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Loneliness and Isolation in Life-Stories of Israeli Veterans of Combat and Captivity

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Abstract

Loneliness holds detrimental ramifications for health and well-being. Nevertheless, loneliness references in the literature addressing combat-related trauma are few. Consequentially, the qualities and characteristics of such experiences in these posttraumatic realities remain uninvestigated empirically. In the current qualitative study we began filling this gap in the literature. We utilized thematic content analysis of life-stories of 19 combat veterans and 7 ex-POWs that have given testimony at the Israel Trauma Center for Victims of Terror and War (NATAL). Our findings suggest that the loneliness in the contexts at hand is primarily characterized by a sense of experiential isolation, rather than social, emotional, or existential. This is the sensation that due to the extraordinary nature of traumatic experiences the fulfillment of needs such as empathy and intersubjectivity may be unattainable. Integrating our findings with existing interdisciplinary literature regarding social sharing, trauma, and loneliness, we discuss implications for clinical interventions and further research. (PsycINFO Database Record (c) 2015 APA, all rights reserved).
Psychological Trauma: Theory, Research,
Practice, and Policy
Loneliness and Isolation in Life-Stories of Israeli Veterans
of Combat and Captivity
Jacob Y. Stein and Rivka Tuval-Mashiach
Online First Publication, June 2, 2014. http://dx.doi.org/10.1037/a0036936
CITATION
Stein, J. Y., & Tuval-Mashiach, R. (2014, June 2). Loneliness and Isolation in Life-Stories of
Israeli Veterans of Combat and Captivity. Psychological Trauma: Theory, Research, Practice,
and Policy. Advance online publication. http://dx.doi.org/10.1037/a0036936
Loneliness and Isolation in Life-Stories of Israeli Veterans of
Combat and Captivity
Jacob Y. Stein
Bar-Ilan University
Rivka Tuval-Mashiach
Bar-Ilan University and Israel Trauma Center for Victims of
Terror and War (NATAL), Tel Aviv, Israel
Loneliness holds detrimental ramifications for health and well-being. Nevertheless, loneliness references
in the literature addressing combat-related trauma are few. Consequentially, the qualities and character-
istics of such experiences in these posttraumatic realities remain uninvestigated empirically. In the
current qualitative study we began filling this gap in the literature. We utilized thematic content analysis
of life-stories of 19 combat veterans and 7 ex-POWs that have given testimony at the Israel Trauma
Center for Victims of Terror and War (NATAL). Our findings suggest that the loneliness in the contexts
at hand is primarily characterized by a sense of experiential isolation, rather than social, emotional, or
existential. This is the sensation that due to the extraordinary nature of traumatic experiences the
fulfillment of needs such as empathy and intersubjectivity may be unattainable. Integrating our findings
with existing interdisciplinary literature regarding social sharing, trauma, and loneliness, we discuss
implications for clinical interventions and further research.
Keywords: captivity, combat, life-stories, loneliness, trauma
Traumatic experiences undergone in the context of combat or
captivity have been previously associated with loneliness (Her-
man, 1992; Solomon, Bensimon, Greene, Horesh, & Ein-Dor,
2013; Solomon & Dekel, 2008; Solomon, Waysman, & Mi-
kulincer, 1990) and estrangement (e.g., Figley & Leventman,
1980). Furthermore, the resonance of loneliness after such trau-
matic experiences has been shown to be long lasting (Solomon et
al., 2013). Hence, it is not surprising that trauma help centers such
as the U.S. Department of Veterans Affairs (VA; http://www.va
.gov/health/newsfeatures/20120906a.asp) and the Israel Trauma
Center for Victims of Terror and War (NATAL; http://www.natal
.org.il/) use the phrase “not alone” as their slogan. Be that as it
may, the nature and characteristics of trauma-related loneliness
have yet to be thoroughly investigated. Because loneliness has
been linked to various health problems, substance abuse, sui-
cidal ideation and actions, and to mental disorders such as
depression, anxiety, and others (for reference see Hawkley &
Cacioppo, 2010), we found such an investigation mandatory.
Conceptualizing Loneliness
Loneliness literature is replete with attempts to define the ex-
perience (e.g., Cacioppo & Cacioppo, 2012; McGraw, 1995; Mi-
juskovic, 2012; Marangoni & Ickes, 1989; Perlman & Peplau,
1981; Rokach, 2011). Although some define it as a deficiency of
intimacy and meaning within a relationship (e.g., Fromm-
Reichman, 1959/1990; McGraw, 1995), some emphasize impedi-
ments to the sense of belonging (Baumeister & Leary, 1995;
Rokach, 2011), failed intersubjectivity (Wood, 1986), and lack of
social connections (Hawkley & Cacioppo, 2010) to name but a
few. Most broadly “loneliness is defined as a distressing feeling
that accompanies the perception that one’s social needs are not
being met by the quantity or especially the quality of one’s social
relationships” (Hawkley & Cacioppo, 2010, p. 218). Following
Perlman and Peplau’s (1981) “discrepancy model,” this definition
emphasizes the cognitive appraisal of the interpersonal discrep-
ancy, distinguishing it from objective states of isolation. Thus,
“perceived social isolation” has become a term often synonymous
to loneliness, and the two are commonly used interchangeably
(e.g., Cacioppo & Cacioppo, 2012; Hawkley & Cacioppo, 2010;
Masi, Chen, Hawkley, & Cacioppo, 2011; Russell, Cutrona,
McRae, & Gomez, 2012).
Although the definition above is relatively broad, loneliness
research is still largely carried out using the UCLA loneliness scale
(Russell, 1982), constructed for the measurement of Weiss’ (1973)
social and emotional isolations. According to Weiss “emotional
isolation is initiated by the absence of a close emotional attach-
ment and the loneliness of social isolation is initiated by the
absence of socially integrative relationships” (Weiss, 1973, p. 33).
But loneliness is a more diverse construct and lends itself to
varying classifications, some undermine the definition above.
For instance, existential literature asserts that loneliness is an
ever-present condition (e.g., Ettema, Derksen, & van Leeuwen,
Jacob Y. Stein, Department of Psychology, Bar-Ilan University; Rivka
Tuval-Mashiach, Ph.D, Department of Psychology, Bar-Ilan University,
and Israel Trauma Center for Victims of Terror and War (NATAL), Tel
Aviv, Israel.
We thank Avram Stein, Noa Vilchinsky, and Boaz Shalgi for reading
and commenting on previous versions of this article. We thank Yehudit
Dor and NATAL for making the testimonial interviews available to us.
Lastly, we thank Sharon Cohen, Maya Erlich, Lee Sclar, Lital Yadid, Or
Wolster, Shirly Arbel, and Raya Lanin for their dedicated work and
transcriptions. This study has been sponsored by the Bar-Ilan University
President’s Scholarship for Outstanding Doctoral Students.
