Island Living: The Experience of Loneliness in a Psychiatric Hospital

Helena Lee, Amy Coenen, and Kathryn Heim

The purpose of this study was to examine perceptions of loneliness among psychiatric patients. The sample included 12 adults receiving treatment in a psychiatric facility. Data consisted of audiotaped semistructured interviews. Ten empirical categories re- sulted. Further analysis of empirical data provided a description of psychiatric pa- tients’ experiences of loneliness. The metaphor of living on an island illustrated the core category. Subcategories included escape attempts and surviving tidal waves. Copyright 0 1994 by W.B. Saunders Company

If I fold you who I was, maybe you would understand why I’m lonely.

-Psychiatric Patient

F OR THE MANY people who experience themselves separated from others by physical

space, ideology, fate, or other reasons, loneliness is a painful part of human existence. The experi- ence of loneliness results in a range of mental and emotional responses of varying degrees of sever- ity. Patients with mental illnesses may experience loneliness resulting from as well as contributing to compromised functional abilities and social prob- lems.

The universality and subjectivity of the human experience of loneliness has been described in the literature (Moustakas, 1961; Weiss, 1973). Sulli- van (1953) described loneliness as the exceedingly unpleasant experience associated with the unmet need for human intimacy. He suggested that lone- liness is a terrible experience and a more powerful motivator than anxiety. Fromm-Reichmann (1959) stated that extreme loneliness renders people “emotionally paralyzed and helpless”; if allowed to persist, loneliness “leads ultimately to the de- velopment of psychotic states” (p. 3). Essential loneliness, according to Burton (1968), is a pro- cess in which “the individual becomes separated from his inner world and its referents” (p. 39). Burton (1968) described loneliness as the unmet need “for authentication, for meaning and unity, in a dehumanizing culture, and the confirmation of the psychic aliveness of the individual” (p. 46). He observed loneliness as central to schizophrenia, where loneliness is observed in its most acute form.

In their writings, philosophers have addressed

A/J/J/~wJ Nursing Research, Vol. 7, No. 1 (February), 1994: pp. 7-13

personal meaning in defining loneliness. Mousta- kas (1961) identified loneliness as “an experience of being human which enables the individual to sustain, extend, and deepen his [sic] humanity” (p. ix). Frank1 (1963) also considered the question of finding meaning in tragedy and suffering, which may contribute to loneliness.

Loneliness influences mental health function- ing. According to the National Institute of Mental Health (NIMH, 1984), psychiatric patients have a high risk for being lonely. In the American Nurses’ Association (ANA) Social Policy Statement (1980), loneliness was identified as one example of a human response appropriate for nursing inter- vention. The ANA Psychiatric Mental Health Nursing Task Force included loneliness as a phe- nomenon of concern for nursing in a classification system of human responses (O’Toole & Loomis, 1989).

In the proceedings of the NIMH (1984) research

From the Nursing Research Committee of the Milwaukee County Mental Health Complex, Milwaukee, WI.

Helena Lee, MSN, RN: Nurse psychotherapist, Temenos Clinic, Milwaukee, WI, and Psychology Associates, Madison, WI; formerly Clinical Nurse Specialist, Milwaukee County Mental Health Complex, Milwaukee, WI; Amy Coenen, PhD, RN, CS: Adjunct Assistant Professor, College of Nursing. Mar- quette University; formerly Clinical Nurse Specialist, Milwau- kee County Mental Health Complex, Milwaukee, WI; Katbryn Heim, MS, RNC: Advanced Practice Nurse, Day Hospital, Milwaukee County Mental Health Complex, Milwaukee. WI.

This research was partially funded through a grant from the Frieda Brunn foundation of the Milwaukee County Mental Health Complex (MCMHC), Milwaukee. WI.

Address reprint requests to Helena Lee, MSN, RN, 508 Elm- side Blvd, Madison, WI 53704.

