R., & Hecht, A. (2016) Sin and Punishment on Campus: Ethnic Differences in Academic Misconduct and Its Treatment by the Academic Disciplinary

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Committee. British Journal of Education, Society and behavioral science, 15:3, 1–11. * Zysberg, L. & Zisberg, A. (2017) Letter to the editor: Regarding the role of EI in candidate selection in nursing programs. Nursing Forum, 52:1, 68-69 * Zysberg, L. & Moore, A. (2017). Demographic and personal correlates of new masculinities: focus on the role of emotional intelligence. International Journal of Psychology and Counseling, 9:1, 1-9. * Zysberg, L & Guttermn, Y. (2017) Culture, personal characteristics and academic achievement. Leaves [DAPIM], 64, [Pagination unavailable yet]. * Zysberg, L & Kasler, J (2017) Learning disabilities and emotional intelligence. The Journal of Psychology: Interdisciplinary and Applied, 171, 1-14. * Siegel, E. O., Bakerjian, D. & Zysberg, L. (2017) Quality Improvement in Nursing Homes: Alignment among Leaders across the Organizational Chart. The Gerontologist, 57,1-10. * Kasler, J., Zysberg, L., & Harel, N. (2017). Hopes for the future: demographic and personal resources associated with self-perceived employability and actual employment among senior year students. Journal of Education and Work, 13: 1-12. * O. Saad, L. Zysberg, J. Heinik, R. Ben-Itshak, A. Zisberg; The Right Kind Of Smart? Emotional Intelligence and Cognitive Impairment in Older Adults. Innov Aging 2017; 1 (suppl_1): 469. doi: 10.1093/geroni/igx004.1672 * Zysberg, L (2017). Emotional Intelligence Moderates Anxiety Reactions in Chronic Health Conditions. American Journal of Applied Psychology. 6: 3, 38-41. doi: 10.11648/j.ajap. 20170603.12 * Zysberg, L and Hemmel, R. (2017) Emotional intelligence and Physical activity. Journal of Physical Activity and Health, 14:9, 114 (published ahead of print). *

In: Psychology of Loneliness Editor: Lázár Rudolf

ISBN: 978-1-53612-900-7 © 2017 Nova Science Publishers, Inc.

Chapter 5

LONELINESS AMONG ROMANIAN IMMIGRANTS LIVING IN PORTUGAL Félix Neto and Maria da Conceição Pinto Department of Psychology, University of Porto, Portugal

ABSTRACT This study approaches the determinants of loneliness among Romanian migrants living in Portugal. Two research questions guided the study: (1) What influences do acculturation problems have on loneliness? (2) What influences does adaptation to the society of settlement have on loneliness? The sample of this research consisted of 181 Romanian immigrants living in Portugal (49% females). The average duration of stay in Portugal was 9 years. Loneliness was measured by the ULS-6. In addition, other scales were used to assess Portuguese language proficiency, perceived discrimination, sociocultural adaptation, multicultural ideology, psychological problems and self-esteem. Results showed that both indicators of acculturation problems and of adaptation significantly predicted loneliness. Implications of the findings for future research are discussed.