Correspondence concerning this article should be addressed to Jacob Y.
Stein, Department of Psychology, Bar-Ilan University, Ramat Gan, 52900,
Israel. E-mail: cobisari@gmail.com
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1
2010; Mijuskovic, 2012; Moustakas, 1961). Consequentially, the
reason we don’t constantly feel lonely is attributed to our capacity
to distract ourselves from our lonely state (e.g., Ettema et al.,
2010). This distraction may be jeopardized by events that are
referred to as “boundary situations,” that may bring forth the full
awareness of existence; primarily the notion of one’s death
(Ettema et al., 2010; McGraw, 1995). According to existential
assertions major events in life, such as birth, old age, and death, as
well as traumatic events may also constitute boundary situations
and generate feelings of existential loneliness (Moustakas, 1961).
But even within the social sciences loneliness is more complex
than Weiss’ two constructs. Different classifications take into
account various criteria such as antecedents (causes), manifesta-
tions, evaluations (positive or negative), expectations, types of
relationship, motivations, temporality (state/trait), and more (Per-
lman & Peplau, 1981). Moreover, phenomenological research has
asserted that loneliness is indeed a multidimensional or multifac-
eted experience (e.g., Cacioppo & Cacioppo, 2012; Mikulincer &
Segal, 1990). To the best of our knowledge, all of the above
classifications and their implications are rarely addressed (if at all)
in empirical trauma research.
Loneliness and Combat Related Trauma
As noted previously, there are several accounts in trauma liter-
ature of loneliness playing a part in the aftermath of combat-
related trauma (e.g., Solomon et al., 2013; Solomon & Dekel,
2008). When dealing with combat related trauma, studies indicate
that loneliness might already be evident in the battlefield and is a
constituent of combat stress reaction (CSR; Solomon, 1993). But
this feeling of loneliness does not end on the battlefield or in the
concrete traumatic scene. A feeling of estrangement may accom-
pany the traumatized person retuning home after the shooting is
long over (e.g., Figley & Leventman, 1980; Herman, 1992; Solo-
mon, 1993). The homecoming has therefore been identified as a
critical juncture for the traumatized soldier (e.g., Basham, 2008;
Johnson et al., 1997; Shay, 2002).
Although existential literature addresses trauma as a potential
evoker of existential loneliness, it seems that empirical research
investigating trauma-related loneliness attends solely to perceived
social isolation. Moreover, while social support may be strongly
associated with loneliness (Rook, 1984), the latter is rarely ad-
dressed in the constantly growing field of research dedicated to the
role of social support in the aftermath of trauma (e.g., Clapp &
Gayle Beck, 2009; Guay, Billette, & Marchand, 2006). Thus, more
varied experiences of isolation remain unaccounted for. The result
is a gap in the literature, as the nature and qualities of loneliness
experiences prominent in the posttraumatic reality are unaccounted
for. Due to the fact that attendance to loneliness and facilitating its
alleviation depend on achieving an understanding the phenomenon
(Masi et al., 2011; Rook & Peplau, 1982), and because loneliness
may exacerbate the initial suffering following traumatic experi-
ences, the gap delineated above is one that must be addressed. To
begin filling this gap in the literature, we devised the current
qualitative inquiry.
The Current Study
To overcome the complexities of loneliness, we implemented
Wood’s (1986) inclination that research into the nature of loneli-
ness experiences should utilize narrative investigations. As she
argues:
An advantage of the narrative approach for viewing emotion, and
particularly loneliness, is that it can incorporate and integrate all of the
elements that may be involved [. . .] whether these are viewed
metaphorically or not. The complexity of the social construction of
loneliness can be captured within the narrative not only because the
story can incorporate a label for the emotion, but also because it has
content. (Wood, 1986, p. 202)
Concurringly, we investigated the narratives that comprise the
life-stories of those who have undergone trauma in the context of
battle and captivity. In our analysis we explored the characteristics
of loneliness experiences that appeared in the portrayal of the life
after the traumatic experience. We were primarily concerned with
two questions: the first was whether loneliness experiences are
evident in the segment of the life-story that relates to the life after
the traumatic experience? Next, we strived to better understand
what are the characteristics and attributes of such experiences? We
resolved to focus on loneliness experiences that are salient after the
trauma, rather than those experienced in the midst of traumatic
experiences. This resolution was guided by the notion that such
loneliness experiences represent the “here and now” in a therapeu-
tic interaction and in the acts of narration carried out in the current
study.
Participants—Sampling Considerations
Since the inception of posttraumatic stress disorder (PTSD) in
the DSM–III (American Psychiatric Association [APA], 1980) the
vast majority of research into the posttraumatic reality has focused
on those exhibiting symptoms of the disorder. Nevertheless, the
vast majority of individuals who experience traumatic events do
not manifest PTSD (for a review of epidemiological studies see
Breslau, 2009; Norris & Slone, 2007). Consequentially, the dis-
tress of the larger part of the population who endure traumatic
experiences is underrepresented in trauma studies. This notion
guided our sampling considerations. Acknowledging that PTSD is
not the sole reaction to traumatic exposure and might not even be
the most disturbing for the individual (van der Kolk, Roth, Pelco-
vitz, Sunday, & Spinazzola, 2005), PTSD symptoms did not serve
as criteria for inclusion or exclusion in the current study. Inclusion
criteria was then only the existence of past combat or captivity
experiences that may be consensually considered as traumatic
(Spitzer, First, & Wakefield, 2007).
The testimonial project at NATAL attempts to explore the
phenomenology of the traumatic and posttraumatic experiences in
a most open and inclusive manner. This method of inquiry to a
great extent resembles therapeutic interventions such as narrative
exposure therapy (NET) and testimony therapy (TT) that have
been shown to be beneficial for treating posttraumatic reactions
(Robjant & Fazel, 2010). Thus, the participants of the testimonial
project served as a purposive sample (Polkinghorne, 2005) for the
current study. Consequentially we analyzed the life-stories of 19
combat veterans, ages 31–68 (M 52.7), and seven ex-POWs,
ages 5667 (M 61.75), that have told their story in the testi-
monial project between 2007 and 2012. Although all participants
in the study have been to some extent traumatized (i.e., psycho-
logically affected by their traumatic experiences), this traumatiza-
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2
STEIN AND TUVAL-MASHIACH
tion did not necessarily amass to PTSD symptomatology justifying
a diagnosis. Of all participants in the study, only 12 (46%) had
exhibited PTSD symptomatology during the screening. The pur-
posive sampling may account for the relatively high rates of PTSD
in the sample.