Copyright 0 1994 by W.B. Saunders Company 0897.I897/94/07OI-ooo3$5.00/0

8 LEE, COENEN, AND HEIM

planning workshop, Preventing the Harmful Con- sequences of Severe and Persistent Loneliness, ex- isting knowledge and directions for further re- search were outlined. Several recommendations for further research were identified including stud- ies of loneliness in clinical populations and studies of severe and persistent loneliness. Recommenda- tions also were made to improve the diagnosis of loneliness.

Existing studies on loneliness most often have used samples of college students or community groups where the general level of mental distur- bance is low (NIMH, 1984). Some early works on loneliness did include clinical observations of pa- tients but were generally theoretical commentaries of loneliness rather than empirical studies (Fromm- Reichmann, 1959; Sullivan, 1953). Selected pop- ulations identified as “at risk” for experiencing loneliness also have been studied. A national epi- demiological study of adolescents (Brennan, 1982) and a study of widowhood (Harvey & Bahr, 1974) examined demographic and personality character- istics related to loneliness in these populations. In addition, a significant correlation has been re- ported between depression and loneliness (Young 1982).

Nursing research of loneliness has focused on special age groups and clinical populations. Healthy adolescents and young adults (Mahon & Yarcheski, 1988; Yarcheski & Mahon, 1986) as well as chronically ill adolescents (Yarcheski, Ma- hon, Kraynyak-Luise, & Baker, 1987) were pop- ulations examined by nurse researchers. Addi- tional groups studied included grieving parents (Kovarsky, 1989), chronically ill adults (Miller, 1984; Nokes & Kendrew, 1990)) and older adults (Walton, Shultz, Beck, & Walls, 1991).

The dearth of clinical studies on loneliness in the psychiatric patient population and the suggestion that loneliness is associated with many mental health problems (NIMH, 1984) justified the need for research among clinical samples and the use of a descriptive design. This investigation was an ef- fort to examine loneliness in a clinical population of a psychiatric setting. The purpose of this study was to describe the experiences of loneliness as perceived by hospitalized adults with mental ill- nesses .

METHOD

In order to study the experiences of loneliness among psychiatric patients, this qualitative study

was developed to gather data grounded in the real- world experience of a clinical sample (Strauss & Corbin, 1990). Content analysis was used to iden- tify major themes and categories. The design and conduct of the study occurred over a 2-year period.

Assumptions of this study included beliefs that people with mental illnesses experience loneliness and that they can describe their perceptions of this experience. These descriptions can assist nurses in understanding the meaning of loneliness, which has implications for the care of people with mental illnesses.

Sample

The sample included English-speaking adults who were receiving inpatient treatment between the 7th and 14th day of hospitalization in a large midwestem public psychiatric facility and who agreed to participate in the study. By nursing as- sessment, each subject had a score ranging from 3 1 to 60 on the Global Assessment of Functioning (GAF) Scale (Endicott, Spitzer, & Fleiss, 1976). The GAF is a standardized, psychiatric assessment scale to measure a person’s psychological, social, and occupational functioning. The GAF scale ranges from 0 to 90 with a score of 31 to 60 rep- resenting some impairment in reality testing or moderate to serious symptoms with impairment in social or occupational functioning.

Twelve adults consisting of 9 men and 3 women agreed to participate in this study. Their ages ranged from 29 to 76 with an average age of 47 years. Two of the 12 subjects were married, 5 were never married, and the remaining 5 were widowed or divorced. Eleven subjects were Caucasian and one was African-American. Eight of the subjects completed high school and 3 continued with some college; the remaining 4 subjects did not complete high school. Three quarters of the sample had mul- tiple previous psychiatric hospitalizations with an average age at first hospitalization of 33 years. Diagnostic categories used during the subjects’ current hospitalization were (a) thought disorders (n = 7), (b) affective disorders (n = 3), (c) per- sonality disorders (n = 1)) and (d) substance abuse disorders (n = 1). The mean GAF score for the total sample was 38, indicating some impairment in reality testing or major impairment in several functional areas.

Before the episode of hospitalization during which the study occurred, three subjects lived in other institutions, one subject was employed part-

ISLAND LIVING

time, and one subject was retired and earning a pension. All other subjects were receiving Social Security Disability, Supplemental Security In- come, or General Assistance.

