Older people are often portrayed as a population particularly vulnerable to loneliness. Media representations of later life can depict loneliness as a distressing and inevitable part of ageing (Uotila et al, 2011; Reul et al, 2022). Loneliness in older people has been extensively investigated in academic literature (see Chawla et al (2021) for a review), exploring the diverse and complex array of experiences of separation and emptiness faced by many older people.
A variety of conceptual frameworks and measurement tools have been developed to examine the emotional, social, physical and spiritual experiences of loneliness in older people, as well as numerous potential interventions aimed at benefiting wellbeing, physical health and public health expenditure (DiTommaso and Spinner, 1997; Adams et al, 2004; De Jong-Gierveld et al, 2006; Sand and Strang, 2006; Hawkley and Cacioppo, 2010; Gale et al, 2018). However, this rich body of research can also lead to confusion rather than clarity, due to the lack of a unifying lens to better underline the multifaceted and often dynamic experiences of loneliness in old age (Bolmsjö et al, 2019).
Existential loneliness and ageing
On an ontological level, it can be argued that humans are inherently lonely and separate from the world, although, as social beings, we seek to reduce this separation through meaningful human and non-human interaction (Ettema et al, 2010; Gallagher, 2023). The existential need to affirm one's existence and alleviate the anxiety arising from life's separate and lonely nature has been described as a fundamental part of being human (Tillich, 1952). This is the essence of the existential loneliness (EL) that often arises at various points in the lifespan (Luhmann and Hawkley, 2016).
Bolmsjö et al (2019) conducted a thorough review of the theoretical and empirical research into EL and concluded that it seems to reflect an “awareness of being fundamentally separated from other people and from the universe, and typically, because of this awareness, experiencing negative feelings, moods and emotions” (Bolmsjö et al, 2019). Their review highlighted that EL can be considered as distinct from other forms of loneliness in several senses. Objective loneliness need not be connected to a feeling of loneliness. That is, people might be objectively lonely in a spatial sense (e.g. they are literally and physically separated from other people in space) or social sense (e.g. they objectively lack social connections such as friends, family, romantic partners or colleagues) but there is no judgement made in relation to whether such spatial or social circumstances are ‘good’ or ‘bad’ for the individual. For Bolmsjö et al (2019), EL is more closely aligned with subjective loneliness because it is about feeling lonely. Subjective loneliness is defined as the emotional experience of having no or few close, intimate or meaningful social connections.
It has been argued that EL may be particularly prevalent in old age (Carr and Fang 2023) when a ‘myriad of losses’—of long-term attachments, social and professional identities, physio-cognitive health and bodily integrity—uniquely challenge people's sense of feeling connected to the world (Bowlby, 1980; Smith, 2012). Despite the fact that EL is likely to exist earlier in the lifespan, most research is predominantly focused on very old and fragile ageing populations or end-of-life care settings (Ettema et al, 2010; Sjöberg et al, 2018).
A recent study by Carr and Fang (2023) sought to qualitatively explore EL in a sample of older people who were not imminently facing death or severe illness. By situating the study in the context of independent retirement community living, the authors were able to explore how EL was experienced for a broader range of older people. This commentary aims to critically appraise Carr and Fang's (2023) study, reflecting on the methods, key findings, and the applicability of these findings in community practice.
Methods
Carr and Fang (2023) conducted 80 in-depth interviews in eight independent-living retirement settings across the UK and Australia. A total of four retirement villages per country were selected after consultation with the senior and retirement village management teams in each country. Management teams considered which villages they felt were most representative in terms of gender, age and ethnicity. Participants were recruited through village managers who acted as gatekeepers to introduce the research project and researchers to the residents. The support of the village managers fostered a clear sense of trust between participants and the researchers that persisted through the research process. This rapport enabled the interviewers to be ‘a safe, interested stranger’ with whom the participants felt at ease to share their often painful and previously unspoken life experiences.
Initially, village managers participated in an online introduction to the study with the research team and then distributed information leaflets and an invitation to participate to all residents in the selected villages. Residents then contacted village managers if they felt that they wished to take part and informed consent was provided in all cases.