Study Design
Although one interview was carried out by a man, all other
interviews were executed by one of six women. All of the inter-
viewers were certified clinicians, specifically qualified for the
purpose of conducting interviews for the testimonial project. The
interviews followed a general protocol while maintaining degrees
of flexibility within the interview. Interview protocol aimed to
capture the life prior to the traumatic events, including family
history regarding the origins of the parents and the participants’
childhood and adolescence. Then the interview turned to examine
the military service and a detailed account of traumatic events.
Last, the interview focused on the life succeeding the traumatic
events from homecoming and repatriation to the present. In each
part of the life-story participants were directed to relate to their
perceptions, evaluations and perceived ramifications of the occur-
rences. Interview length ranged from 3 to 8 hr, and interview
sessions were up to an hour long. The interval between sessions
ranged from 1 to 3 weeks. The amount of time elapsed between
participants’ combat exposure or repatriation from captivity and
their testimonies was generally over 30 years. Some have partic-
ipated in several wars, the earliest of which was roughly at that
time, and the later exposures were 20 years prior to testimony. One
exception is a veteran of the 2006 Israel–Hezbollah War, a mere 6
years before giving testimony.
Once the accounts were obtained, they were transcribed by the
first author and five other research assistants. Transcription aimed
to capture not only the wording, but also the pauses, half words,
silences, gestures, difference in tone, rhythm, and facial expres-
sions such as smiles, laughter, concern, seriousness, tears, and so
forth.
Analysis
Taking an interpretative phenomenological approach (Smith &
Osborn, 2008), the analytical process was comprised of five over-
lapping iterative phases mostly in accordance with Braun and
Clarke’s (2006) outline for thematic analysis: First, regarding each
account, we familiarized ourselves with the data by viewing the
filmed interviews, transcribing, reading, and rereading the ac-
counts. Analysis was done parallel to transcription of the data.
Although we familiarized ourselves with each account as a
holistic unit, our analysis utilized categorical content analysis
(Lieblich, Tuval-Mashiach, & Zilber, 1998), focusing on the sec-
tions of the narrative relating to those points in time after the
traumatic period. We identified the section of narrative devoted to
the return from either war or captivity as the critical cutpoint for
determining when the traumatic period ends and the posttraumatic
begins. That said we were aware of the fact that a story is told from
its end (Mishler, 2006). As the testimony takes place in the present
(i.e., after the trauma) there were references in previous parts of the
narrative that alluded to perceptions maintained after the traumatic
period. Those were accounted for in the analysis.
The third phase of the analysis consisted of generating initial
codes by deconstructing the text into identifiable units of meaning.
We combined theoretical and deductive approaches (Braun &
Clarke, 2006) in an attempt to extract meanings and recurring
themes. That is to say, we both had existing categories derived
from the literature (e.g., types of isolation, deficient relational
needs), and were prepared to generate new codes and themes that
would emerge from the data in a bottom-up process. Thus, the
fourth phase consisted of searching for themes and categories that
would organize the emerging codes, while sorting additional codes
to those preexisting categories. The fifth phase of the analysis then
consisted of reviewing the emerging themes and scrutinizing them
for consistency.
Guided by the literature we anticipated a dearth of literal refer-
ences to lonely states. It is stressed in the literature that people in
general, and men in particular, tend to hold back disclosing their
loneliness (e.g., Ernst & Cacioppo, 1999). This is attributed in part
to the shame and guilt associated with loneliness (Marangoni &
Ickes, 1989; Wood, 1986). Admitting loneliness entails a tacit
admission of being in a state of pain and in the need of others,
while masculinity scripts often dictate competence and fortitude
(Mahalik, Good, & Englar-Carlson, 2010). Hence, men who con-
form to such masculinity scripts are less likely to disclose their
loneliness, as the two might counteract. Moreover, it is maintained
in the literature that at times one may not be aware that what he is
experiencing is loneliness (Ettema et al., 2010; Fromm-
Reichmann, 1990; Marangoni & Ickes, 1989). Hence, the chal-
lenge we faced was that of identifying experiences of loneliness
that have not been labeled as such by the participants. Therefore,
we disassembled the construct of loneliness into its constituting
elements (Stein & Tuval-Mashiach, 2014), and accordingly
searched primarily for those expressions which alluded to experi-
ences of isolation. Next, we examined whether these expressions
exhibited explicit or tacit expressions of related pain or aversion,
thus discerning experiences of mere isolation from those of lone-
liness. Next, we inferred from the expressions the unarticulated or
otherwise tacit deficient relational needs, some identified others
that in relation to this isolation is formed. Thus further determined
the evaluation and nature of the isolated states at hand.
Interpretation and Validity
The current study took as its point of departure an interpretative
constructionistic point of view. That is to say that we perceived our
findings as one of many possible interpretations of the data (Lin-
coln, Lynham, & Guba, 2011). Adopting an interpretative phe-
nomenological (Smith & Osborn, 2008) approach, we were inter-
ested in identifying what the participants themselves were
revealing in their accounts, so as to give voice to their authentic
testimony regarding their experiences. Thus, throughout the ana-
lytical process we read and interpreted the material maintaining a
hermeneutics of faith (Josselson, 2004), accepting the participants’
accounts at face value.
Once tentative interpretations were conceptualized, we then
evaluated those interpretations by using the following validity
criteria: (a) The source of an interpretation should only be an
actual piece of data, and theoretical support served merely as a tool
for explanation. (b) There must be no contradictions in the data
concerning interpretations that are considered valid. Finally, all the
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3
LONELINESS IN POSTTRAUMATIC LIFE-STORIES
accounts were compared with each other in order to arrive at a
comprehensive understanding in line with the aim of the study.
Ethical Considerations
Taking ethical considerations into account, the interviews in the
current study aimed to capture the entire life story of the partici-
pants in an inviting atmosphere. That is in opposed to an interac-
tion of an investigative nature that might reenact experiences of
investigation that were prominent in the time of captivity, thus
reactivating traumatic experiences. Furthermore, participants were
given the choice whether to elaborate or not on any given expe-
rience. Moreover, the participants have all undergone a screening
interview prior to the testimonial process to assess the likelihood
of reactivation of traumatic experiences, thus attempting to take
necessary precautions. Furthermore, only participants that have
signed a consent form permitting the submission of their testimo-
nies to research were included. All names have been changed to
keep the identity of the participants confidential (Josselson, 2007).
All ethical procedures have been reviewed and approved by the
review board at the Department of Psychology in our institute.
Findings
The analysis led to the identification of four recurring themes
indicating fundamental experiences of aversive isolation which we
regard as loneliness. An examination of these themes led us to the
realization that they all converge into one very prominent construct
of loneliness. Subsequently we shall elaborate on each theme as it
unfolds to further understand how these experiences relate to each
other and form a distinct experience of loneliness. All quotes were
translated from Hebrew by the first author and confirmed as loyal
to the original Hebrew wording by the second author.