Data Collection

Data collection consisted of audiotaped inter- views of subjects using a semistructured guide (Figure 1). To enhance the description of the sam- ple, the Revised UCLA Loneliness Scale (Russell, Peplau, & Cutrona, 1980) was administered. The interview was completed before the administration of the Loneliness Scale so that the scale items did not influence responses to interview questions. De- mographic information was gathered from the pa- tient record.

14 set of open-ended questions was used to guide the interview. The interview guide was piloted, and the questions were revised for clarity. A stan- dardized open-ended interview was used to en- hance reliability because of the large number of data collectors (Patton, 1990). Throughout the data collection phase an ongoing group consensus pro- cess was used to assure intercoder reliability.

The revised UCLA Loneliness Scale, a 20-item Likert-type scale, is a measure of the experience of loneliness. The scale has been used by researchers to examine personality correlates and situational determinants of loneliness with samples of college students (Chelune, Sultan, & Williams, 1980; Cu- trona, 1982; Horowitz, French, & Anderson, 1982). A 4-point Likert Scale for each item results

k&oductorv Statement

9

in a range of total scores from 20 to 80; the higher the score, the higher the degree of loneliness. The items are short and clearly stated.

Data Analysis

Field notes and transcribed interviews were coded and analyzed throughout the data collection process. Each interview was coded by at least three researchers and evaluated for intercoder reliability and semantic content validity. Line-by-line coding of subject responses to the interview questions lead to development of empirical categories mutually agreed on by the research team (Strauss & Corbin, 1990). Empirical categories are descriptions of concepts; analytical categories reflect a higher level convergence of the data. The next level of analysis, development of analytical categories, at- tempted to move closer to describing the experi- ence of loneliness among mentally ill adults through the use of a metaphor conceptualized and agreed on by the authors.

FINDINGS

The UCLA Loneliness Scale was administered to 11 of the 12 subjects. It is interesting to note that the mean of 50.36 (SD = 12.99) was greater than the mean of all comparative samples found in the literature. Means in nonclinical populations have been reported in samples of (a) college students as 40.08, SD = 9.50 (Russell, Kao, & Cutrona, 1987), (b) nurses as 40.14, SD = 9.52 (Constable & Russell, 1986), (c) teachers as 19.22, SD =

I’m very interested in what loneliness is like for people who are patients here. You can tell me anything you’d like about loneliness. Whatever you tell me will be helpful. I’ll be asking you some general and some more specific questions to try to understand what loneliness is for you.

Questions

1. Are you lonely now? Yes: What is that like for you?

Tell me how it feels to be lonely No: How do you know that you’re not lonely now?

When was the last time you felt lonely? What was that like for you? How did it feel to be lonely?

2. Have you ever noticed when someone else is lonely? What is that person like at that time? Have you ever noticed similar things about yourself?

When? What was that like for you?

3. What kinds of things make you feel lonely?

4. What kinds of things make you feel less lonely? Figure 1. Interview guide.

10 LEE, COENEN, AND HEIM

5.11 (Russell, Altmaier, & Van Velzen, 1987), and (d) elderly as 37.8, SD = 8.06 (Walton, Shultz, Beck, & Walls, 1991) and 31.5, SD = 6.92 (Russell & Cutrona, 1987). The findings of Kovarsky (1989) reported UCLA Loneliness Scale means for suicide and accident survivors as 39.9 and 45.0, respectively.

Qualitative analysis, using coding and inter- coder review, allowed for the emergence of 10 empirical categories that were closely aligned to the interview questions. According to Patton (1990), when a standardized open-ended interview is used, this guide can actually constitute a descrip- tive analytical framework for analysis. These em- pirical categories included loneliness descriptions of self, loneliness descriptions of others, descrip- tions of not lonely, impact of family on loneliness, impact offriends on loneliness, what helps to feel less lonely, what makes loneliness worse, feelings associated with loneliness, beliefs and attempts to cope with loneliness, and mental illness and lone- liness.