The study was approved by the Social Sciences Research Ethics Committee at the University of Bath (Reference number S19-052). Ethical approval was also granted according to the internal processes in place for the management teams of villages in both the UK and Australia. Permission was also gained from the local site managers at each of the eight participating villages. All participants were 55 years old or over with an average age of 79 (standard deviation = 7.6). The oldest participant was 93 years old and the youngest was 55 years old, and the gender split was 55 women and 25 men. Despite the wide age range, all participants were relatively healthy and maintained an active and independent lifestyle. Few had chronic health conditions, and none were facing any severe or life-threating illnesses at the time of the interview. Of these, 26 people were married and were living with their spouses, while the remaining 54 participants were living alone due to widow(er) hood, divorce or unmarried status. Another 45 participants had lost loved ones in recent years (often a spouse or partner). As such, more than half of the sample were facing (or had faced) loss and bereavement.
All interviews were conducted in the participants’ homes by a team of eight trained researchers. Interviews ranged from 70 to 200 minutes in length (in longer interviews, on occasions, participants and interviewers stopped for a refreshment break before recommencing their conversation) and averaged around 100 minutes. The project generated approximately 8000 minutes of in-depth audio data that was audio recorded and professionally transcribed.
The objective was to allow participants the time and space to talk freely about their thoughts and feelings in relation to a number of key areas:
- Their lives up to this point (including childhood, adolescence, career, family, and anything else they wished to share and discuss)
- Their experiences of loss, and
- Their feelings of loneliness and isolation.
Each of these areas was broad, complex, overlapped with other areas and opened-up numerous avenues of discussion that were personal and unique to the person concerned and their lived experiences.
A narrative approach permitted participants to tell their stories freely around these core structural themes. As the interviews evolved, emerging material connected to the participant's experiences of loneliness and isolation was explored in conjunction with the interviewer, in relation to the personal experiences and narrative of the person concerned. Participants could talk as freely as they wished and interviewers were trained to listen and to interrupt minimally. Several participants commented on the value of the interview for them – it provided a welcome and (often) rare space for them to open up and feel genuinely ‘listened to’. A thematic analysis (Braun and Clarke, 2012) was conducted to interpret these rich data and an inductive approach was adopted. This method of analysis allowed for important messages about lived experiences and nuanced feelings in relation to loneliness to emerge from a large amount of data, without being dominated by pre-existing frameworks (Mason, 2002).
Findings
Four main themes were identified in Carr and Fang's (2023) analysis of EL in older people: (a) loss, (b) EL as a consequence of cultural and/or generational suppression of emotional expression, (c) existential fears, and (d) attempts to close an increasingly insurmountable gap (see Table 1 for a summary and illustrative quotes).
Table 1. Themes, sub-themes and illustrative quotes of older people's existential loneliness experiences in Carr and Fang (2023)
| Theme | Sub-themes | Illustrative quotes |
|---|---|---|
| Loss | Loss of relationships | “When he was gone, I didn't know where I fitted anymore. I didn't know who I was anymore because I wasn't … (upset) … You just existed. Went shopping when you needed food. I didn't want to see people. I didn't go anywhere.” (Paula, aged 72 years; Carr and Fang, 2023: 1444) |
| Loss of physical intimacy and touch | “I suppose all my life ‘sex’ has been ‘lovemaking’. I mean, we are really getting personal now but when my wife died, I missed that so much. It's much more enjoyable in old age … because, I mean, if I said it to you you'd think oh good grief, that horrible old body and all the spots and bumps and cuts and wounds and takes off a wooden leg and one thing and another (laughs), takes out the eye. Sorry (laughs).” (Philip, aged 83 years; Carr and Fang, 2023 1445) | |
| Loss of health and bodily integrity | “She belonged to a book club. Well she's tried the book club here and she gets so … how best to describe it? Frustrated. She can't complete a sentence, frustrated because she hasn't been able to read the books because the font size is too small, she has to have a relatively large font size to be able to read, it has to be a lightish book because otherwise it's too heavy for her and so on. There are all these little things. In some ways I just feel she's a bit like a leper, really, because no one actually wants to get close to her.” (Peter, aged 78 years; Carr and Fang, 2023: 1446) | |