“A Different World”—The Sense of Alienation
Several times in the narratives it has become evident that par-
ticipants are trying to convey their sense of alienation. What better
way to accomplish this than through the use of the metaphor of “a
different world”? Tom describes his return from combat to head-
quarters in the midst of the 1973 Yom Kippur war:
I remember entering a shack there in [a name of a military base in
southern Israel, J.S.], a place that was familiar to me [. . .] And I see
a different world. A different world [. . .] there was an atmosphere of
amusement there, or something like that. I can’t forget the atmosphere
of amusement as I opened the door and entered. Me with the overalls
. . . blood stains. They [the people in the shack, J.S.] were shocked
(lifts his gaze and seems to hold back tears). They knew that I had
come from some different world.
The affect during this part of the narration is of intense sorrow,
barely contained. It is clear that the “different world” metaphor
serves to convey the sense of extreme isolation and alienation. It
seems that for Tom the change of atmosphere has awakened the
discrepancy between a desired shared reality and the realization of
its nonexistence. In accordance with the metaphor of different
worlds, the contrast of the blood-covered overalls with that of the
“amused atmosphere” renders him alien and isolated. As Tom’s
account demonstrates, this isolation may be evident from the first
encounter with those who have not “been there.” Similarly, Arney
describes his return home from that same war:
. . . the war ended, you feel the...thefeeling of...that dissipation
of the fear and the...andthat the war is over [. . .] and I go home
for the first time and I tr-...land fro-...from a different world to
a different world. You...youlook around you and you see...the
whole country continues to act as if nothing happened. People walk in
the streets, and shops are open, and coffee shops, and you....and
you...you...youdon’t understand, you just can’t understand how
is it that not everyone feels like you feel. And it’s...its...andthis
business in the end result makes you...youinfact live...youin
fact live...from that moment you in fact live in detachment [. . .] and
I don’t want to remain this way to the day I die.
Once again the metaphor of different worlds is prominent, and
once again the sensation of alienation is attributed to a lack of
fulfillment of a most primal need for mutuality. While Tom gave
a graphic description of his blood-stained overall to contrast the
“amused atmosphere,” Arney contrasts the every-day-life with the
fear-infested experience of war. Regarding the identified Others,
we might notice that Arney isn’t only addressing his hometown,
but the entire country as a people. His concluding remark that he
would not like to stay detached in this manner to the day he dies,
emphasizes the aversive aspect of the experience. Both Arney and
Tom acknowledge the return from the war as a critical time of
alienation. A home which is usually a symbol for the safe and
familiar is now depicted as a place of estrangement and alienation.
Such too is the case for Allen who proclaims that, “The first time
I took leave to go home. I remember I got home, it was...Ifelt
that I have arrived at a completely different world...Ididn’t
connect to anything. Nothing. Nothing!” As Figley and Leventman
(1980) poignantly titled their book depicting the American soldiers
returning from Vietnam, figuratively speaking the veterans above
very clearly feel Strangers at Home. Moreover, the narratives
above emphasize the hardship that homecoming may entail for the
retuning veteran (e.g., Basham, 2008; Shay, 2002).
“Those Who Have Been There (and Those Who
Haven’t)”—The Sense of Two Populations
Concomitant to the sensation that the world has been divided
into two experiential realms—that of normalcy and that of war—in
some narratives the population too seems to be experienced as
bifurcated. There are those who have access to the experience (i.e.,
those who have experienced such traumata and those who do not
(i.e., the rest). Sam’s narrative demonstrates this feeling as he
recaps his search for an adequate therapist to assist him with
coping more than two decades after returning from captivity. In
this search he explains why he specifically requested for a therapist
who, like him, had endured torture in captivity:
I don’t think that anyone else but Arthur [his therapist] would have
been able to do it [. . .] I don’t think anyone else would have been able
to enter my head (points with his hand to the center of his chest). Not
only mine, by the way. Arthur’s or anyone who has been through what
we [him and his therapist] have been through. I don’t think that
anyone could have entered our head, unless he was there [in
captivity].
It is quite evident that for Sam only one type of person exists
that might have a chance of understanding what he is experiencing
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4
STEIN AND TUVAL-MASHIACH
and what he has been through. Such a person may only be he who
has been unfortunate enough to go through the same dreadful
experiences that he has suffered. The remainder of the population
is “out of the picture,” so to speak. This sensation reappears in his
narrative.
I underwent surgery 2 months ago, 3 maybe...andthesmell of blood
killed me even now. Listen, it goes into your...it’s like a scratch on
a record, or a disk, it enters your...andthis smell of blood never
leaves. I told Ruth [his wife] at home, she didn’t understand what I
was talking about. People can’t understand what I’m talking about...
I met someone who has experienced the experience [of combat], and
I said to him “Do you remember that smell of blood in the battalion
aid station?” he said “Yes. It’s the smell of death.”
Strongly associated to this sensation that there are those who
have experienced the traumatizing experience and those who have
not is this sense of isolation in quotidian life. Mardi echoes this
sensation as he relates to the difficulty to understand why Holo-
caust survivors act as they do. He says “Only those who have gone
through trauma as I have undergone, know how much these people
have suffered, and why they behave as they do.” Noting the
discursive positioning (Harré & van Langenhove, 1999) of the “I”
in opposed to the “them” throughout the narratives, may further
emphasize just how this sensation may dominate the experience.
Allen’s words depicting the way his traumatic realizations became
detrimental to his capability to communicate with his wife may
once again demonstrate this and serve as a transition to the next
theme:
This [the realization that some aspects of everyday life are petty]
might be an insight of someone who understands how life may end in
a second [. . .] And whoever hasn’t been in this situation doesn’t
understand what [we’re] talking about at all. [They] literally can’t
understand what we’re talking about. And truth must be told that here
lay many gaps, because for me priorities in life have changed and for
her...[not].
Once again it is clear that the population may seem bifurcated
into those who have endured the experience and those who have
not, and respectively to those who may and may not understand.
This dearth of understanding is then the reason why such bifurca-
tion is of significance. As the population is experienced as bifur-
cated into these two separate social entities, one very prominent
relational need is compromised, the need for intersubjectivity.
“No One Can Understand”—The Sense of Failed
Intersubjectivity
Driven by the need to feel understood, one may search for an
outlet from his painful isolation. Mickey’s words very poignantly
demonstrate this, once again exemplifying the sensation that the
population is bifurcated by the experience:
Um...itwasimpossible to talk to anyone about it, because no one
understands. No one understands, I mean, until you meet someone
who was there and suddenly you say a word and you...like, you
understand that you understand what you are talking about with that
person. And there weren’t, sadly there weren’t many that...that have
experienced it at all. Many people didn’t do reserve [military reserve
duty, J.S.] in...inthis thing. And it was...itwasabsent for me
because there was no one to share with.