Further examination of the empirical data re- sulted in development of analytical categories (Figure 2). The empirical categories were col- lapsed within the analytical framework. The expe- rience of loneliness as described by adults with severe mental illnesses in a psychiatric hospital showed patterns reflecting the metaphor of living on an island. Commonly shared characteristics among the sample evident in the data were more easily illustrated through use of this metaphor. As the core category of Island Living emerged from analysis, two subcategories also were identified: surviving tidal waves and escape attempts.

Figure 2. Relationships SURVIVING TlDAl WAVFS

among the analytical cate- gory, Island Living, analyti-

Impact of Family on Loneliness

cal subcategories, surviving ,

tidal waves and escape at- mpact of Friends on Loneliness

temPt% and 10 empirical Feelings Associated with Loneliness categories.

Island Living

The core category, Island Living, contained data from the empirical categories of loneliness de- scriptions of self and others, descriptions of not lonely, and mental illness and loneliness. Living on an island creates physical separations from oth- ers similar to the severe emotional distance some patients used to describe their loneliness.

One 38-year-old woman who said she had been using alcohol to escape painful feelings for the past 21 years described loneliness as an uncomfortable, empty feeling with other people around who “don’t understand and they think everything is okay when it’s not.” Other subjects also reported feeling distanced or unconnected from others in statements such as, “I have no one to talk to, no one to relate with” and “My very existence is being threatened by the voices. ”

After spending half of his 53 years living in institutions, a man described the loneliness he has observed in others:

There is a lot of patients in here that might be worse than me, that seem to be lonely, but I leave them alone. 1 don’t touch them. Usually they’re grumpy, they’re on edge, and if you pester ‘em for money or anything else, you know, you got to watch yourself when they’re lonely, they, they’re usually better off left alone, so I leave them alone.

Distance from others also is what a 57-year-old woman with depression described as the result of living for years with a mental illness:

I’m a very lonely person. I have only two friends. And I’m losing them because of this mental illness. My children have very little to do with me because they said this mental illness has destroyed them.

UVING.

Descriptions of Self

Descriptions of Others

Descriptions of Not Lonely

Mental Illness and Loneliness

FSCAPF ATTFMPTS

What Helps to Feel Less Lonely

What Makes Loneliness Worse

Beliefs and Attempts to Cope with Loneliness

ISLAND LIVING 11

Another young man with a thought disorder di- agnosis and numerous psychiatric hospitalizations talked about his experience of loneliness:

I’m alone. There’s nobody, there’s nobody there. I could of had a home pass last Friday and return Monday mom- ing--I came back on Saturday. I’m walking, pacing in my apartment. There’s nobody there, no mothers, no brothers and sisters, no mother, no parents. It’s just me, myself, and I didn’t even have a plant to talk to!

He commented that his brother refers to him as “the lone ranger,” reflecting the family’s aware- ness of his loneliness and his patterns of isolation.

Surviving Tidal Waves

Surviving tidal waves, one subcategory of Island Living, contained data to describe the affective re- sponses to the experience of loneliness. The em- pirical categories of impact offamily on loneliness, impact of friends on loneliness, and feelings asso- ciated with loneliness were included in this sub- category. Various moods and feelings were used by subjects to explain their experiences of loneli- ness.

One man diagnosed with schizophrenia ex- plained his experience in a way that captured the essence of this subcategory: “I’m picturing myself nolw in my small apartment, alone. When I’m alone in my small apartment, when I, when I feel a wave, like a tidal wave, of loneliness.” Another 47-year-old unemployed married man stated, “And, then of course, you would start crying all the time because you felt totally alone. Your friends would fail, my sons, my daughters, and everything would. ”

Intense feelings associated with loneliness and used by subjects to describe their experiences in- cluded anger, hurt, despair, sadness, horror, dis- comfort, aloneness, depression, and emptiness. An unemployed college graduate who has had a mental disorder for over 20 years described his feelings: “I hurt. My needs aren’t being met . . It’s like having, not having . . . It’s just like, geez, I want to love somebody and I want to be loved in return . , . I can’t get my needs met.”