| Suppression of emotional expression | “I think … if you don't think about it, if you don't give it words, then you don't have to feel the pain. Stiff upper lip, very much part of the background until quite recently. How long is it since men cried in public? Never cry. Big boys don't cry. That is certainly what was said when I was growing up.” (Polly, aged 73 years; Carr and Fang, 2023: 1447) | |
| Existential fear | Realisation of death | “Yes, I think it makes me think, you know, that I'm headed there too, I guess, aren't I?” (Joyce, aged 71 years; Carr and Fang, 2023: 1448) |
| Feeling forgotten | “And the older you get, the more you like finding people who remember your parents and your home and your youth. Which is what I most fear about getting too old. But all of the people who remember any of that are gone.” (Margaret, aged 77 years; Carr and Fang, 2023: 1448) | |
| Biographical pain | “This is what I miss a lot, a private space to talk … All my life I've suffered … and some things I do find very hard, like this illness now. With everything that's gone wrong, I would have liked to talk to somebody, no advice, I want to let off steam, I suppose. But it doesn't happen here.” (Janet, aged 75 years; Carr and Fang, 2023: 1449) | |
| Responding to existential loneliness | Moving to retirement living | “Before coming here, like, on a weekend, if I wasn't seeing my son, I could go from maybe Friday evening to Monday morning and hadn't spoken to anyone. [After moving here] … you only have to go downstairs and you'll meet someone in Eric's, the coffee bar.” (Jacqueline, aged 86 years; Carr and Fang, 2023: 1450) |
| A need to share one's life stories | “Absolutely, and ‘who am I?’ This is why old people talk about their lives, their past or whatever, because they desperately want you to know who they really are inside of the old visage.” (Emma, aged 77 years; Carr and Fang, 2023: 1451). | |
Loss
Relationships
One of the most significant circumstances in which the older people felt disconnected from the world related to the loss of someone or something that had previously enabled them to feel a sense of belonging or connectedness. Many people's EL was significantly connected to the loss of a spouse or partner. The importance of enduring and meaningful emotional connections to others has been well documented (Bowlby 1973; 1980). Bowlby et al (1986) have argued that deep attachments to others may be one of the most important ways humans can bridge the subjective gap between themselves and the world and that such unique bonds are unlikely to be easily replaceable.
Physical touch
A corollary of such bereavement was frequently a feeling that people also experienced loss of touch, physical intimacy and ‘contact comfort.’ It has been argued that these are core mechanisms through which a sense of attachment to others and connection to the world are created and maintained (Playfair, 2010; Carr and Rockett, 2017).
Bodily integrity
Bolmsjö et al (2019) have argued that EL can arise when the body becomes unhealthy or dysfunctional because such changes have the capacity to disconnect people from the world. In Carr and Fang's (2023) study, an ageing body, loss of functional capacity and perceived deterioration of outward appearance were difficult for some people to tolerate and were connected to a sense of feeling ‘alien’ and less connected to the rest of the world.
Suppression of emotional expression
Carr and Fang (2023) identified an inability or reluctance to articulate experiences of alienation and meaninglessness as a core theme in many older people's experiences of loneliness. Feeling unable to communicate was not simply connected to physical barriers to communication but also to apparent deficits in the social and emotional tools necessary to communicate deeper emotional needs and feelings to the world. The authors argued that this may reflect cultural, generational or familial circumstances that have historically smothered people's ability to express their emotions and enhance their sense of existential isolation.
Existential fears
Integral to the experiences of EL was a frightening sense that older people's lives, memories, narratives and identity were increasingly forgotten, unimportant and undervalued, irretrievably lost in the past (Ettema et al, 2010). Such fears tended to revolve around a realisation of death, feeling forgotten and the concept of biographical pain.
Realisation of death
An ontological realisation of death's imminence need not be restricted to extreme conditions but can also be observable in healthy old age. For Carr and Fang's (2023) participants, there was evidence that for some people death felt ‘closer’ and this contributed to a feeling of being disconnected from life.
Feeling forgotten
Aligned with the literature on EL, some participants talked about a fear of fading away and that their lives would be forgotten or would no longer matter. As one participant put it, “My life? Nobody wants to know about my life?!” (Carr and Fang 2023: 1449).