The need to be understood, as illustrated here by Mickey and
above by Allen and Sam is part of a more profound need for an
intersubjective sharing of the experience and its affective ramifi-
cations. Barney’s account depicting his motivation to participate in
the testimonial project poignantly illustrates this need:
Barney: [People] need to know about it [what he has gone through in
the war], they need to know about it [. . .] This for me is like a big
wound that I dig up all the time. I dig it up and as if I want everyone
to be inside the wound. I want my pain to be felt. (3-s silence)
Interviewer: You want [people] to understand what you have been
through.
Barney: I don’t know if they will understand what I have been
through, but, but I am in pain. Things—things hurt me—things that
trouble me. Yes, not only physical (word emphasized) pain, it is
spiritual pain, emotional. Yes.
Barney extends the deficit to the realm of emotional understand-
ing and empathy. It is not only his need that people will under-
stand, but also the need that they will feel what he feels. This may
remind us of Arney’s sensation upon returning home from the
battlefield that no one feels what he feels. An additional under-
standing that may be drawn from Barney’s account is that by
telling his story, by disclosing his emotional state, he is in actuality
working to alleviate his painful sense of isolation. Thus, trying to
figure out why he feels a sense of serenity due to the testimony, he
says,
I started to think about it [. . .] and I saw for myself that there were
certain things that I talked about, [. . .] and like someone has finally
listened, and like that someone finally understood [. . .] or if not
understood, then maybe in time, because it is documented, then
someone will understand it [. . .] and I felt this sort of quiet.
Boris reveals an identical motivation as he relays a similar act of
disclosure in the attempt to fulfill his need for intersubjectivity:
Boris: Um...formeIremember that in the first half a year after the
war, I had an urge like to...totell what happened. Like...toevery
...totell everyone that...IwasinLebanon, I did so and so and so
andsoandso.Um...Ihad...Ihadadesire like to give a lot of detail
that is frightening and...like I wanted to project what I had felt so
other people will feel it.
The act of disclosure is aimed at the goal of projecting “what I
had felt so other people will feel it.” But the eventuality of this
disclosure is of grave implications. As Boris concludes,
My girlfriend at the time couldn’t cope with it. [She] just couldn’t and
she said that she doesn’t want to hear about it. And I think that . . .
kind of damaged our relationship, which actually ended a year later.
A similar eventuality is evident in Ian’s account:
Ian: In the social domain it is like this. There was a time immediately
after the war that I didn’t stop talking about it [about the war]. In a
really obsessive manner. So my wife also says...(Interrupted by the
interviewer).
Interviewer: About what? About the details?
Ian: Yes. Yes. About everything, about everything. It was a terrible
thing. You know...sothey couldn’t take it. People simply stayed
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5
LONELINESS IN POSTTRAUMATIC LIFE-STORIES
away. So my wife says “Listen, soon we will have no friends.” So now
all of the friends that come to our house are her friends [. . .] and . .
. I put a taboo on the subject. I don’t...about this—I don’t talk about
my feelings.
Both Boris and Ian are driven by an inner force to disclose
their experiences in a very vivid manner. This inner force may
very likely be the isolation they felt as they were faced with the
magnitude their past traumatic experiences. Attempting to es-
cape the feeling of failed intersubjectivity then proved to bring
about either emotional or social isolations. As Ian remarks
[. . .] then I cherished this story [. . .] and that is one of the most
difficult things that there are in this business of um [. . .] mental injury,
that [. . .] something terrible happens to you, to yourself, and you can’t
share it with anyone anymore. [People] don’t want to hear. They
can’t—incapable of hearing.
Evidently, attempts to disclose and socially share traumatic
states may eventuate in further isolation. Moreover, such attempts
may entail yet another obstacle—the ineptitude of language.
“There Are No Words”—The Sense of
Incommunicable Experience
John tells of his attempts to disclose his experiences from the
battle to others. “I shared it with them. I’m not sure they were
able to digest it because war is hard to communicate in stories.
It’s more of a personal sensation that a person feels.” Language,
as John articulately put it, is not the ideal vehicle for conveying
affective aspects of experience. Throughout the narratives,
painful experiences have very often eventuated in the lack of
words to describe them. When describing battle or captivity,
statements such as Tom’s “I can’t explain” or Arney’s “it is
unbelievable, it cannot be comprehended” were ubiquitous. Ron
poignantly illustrates this sensation as he brings together sev-
eral of the themes delineated above in one description from the
battlefield: “The plane was hit, exploded and crashed. A pilot
never ejected no...nothing, it was a very difficult feeling
because the...Idon’t know how to even explain this” and he
continues “like a different world I don’t...Idon’t even know
with what words to describe it. It’s more of a sensation.” The
inaptitude of language then serves as yet another obstacle in
overcoming the sense of isolation and potential loneliness that
is the eventual outcome of bearing such traumatic experiences.
Discussion and Theoretical Integration
Studies have shown that humans have a fundamental need to
experience a shared reality with others (Echterhoff, Higgins, &
Levine, 2009). That shared reality involves a (subjectively per-
ceived) commonality of individuals’ inner states, and is generally
about some target referent. This desire is referred to in experimen-
tal existential psychology as I-sharing (Pinel, Long, Landau, &
Alexander, 2006). That is “the sense that one’s subjective experi-
ence overlaps with that of at least one other person” (p. 244). For
the participants in the current study the satisfaction of this need
seems unattainable. This is in line with findings by van der Kolk,
Roth, Pelcovitz, Sunday, and Spinazzola (2005, p. 393, Table 2).
Pointing at the sensation that “nobody can understand” as a com-
mon experience following trauma.
A possible explanation may be rooted in a long abandoned
definition of traumatic events postulated in the DSM–III (APA,
1980). Accordingly a traumatic event is an “event that is generally
outside the range of usual human experience” (p. 236). Although
this definition might be objectively incorrect (Breslau, 2009; Nor-
ris & Slone, 2007), it seems that traumatized persons may maintain
a subjective notion that their experiences abide to this description.