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Keywords: acculturation, adaptation, immigration, loneliness, Romanian immigrants Loneliness is experienced universally, as shown by investigations with diverse cultural samples, such as Canadians (Rokach & Neto, 2005), Cape Verdeans (Neto & Barros, 2000b), Filipinos (2012), Koreans (Seeparsad, Choi, & Shin, 2008), and Portuguese (Neto, 2015). A large corpus of literature calls our attention to the negative consequences of loneliness (Masi, Chen, Hawkley, & Cacioppo, 2014; Holt-Lunstad, Smith, Baker, Harris, & Stephenson, 2015). Specifically, moving to another country affords a singular opportunity to understand loneliness. Following Ponizovsky and Ritsner (2004) “newly immigrated persons find themselves in a drastically different network of social relationships and experience multiple stressors, including losses” (p. 408). However, the quantitative investigation of loneliness among migrant people is scarce (Neto, 2016). The aim of this work is to analyze the level and the predictors of loneliness among Romanian immigrants residing in Portugal. According to SEF (Portuguese Immigration Service) in 2014, Romanians were the fourth largest foreign community in Portugal (after Brazilians, Ukrainians and Cape Verdeans), with 31 505 registered citizens. There were more men (54.9%) than women (45.1%). They represented 8% of the foreign community in Portugal. The Romanian immigrants who chose Portugal came across several challenges, such as: the language, housing, the climate, the lack of social support, the understanding of cultural differences, among other issues. Many changes may supervene during the acculturation process and these alterations may impact on loneliness experienced by immigrants. The great majority of the definitions of loneliness set off the perceived deficits in relationships. Just to give an example, for Ascher and Paquette (2003, p. 75) loneliness is “the cognitive awareness of a deficiency in one’s social and personal relationships, and ensuring affective reactions of sadness, emptiness, or longing.” Loneliness is a complex issue. It is determined by the interaction of personal and situational factors (Weiss, 1973). Hence in the current

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research we are going to examine a range of acculturation and adaptation factors often mentioned in the culture shock domain (Ward, Bochner, & Furnham, 2001). Specifically, we will examine whether acculturation problems (language proficiency and perceived discrimination) and adaptation outcomes (psychological adaptation, sociocultural adaptation and intercultural adaptation) predict the level of loneliness. There exists a large corpus of literature on acculturation and adaptation in cross-cultural psychology (Ward et al., 2001). Acculturation concerns the changes resulting from the contact between groups and individuals of different cultural backgrounds (Redfield, Linton, & Herskovits, 1936; Berry, 1997). Furthermore, adaptation concerns the long-term outcomes of acculturation changes (Berry, 1997). During the acculturation process, migrants may face some difficulties, such as language proficiency and perceived discrimination. Competency in the language of the society of settlement is a core indicator of the acculturation (Phinney, 2003). Indeed, language proficiency constitutes a first step to learn skills in a new society of settlement. The literature indicates that host language proficiency predicts psychological maladjustment (e.g., Zhang & Goodson, 2011). As well as Portuguese language proficiency, we also examine whether perceived discrimination predicts loneliness. Previous investigation has explored whether perceived discrimination was linked to psychological maladjustment. For instance, a meta-analytic research, including over 100 studies of ethnic or racial discrimination against Latina/os in the U.S.A., showed that mental health indicators such as acculturative stress were mostly strongly linked to discrimination (Lee & Ahn, 2011). Perceived discrimination was found to be positively related to loneliness (Neto, 2002; Liu et al., 2014; Neto & Costa, 2015). Two kinds of adaptation, psychological adaptation and sociocultural adaptation, have been distinguished (Ward & Kennedy, 1999). Psychological adaptation “refers to how comfortable and happy a person feels with respect to being into the new culture, or anxious and out of place” (Demes & Geeraert, 2014, p. 91). In the current research we are going to use two indicators of psychological adaptation, in particular, self-