Biographical pain
When people feel separated from the world the level of emotional distress may be connected to what they are alone with. Some participants in Carr and Fang's (2023) study carried painful and distressing narrative and memories from the course of their lives that increasingly haunted them as their sense of disconnection from the world intensified. People were often alone with burdens, memories and challenges that remained unresolved from the course of their lives. Gerontologists have used the term ‘biographical pain’ (Johnson, 2016) to describe psychological and spiritual suffering in later life that involves profoundly painful recollection and reliving of experienced wrongs, self-promises and regretted actions.
Attempting to close the gap
Moving to retirement living
Carr and Fang's (2023) sample attempted to close the perceived gap between themselves and the world in a number of ways. For some, a move to retirement living was a response to circumstances that had given rise to feelings of EL, such as loss of a spouse or increased frailty and dependency. In such cases, retirement communities were viewed hopefully, as a solution to intensifying feelings of EL. For others, the move to retirement communities reflected an attempt to ‘future proof’ against a dawning realisation that the life circumstances that so often give rise to existential isolation were on the horizon (although had not yet been directly experienced). For these older people, the move to retirement living was a defence against, not a response to, such circumstances.
Sharing life stories
Older people also sought more symbolic means of preserving and justifying their existence within the external world. Some found that sharing life stories and passing on their wisdom to others was important to continue their sense of meaning and the feeling that their life still ‘mattered.’
Commentary and discussion
‘Curing’ older people's experiences of loneliness is likely to be an unrealistic expectation. In social psychiatry, Basu (2021) has warned practitioners that medicalising and pathologising the human experience of loneliness is both dangerous and naïve. However, better understanding EL can at least bring us closer to supporting and alleviating the undeniable suffering that so often accompanies it.
Understanding the unique features of EL in older people is critical if we are to develop compassionate and humane mechanisms of support for ageing populations across a variety of contexts. Carr and Fang's (2023) study is a useful qualitative listening exercise that helps to map the nature of older people's lived experiences of EL and connects them to a myriad of ageing-related losses that gradually serve to disconnect people from the outer world.
A point to note is that the sample in this study was limited by a lack of ethnic diversity. Only three non-white participants were recruited, making it difficult to explore how factors such as race or ethnicity may shape older people's lived experiences of EL. Future research is needed to explore whether and how the ageing-related challenges of EL identified and experienced by Carr and Fang's sample (2023) are also shared by diverse groups of older people. For example, Olofsson et al (2021) have identified that there are particular challenges for ageing migrant populations that give rise to particularly unique experiences of loneliness that may not be shared by samples such as that of Carr and Fang (2023).
Recent reviews of the loneliness literature (Luhmann et al, 2022) have advocated moving beyond a search for individuallevel predictors of loneliness, highlighting what have been termed macro-level factors that may account for variation in loneliness across time and space. These include:
- Values and norms (individualist versus collectivist cultures)
- Families and social lives (cultural norms relating to family living structure and relationships)
- Technology and digitalisation (social media use and digital literacy), and
- Living conditions and individual resources (physical and perceived neighbourhood and community characteristics).
Attempts to explore the relationship between these macro-level factors and experiences of EL are likely to have important implications for policy. It will be important to explore whether variations in these factors are associated with intensified or exacerbated suffering.
Recommendations
There is an urgent need for practitioners working with older people across a variety of contexts and settings to better support the suffering associated with experiences of EL. This is likely to require better understanding of loneliness in populations of practitioners, which may include what some researchers have called ‘loneliness literacy.’
As Carr and Fang (2023) noted in their investigation, the method in their study was also highly likely to be a part of the solution. That is, the benefit of dedicated, compassionate, deep listening cannot be underestimated in relation to alleviating EL.
Key points
- Existential loneliness (EL) is a complex, multifaceted experience in older people that requires deep and compassionate listening in order to explore, understand and alleviate it
- EL is connected to a myriad of ageing-related losses and fears that serve to exacerbate a sense of disconnection to the outside world
- Older people may not have the emotional and linguistic tools with which to communicate and express their experiences of EL, further exacerbating a sense of isolation
- There is an urgent need to explore compassionate mechanisms of support for what may be an inevitable part of the ageing process for most people.
CPD reflective questions
- How can practitioners better support older people and help alleviate the suffering connected to existential loneliness (EL)?
- In what ways might practitioners and researchers work together to both understand and support EL?
- Is EL exacerbated by certain macro-level factors that could intensify the experience for certain groups of older people?