One of the participants in the current study articulated this in
extreme precision. Max elaborates that the testimonial project is
for him an opportunity “to speak about the most difficult things
there are,” things that, “no person encounters them in his every day
routine and not in the frame of extraordinary events that you go
through in life.” Thus, acquiring a shared inner-state might be
rendered impossible, and the traumatized person may indeed feel
condemned to remain isolated in this respect. The failure of lan-
guage in representing painful experiences (Bar-On, 1999; Scarry,
1985) may serve to exacerbate this isolation. This sense of an
unfulfilled desire to share a subjective reality with others is de-
picted in Linda Wood’s (1986) definition for loneliness. Accord-
ingly “loneliness does not involve the simple absence of intersub-
jectivity. Rather, loneliness is the individual experience of failed
intersubjectivity” (Wood, 1986, p. 188, italics in the original). In
the current study this sense of failed intersubjectivity was found in
regard to experiences from the battle or captivity (e.g., experiences
of fear, near death experiences, torture, etc.) or experiences that
took place in the posttraumatic reality (e.g., PTSD symptoms,
depression, helplessness etc.).
Wood’s definition of loneliness closely relates to Stolorow’s
(2007) conceptualization of trauma. As Stolorow asserts,
I view trauma as, in essence, an experience of unbearable affect.
Furthermore, [. . .] the intolerability of an affect state cannot be
explained solely, or even primarily, on the basis of the quantity or
intensity of the painful feelings evoked by an injurious event. Trauma
is constituted in an intersubjective context in which severe emotional
pain cannot find a relational home in which it can be held. In such a
context, painful affect states become unendurable—that is, traumatic
(Stolorow, 2007, pp. 9–10).
This experience of loneliness does not adequately fit any of the
types of isolation dominating the literature: perceived social iso-
lation, perceived emotional isolation (Cacioppo & Cacioppo,
2012), or existential isolation (Ettema et al., 2010). Thus, we saw
fit to apply a novel term.
As noted, central to the manifestation of loneliness delineated
above are certain experiences and their inveterate incommunica-
bility and unshared eventuality. Hence, it seemed most fitting to
term this experience “loneliness of experiential isolation,” or in
short “experiential loneliness.” We found the term “experiential
loneliness” in one additional place in the literature. While explor-
ing the phenomenon of “feeling really understood,” van Kaam
(1966) asserts that feeling really understood entails a sense of
relief from such experiential loneliness. While not elaborating on
the sense of loneliness itself, he states: “The adjective experiential
specifies that it is not primarily a physical loneliness, but being-
alone in certain psychological experiences” (van Kaam, 1966, p.
338, italics in the original). In the current study those experiences
were all related in some way to the traumatic or posttraumatic
realities.
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6
STEIN AND TUVAL-MASHIACH
The nature of the loneliness delineated above may also account
for the abundance of references to sharing and emotional disclo-
sure in the current study. Whether they had succeeded or failed in
this endeavor, all participants related to either sharing or not
sharing their past traumatic experiences with others. It seems, in
accordance to theories of social sharing of emotion (Rimé, 2009),
that the capacity to see the act of sharing as being potentially
successful may be a key for alleviating the traumatized person’s
loneliness.
Although this type of loneliness may be accounted for in exis-
tential assertions (e.g., Ettema et al., 2010; Mijuskovic, 2012;
Moustakas, 1961), we would argue that traumatized persons may
not perceive or experience their isolation as such. Rather, the
accounts in the current study exhibit a strong inclination that the
essence of the experience of isolation, and consequentially that of
loneliness, rests in inner experiential states and their contrast to
their surrounding relations. Ian describes this very clearly as he
elaborates on the extremity of this loneliness experience:
In its most extreme it is when we [his wife and himself] are at let’s say
...a...Bar-Mitzvah party or a wedding or anything [. . .] as the party
gets more cheerful, and people become more joined among them-
selves, I feel lonelier. As if...inthe, in the, I know there are let’s say
600 people [there]. But within the 600 people, I suddenly feel really,
really alone. And alone with my sadness. And the sadness intensifies
as the happiness intensifies. It, it is really in correlation [. . .] and this,
this, this is a matter of continued grief over something, that I have
experienced myself, and others have not.
Implications for Clinical Interventions
Although the literature linking social support and PTSD is
constantly accumulating (Charuvastra & Cloitre, 2008), it is im-
portant to note that our findings do not indicate any causal link
between loneliness and PTSD symptomatology, and therefore any
clinical recommendations hereafter refer primarily to the facilita-
tion of loneliness reduction in the context at hand. That said,
considering the deleterious ramifications associated with loneli-
ness (Hawkley & Cacioppo, 2010), and acknowledging it as “a
distinct phenomenon worthy of attention in its own right” (Hei-
nrich & Gullone, 2006, p. 712), we advocate that clinicians be
minded to its existence in addition to and regardless of PTSD
symptomatology.
A meta-analytic effort to assess the effectiveness of interven-
tions aimed at loneliness reduction has focused primarily on the
amelioration of perceived social and emotional isolations (Masi et
al., 2011). Although attending mainly to differences in study
design, the researchers point at interventions that addressed mal-
adaptive social cognitions as being slightly more effective com-
pared to interventions that addressed social support, social skills,
and opportunities for social intervention. Nevertheless, the re-
searchers acknowledge that, “the causes of loneliness are likely
unique in each person, and matching specific therapies with spe-
cific interventions is worth further investigation and may prove
valuable in future studies” (Masi et al., 2011, p. 257).
In the current study the participants exhibited a need for
strengthening relational connections based on mutual experience
and intersubjectivity. Consequentially, of the interventions exam-
ined by Masi et al. (2011) it seems that only attending to social
cognitions might be of relevance. More specifically, our findings
suggest that should therapists choose to attend to maladaptive
social cognitions leading to loneliness, they may and should focus
on the manner in which traumatized persons perceive their trau-
matic experiences in relation to their environment’s capacity to
relate to those experiences.
Be that as it may, various other interventions might prove
beneficial in attending to the relational needs at hand. For instance,
providing psycho-education for both patient and support figures
(e.g., family, spouse, community, etc.), and teaching the patient to
communicate his feelings and experiences as he learns to under-
stand them may prove beneficial. A psychoanalytic intervention
attending to experiential loneliness would most likely benefit from
an intersubjective-systems approach, focusing on attunement to the
patients’ affective states (Carr, 2011; Stolorow, 2007). Another
course of action might be to turn to existential therapy, thus
disconnecting the isolation from specific experiences, and possibly
enabling a process of growth (Ettema et al., 2010; Yalom, 1980).
Furthermore, therapies oriented both to trauma and narrative (e.g.,
Peri & Gofman, 2014; Robjant & Fazel, 2010) may too prove
beneficial for alleviating such experiential loneliness because they
strongly relate to subjective experience as it appears in the lived
experience explored in the narratives. Last, taking into account
participants’ aspirations to find fellow veterans who might be
capable of relating to their experiences, veteran support groups
(e.g., Herman, 1992, pp. 214–218) and peer support programs
(e.g., Grenier, Darte, Heber, & Richardson, 2007) may prove
beneficial. Such interventions bring together veterans who are
experience-wise “in the know” to support and relate to one anoth-
er’s experiences and thereupon may serve to shatter the boundaries
of experiential isolation. Having said this, it stands to reason that
empathic treatment settings that facilitate self-disclosure are likely
to ameliorate experiential loneliness to some extent over and above
specific therapeutic methods (e.g., Wilson & Thomas, 2004). As a
study investigating loneliness reduction in trauma victims has yet
to be conducted, these postulations await further research. Such
research should, among other things, address treatment settings,
types of patients being treated, and ways of identifying those in
need of such treatment.