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esteem and mental health problems, to examine their relationship with loneliness. Self-esteem concerns an individual’s general sense of his or her worth (Rosenberg, 1979). Research presents a consistent link between loneliness and poor self-esteem (Heinrich & Gullone, 2006; Ben-Zur, 2012). Experiencing loneliness and feeling low self-esteem is an everyday problem (Vanhalst et al., 2013). Researchers have identified depression, anxiety and psychosomatic symptoms as the most common mental health consequences of acculturation (Berry, 1997). Therefore, in this research we consider depression, anxiety and psychosomatic problems, collectively reported as mental health problems. Loneliness as a negative experience has been associated with decrements in mental health problems (Cornwell & Waite, 2009). Sociocultural adaptation refers to the competence in carrying out the activities of daily intercultural living (Ward et al., 2001). It is evaluated as the level of difficulty that migrants face in everyday social situations in response to cultural differences (Ward & Kennedy, 1999). Past investigation has shown that greater adaptation difficulties among migrants were associated with psychological maladjustment (Wilson, Ward, & Fisher, 2013). Intercultural adaptation has more recently been identified as a third form of adaptation, in addition to psychological adaptation and sociocultural adaptation (Berry, 2015). Intercultural adaptation concerns the degree to which people are able to establish harmonious intercultural relations with others, including low prejudice and discrimination. We will consider multicultural ideology as an indicator of intercultural adaptation. Multicultural ideology refers to views that cultural diversity is good for a society (Berry & Kalin, 1995). It includes the core characteristics of multiculturalism: cultural maintenance, intergroup contact, and willingness to engage in mutual exchange. We will also examine whether multicultural ideology is related to loneliness.

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According to the aforementioned research two hypotheses on loneliness were tested: 



Hypothesis 1: It is hypothesized that acculturation problems (Portuguese language proficiency and perceived discrimination) will predict positively loneliness. Hypothesis 2: It is hypothesized that adaptation (sociocultural, intercultural, and psychological) will predict negatively loneliness.

METHOD Participants The participants were 181 Romanian immigrants (92 men and 89 women) (see Table 1). The immigrants ranged in age from 18 to 57 years (M = 37.52; SD = 9.5). The average duration of stay was 9 years (SD = 6.25). Married respondents were 62% of the sample. Concerning work, the modal category was unskilled work (33%). Relatively the instruction level 82% had concluded secondary education or below, and 18% attended tertiary education. The great majority of the immigrants declared to be Orthodox Catholics (90.0%).

Measures For this study, we used the following measures: Portuguese language proficiency. Four items evaluated the migrants’ self-evaluation proficiency in speaking, reading, writing and understanding the Portuguese language (Berry et al., 2006; Neto, 2002b) (e.g., “How well do you speak the Portuguese language?”). Respondents endorsed each item on a 5-point scale from 1 (not at all) to 5 (very well). The alpha coefficient in the present study was .97.

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Variables Mean age (SD) Age 18-35 years 36-57 years Gender Male Female Place of birth Romania Education Secondary education or below Tertiary education Work Unskilled work Skilled work Managerial work Professional work No work Not answer Mean duration of sojourn (SD) Duration of sojourn 1- 10 years 11-29 years

Romanian Immigrants (N = 181) 37.5 (9.5) 61 (33.7%) 120 (66.3%) 92 (50.8%) 89 (49.2%) 181 (100%) 148 (81.8%) 33 (18.2%) 59 (32.6%) 52 (28.7%) 22 (12.2%) 11 (6.1%) 32 (17.7%) 5 (2.7%) 9.0 (6.3) 135 (74.6%) 46 (25.4%)

Perceived discrimination. This scale includes five items (Berry et al., 2006; Neto, 2006) evaluating the direct experience of discrimination negative or unfair treatment from others (e.g., “I have been teased or insulted because of my Romanian background”). Respondents endorsed each item on a 5-point scale from 1 (strongly disagree) to 5 (strongly agree). The alpha coefficient in the present study was .90. Sociocultural adaptation. The Sociocultural Adaptation Scale (SCAS, Ward & Kennedy, 1999; Sequeira Neto, 2014) asked immigrants the