Escape Attempts

Another analytic subcategory identified was es- cape attempts. This category showed more active measures to deal with loneliness. These included the empirical categories of what helps to feel less lonely, what makes loneliness worse, and beliefs

and attempts to cope with loneliness. Escape at- tempts ranged from healthy, growth-producing strategies to unhealthy and sometimes life- threatening measures.

A 37-year-old man with multiple psychiatric hospital admissions talked about his beliefs about loneliness:

I be so lonely I reach to the point of despair and I got to get some help before then. I got to find someplace where I can use up all my time, use up a little bit of time, it’s the main thing of the day I got to find something to do instead of drinking coffee and smoking cigarettes.

An elderly widowed woman described the ways other patients escape their loneliness through mak- ing contact and talking with others. However, her own experience of loneliness intensified at night and was relieved only by someone spending time with her or by the arrival of the morning. A 45 year-old divorced man recovering from alcohol de- pendence described his escape attempts in this way, “It [loneliness] is just a feeling inside, like you’re all alone in the world, so I just drank to forget about it and go to sleep. ”

Other subjects shared what lessened their lone- liness, for example: “You shouldn’t even think about your loneliness,” “make friends,” “televi- sion,” “I might read a book,” “go to Mass,” and “somebody to talk to.” Subjects stated some cir- cumstances that made loneliness worse: “not hav- ing anyone around, ” “I try to fit in and I just don’t know how to do it,” and “thinking about past events that were sad.”

A 36-year-old man associated loneliness with his vivid imagination, a way he used to describe his thought disorder:

I have a vivid imagination. I imagine things like, ah, peo- ple were trying to hurt me or, you know, people are fol- lowing me around or people are trying to make me out of something that I’m not. And, ah, and then I come to the conclusion where maybe I can be helpful and learn a little self-control with the meds it would be helpful to get the discipline back.

By taking his medications regularly and by being more disciplined, he believed that the loneliness that was a part of his vivid imagination would di- minish.

One of the 12 subjects, a 53-year-old divorced man with several previous psychiatric hospitaliza- tions, described ineffectual attempts to escape loneliness such as sharing in a special treat (candy or soda) on the clinical unit, smoking cigarettes,

12

making friends with another patient who then was discharged, and wishing for a pet. Several months later this man finally escaped his loneliness through suicide.

CLINICAL IMPLICATIONS

The purpose of this study was to identify the nature of loneliness as described by adult psychi- atric patients. The findings suggest that adults with mental illness are at risk for experiencing loneli- ness, which impacts their quality of life. All sub- jects who agreed to be interviewed were able to identify experiences of loneliness, including what was helpful when they were lonely and what made the experience worse. Despite the presence of symptoms such as depression, hallucinations, and paranoia, subjects actively participated and were engaged in the interview process. Each subject was able to identify healthy and unhealthy attempts to cope with loneliness and to evaluate effectiveness for themselves.

LEE, COENEN, AND HEIM

The stigma of mental illness compounds the ex- perience of loneliness and further contributes to the lack of understanding of the concept. The findings of this study can be used to enhance awareness and sensitivity of nurses caring for persons with mental illness. This study provided a preliminary exami- nation of the subjective experiences of loneliness in a clinical psychiatric population. Subjects’ abil- ity to identify what made them feel less lonely has implications for further research of nursing inter- ventions for loneliness.

ACKNOWLEDGMENT The authors would like to acknowledge the assistance of the

Milwaukee County Mental Health Complex Nursing Research Committee: Pat Danaher-Dunn, MS, RN; Debbie DuMez, BS. RN; Lisa Englehardt, BS, RN; Carole Hedges, BS, RN; Pau- line Maclean, MS. RN; Karin Mueller, BS, RN; Pam Myers, BS, RN; David Rohde, BS, RN; Susan Lucas-Smith. B.S. RN; Lonna Taylor, MS, RN; and consultants Kathleen Cowles. PhD, RN, Marilyn Frenn, PhD, RN, and Gladys Simandyl. PhD. RN.

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ISLAND LIVING 13

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