Limitations and Further Research
The current study is limited in several aspects. First and fore-
most this study does not address the issue of generality. In the
current study we do not claim that experiential loneliness is more
common than other types of loneliness, nor do we claim to any
extent of prevalence in the population at hand. These issues may
and should be tested utilizing quantitative methods, once a mea-
surement for experiential loneliness is devised.
Second, we must address the challenges that arise as a result of
the study design, namely the fact that the interviews were not
aimed at identifying loneliness, but rather to explore the life-story
and the phenomenology of trauma and its aftermath as a whole.
Future research should apply phenomenological methodology, di-
rectly addressing loneliness, to further investigate this phenomena,
whether in the context at hand or other posttraumatic contexts.
Nevertheless, this indirect inquiry into the experience of loneliness
may also be an advantage in a twofold manner. Although a direct
approach may lead to further understandings, in actuality it may
only be able to address those experiences of loneliness that corre-
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7
LONELINESS IN POSTTRAUMATIC LIFE-STORIES
spond with the subjects’ understanding of the term ”loneliness.”
Moreover, as isolation and loneliness experiences were not solic-
ited by the interviewers, it is of greater significance that they have
been addressed on the participants’ own volition.
Third, the current study was conducted maintaining a herme-
neutics of faith (Josselson, 2004). That is to say that in listening,
reading, and analyzing the accounts we have assumed the partic-
ipants are disclosing their true experiences and inner states as best
as they can. Consequentially only those experiences that are ex-
hibited on face value are represented in the analysis. As both
trauma (e.g., Herman, 1992) and loneliness (e.g., Marangoni &
Ickes, 1989) hinder emotional disclosure, future research may
benefit from analyzing the accounts maintaining a stance of sus-
picion. Assuming that the participants may be constrained in
revealing their true inner states may reveal deeper aspects of the
participants’ experiences.
Last, in the current study we addressed two very specific con-
texts of trauma (i.e., combat and captivity). Further research into
other posttraumatic contexts (e.g., sexual abuse, traumatic loss,
relational trauma, etc.) and the loneliness embedded in the life
thereafter is much needed. Be that as it may, it would stand to
reason that this type of loneliness would transpire in other con-
texts, as is very prominent in Stolorow’s (2007) assertions regard-
ing emotional trauma.
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Received November 24, 2013
Revision received February 18, 2014
Accepted April 6, 2014
This document is copyrighted by the American Psychological Association or one of its allied publishers.
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
9
LONELINESS IN POSTTRAUMATIC LIFE-STORIES
... A total of 20 the 155 included studies conceptualised existential loneliness [159][160][161][162][163][164][165][166][167][168][169][170][171][172][173][174][175][176][177][178]. In contrast to emotional or social loneliness, existential loneliness was defined as a feeling of fundamental separateness from others and the wider world, not simply as the absence of meaningful relationships and negative emotional experience. ...
... In contrast to emotional or social loneliness, existential loneliness was defined as a feeling of fundamental separateness from others and the wider world, not simply as the absence of meaningful relationships and negative emotional experience. Participants described it as a feeling that occurred when important others were absent through some form of psychological rejection or absence [159,161,162], or when people felt left behind by life events, such as death or divorce, and/or experiences of physical or mental decline or limitation through illness, traumatic experience, aging, and a sense of one's mortality [160,[163][164][165][166][167][168][169][170][171][172][173][174][176][177][178]. Similar explanations of existential loneliness were reported by healthcare professionals supporting older people experiencing this type of loneliness [175]. ...
... This conceptualisation of existential loneliness was connected, in all studies examining the concept, to feelings of separateness from other human beings, feelings of loss and longing, and/or a sense of being an outsider against a need for connectedness, belonging, and companionship. Studies indicated that existential loneliness may also be felt while with others, as a sense of disconnection from a group [159,161,163,167,168,[170][171][172]174]. In such situations, participants reported that existential loneliness was experienced through being misunderstood, psychologically and emotionally detached, and more deeply as a perception of being without others. ...
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The paper reports an evidence synthesis of how loneliness is conceptualised in qualitative studies in adults. Using PRISMA guidelines, our review evaluated exposure to or experiences of loneliness by adults (aged 16+) in any setting as outcomes, processes, or both. Our initial review included any qualitative or mixed-methods study, published or unpublished, in English, from 1945 to 2018, if it employed an identified theory or concept for understanding loneliness. The review was updated to include publications up to November 2020. We used a PEEST (Participants, Exposure, Evaluation, Study Design, Theory) inclusion criteria. Data extraction and quality assessment (CASP) were completed and cross-checked by a second reviewer. The Evidence of Reviews of Qualitative Research (CERQual) was used to evaluate confidence in the findings. We undertook a thematic synthesis using inductive methods for peer-reviewed papers. The evidence identified three types of distinct but overlapping conceptualisations of loneliness: social, emotional, and existential. We have high confidence in the evidence conceptualising social loneliness and moderate confidence in the evidence on emotional and existential loneliness. Our findings provide a more nuanced understanding of these diverse conceptualisations to inform more effective decision-making and intervention development to address the negative wellbeing impacts of loneliness.
... Veterans' logic seems quite sound here. Better yet, how can a combat veteran trust a civilian clinician with no combat experience to comprehend the scope of trauma they experienced in combat (Brewin et al., 2011;Ahern et al., 2015;Stein & Tuval-Mashiach, 2015)? Garcia (2016) stated, "The demands of treatment often run directly counter to the demands of the battlefield. ...
... The creation of community ceremonies could return the experiences of war back to the U.S., rather than just leaving it to the warriors who fought the wars to hold in secrecy (Junger, 2016). Combat veterans tend to feel misunderstood by civilians (Brewin et al., 2011;Ahern et al., 2015;Stein & Tuval-Mashiach, 2015), which underscores the importance of peer support and reliance on peers' assistance in the military (Greden et al., 2010;Caddick et al., 2015). ...