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degree of difficulty experienced in 20 social situations in the host society. Migrants indicated how much difficulty (ranging from no difficulty, 1 to extreme difficulty, 5) they experienced while living in Portugal in each of 20 areas of daily life (e.g., “The pace of life” and “Going to social gatherings”). Items were recoded positively. Higher scores denoted a lower amount of difficulty. The alpha coefficient in the present study was .83. Multicultural ideology. It was previously adapted to the Portuguese context (Berry & Kalin, 1995; Neto, 2007; 2009b). We used 8 items (e.g., “People who come to live in Portugal should change their behaviour to be more like the Portuguese”). Respondents endorsed each item on a 5-point scale (where 1 = strongly disagree and 5 = strongly agree). Greater scores denoted greater levels of multicultural ideology. The alpha coefficient in the present study was .68. Mental health problems. This measure included 15 items and was designed to measure depression, anxiety and psychosomatic symptoms. Five items measured each of the three areas (Berry et al., 2006; Neto, 2009a). Respondents endorsed each item on a 5-point scale ranging from “not at all” (1) to “very often” (5). Sample items included “I feel tired”; “I feel tense and anxious”; and “I feel lonely even if I am with people” corresponding to psychosomatic complaints, anxiety and depression, respectively. The alpha coefficient in the present study was .93. Self-esteem. Self-esteem was measured using the Rosenberg’s (1965) 10-item inventory (e.g., “On the whole I am satisfied with myself” and “I have a positive attitude toward myself”). Respondents endorsed each item on a 5-point scale from 1 (totally disagree) to 5 (totally agree). The scale was previously adapted into Portuguese (Neto, 1996). The alpha coefficient in the present study was .68. Loneliness. The brief Portuguese version of the Revised UCLA Loneliness Scale (Russell, Peplau, & Cutrona, 1980) was used (Neto, 1992; 2014). This is a six-item scale (ULS-6). (e.g., “People are around me but not with me”). Migrants endorsed each item on a 4-point scale ranging from 1 (never) to 4 (often). The alpha coefficient in the present study was .73.

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Demographic information. Demographic information was collected on age, gender, place of birth, time since arrival in Portugal, marital status, level of education, occupation, and religion.

Procedure Respondents were recruited by a trained research in the Lisbon Metropolitan area. The participation rate was high (about 80%). Participants were informed about the aims of the work. Their consents were obtained. The participants’ responses were anonymous. The average time for filling out the questionnaire was 30 minutes to complete. No rewards were given to the participants for completing the survey.

RESULTS Before testing the hypotheses of the current study, descriptive statistics of the measures used are shown in Table 2. One-sample t-test displayed that the average score of Romanian immigrants on loneliness (M = 1.67; SD =.57) was significantly lower than the midpoint of the scale (p < .001). Globally, this finding indicates that Romanian immigrants experienced a low level of loneliness. Also, one-sample t-tests were conducted for the other variables of this work. On the one hand, the average scores of Portuguese language proficiency (M = 4.10; SD =.91), sociocultural adaptation (M = 4.33; SD =.50), multicultural ideology (M = 4.34; SD =.72), and self-esteem (M = 4.40; SD =.35) were significantly above the midpoint (3) of the scales (all ps < .001). On the other hand, the average scores of perceived discrimination (M = 2.48; SD = 1.31), and psychological problems (M = 2.06; SD =.79) were significantly lower than the midpoint (3) of the scales (all ps < .001). Overall, results suggest that these immigrants presented a positive picture of their process of acculturation and of adaptation outcomes.

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Table 2. Means, standard deviations, and reliability coefficients of the measures for the Romanian immigrants (N = 181)

Portuguese language proficiency Perceived discrimination Sociocultural adaptation Multicultural ideology Mental health problems Self-esteem Loneliness

M

SD

4.10 2.48 4.33 4.34 2.06 4.40 1.67

.91 1.31 .50 .72 .79 .35 .57

Number of items Cronbach’s α 4 .97 5 .90 20 .83 8 .68 15 .93 10 .68 6 .73

To test our first hypothesis, we conducted a hierarchical multiple regression. Gender, age, level of education and length of residence were entered in the first block. Portuguese language proficiency and perceived discrimination were entered in the second block. In the first block no significant socio-demographic predictor was found. In the second block the regression displayed that 11% of the total variance in loneliness could be explained by the independent variables, F(6, 174) = 3.49, p < .01 (see Table 3). Loneliness was predicted by higher level of perceived discrimination (β = .31, p