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The progressive escalation in military suicides, along with a substantial increase in post-traumatic stress diagnosis among active military personnel and veterans, has become a significant humanitarian, societal, and cultural concern. Such a defining moment illuminates the need for timely and innovative treatment approaches for combat-related post-traumatic stress. This research explored depth psychological practices within short-term, group-based treatment programs. Using a phenomenological research method, interviews were conducted with six former combat veteran alumni of these programs to gather new insights and understanding into their lived experience. Informants described meaningful reductions in post-traumatic stress, moral injury, and treatment-resistance, while treatment completion rates increased significantly. Research findings suggest depth psychological practices do exhibit compelling potential as valuable, or formidable treatment approaches, alongside current evidence-based treatments. Based on the findings of this preliminary exploration future research is warranted on depth psychological treatments and group-based programs for combat-related post-traumatic stress.
... Social isolation is an objective state of having low integration in the social environment including few social relationships and infrequent social contact with others (Seeman, 1996;Victor et al., 2000). Whereas, loneliness is a subjective state and has been defined as "perceived social isolation" Kuwert et al., 2014;Stein & Tuval-Mashiach, 2015). Social isolation and loneliness are problematic for veterans' mental health (Umucu, Reyes, Nay, et al., 2021). ...
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Background Veterans with mental illness are a growing population in the United States (US). For some veterans, their military service has a negative effect on well-being. Social isolation is problematic for veterans’ mental health by increasing incidence of depression, suicidal ideation or attempts, and readmittance to psychiatric hospitals. Social support is a protective factor for individuals with mental illness and is key to a successful military-to-civilian transition. Aim Thus, we examine the relationship of social isolation on well-being among veterans with any mental illness. Methods This cross-sectional correlational study consisted of a sample of 146 US veterans with any mental illness. A three-step hierarchical regression analysis was used to determine if social isolation is a predictor of well-being after controlling for demographics, functional limitations and depression. Results Findings revealed social isolation was positively correlated with functional limitations (r = 0.48, p < 0.001), depression (r = 0.66, p < 0.001) and negatively correlated with well-being (r = −.64, p < 0.001). Hierarchical regression analysis revealed social isolation was negatively correlated (β = −.44, p < 0.001) with well-being. Overall, our three-step model accounted a total of 50% of variance in well-being, a large effect size. Conclusion The findings underscore the importance of assessing the relationship of social isolation on well-being in veterans with mental illness. The findings also highlight promising targets to improve prevention and psychosocial interventions to improve well-being among veterans with mental illness.
... All the interviews were carried out in friendly and quiet spaces, without time limitations, to allow the interviewee to introspect and thus transmit her experience in her own words. As Stein and Tuval-Mashiach (2015b) show in the case of Israeli veterans, the process of sharing their emotional load with someone ready to pay attention without judgment was a pivotal element to explore these feelings and emotions: "We all need to sense that others experience, feel, think, evaluate, and altogether view the world as we do… this is what motivates people to tell stories of those experiences" (Stein & Tuval-Mashiach, 2015b, p. 13). ...
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Loneliness poses one of the significant problems of our modern post-industrial societies. Current research on loneliness has been developed primarily by psychology, biomedicine, nursing, and other health-related disciplines, showing a surprising number of variables and risk factors involved in the experience of loneliness, along with positive correlations with premature mortality and morbidity. However, most of these analyses often overlook the social interactions and context in which loneliness is experienced. Drawing on a subsample (N = 24) of Spanish "mothers" from impoverished families, the article proposes a mixed-method approach (both relational and interpretative) that may potentially complement quantitative approaches, showing relational and contextual factors that may contribute to a better understanding of the subjective dimension of loneliness.
... Cacioppo et al. (2000Cacioppo et al. ( , 2002Cacioppo et al. ( , 2003 and Hawkley et al. (2003) utilizing questionnaires and direct observations or measurement of physical variables, subscribed to Peplau and Perlman's conceptualization of loneliness and furthered the field by researching how it is related to physical and mental health, to depression, to various social variables, and how it may even be "contracted" from one person in a group, to others. Salient threads in those definitions focus on deficiency of intimacy and meaning within a relationship, while others emphasize shortcomings in people's sense of belonging and limited or lack of social connections (Stein and Tuval-Mashiach, 2015). In the beginning of the twenty-first century, people are apparently far more isolated than they were in the past. ...
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... 5,14,15 Preexisting mental health problems become exacerbated during a pandemic 16 and increased life concerns may leave some individuals particularly vulnerable to COVID-19-related stressors. 17 ...
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Communities of color in the United States have been disproportionately impacted by the COVID-19 pandemic. Studies exploring the mental health implications of these disparities have only just begun to emerge. The purpose of this study is to better understand mental health concerns and test whether social determinants of health and COVID-19-related experiences influence these concerns. In April 2020, we launched a community-based survey for adults across the United States. A total of 341 respondents completed the survey, which included questions about demographics, depression, social isolation, work environment, and preexisting mental health conditions. We generated matched controls by adding county data from the Robert Wood Johnson Foundation to our survey. Chi square, Pearson product-moment correlation, point biserial correlation, and logistic regression were estimated. Our analysis revealed that respondents who identified as Latinx, Latin@, or Hispanic were 10 times more likely to meet the threshold score for depression. Similarly, individuals with prior mental health conditions and those who expressed feelings of social isolation due to COVID-19 were 3 times more likely to meet the threshold score for depression. These results confirm our hypothesis that communities of color will likely experience disproportionate mental health impacts of COVID-19-specifically, the mental health sequela that emerge from exposure, cumulative burden, and social isolation. We discuss the implications for expanding access and quality of health and mental health services to address current inequities.
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Background It has been identified that military veterans have distinct experiences of loneliness and social isolation and, when comparing this community to other client groups with a PTSD diagnosis, veterans respond less favorably to treatment. However, the link between PTSD and loneliness for veterans remains insufficiently researched and it is unclear if there are effective interventions tackling this distinct experience of loneliness. Aims This systematic narrative review aimed to synthesize existing evidence incorporating elements of social connection, social isolation, and loneliness within interventions for military veterans with a diagnosis of PTSD, consequently aiming to examine the impact of such interventions upon this community. Methods Six databases were searched, utilizing relevant search criteria, with no date restrictions. Articles were included if they involved intervention or treatment for military veterans with PTSD and considered elements of social connection, social isolation, and/or loneliness. The initial search returned 202 papers. After exclusions, removal of duplications, and a reference/citation search, 28 papers remained and were included in this review. Results From the 28 studies, 11 directly addressed social isolation and two studies directly addressed loneliness. Six themes were generated: (i) rethinking the diagnosis of PTSD, (ii) holistic interventions, (iii) peer support, (iv) social reintegration, (v) empowerment through purpose and community, and (vi) building trust. Conclusions A direct focus upon social reintegration and engagement, psychosocial functioning, building trust, peer support, group cohesiveness and empowerment through a sense of purpose and learning new skills may mitigate experiential loneliness and social isolation for veterans with PTSD. Future research and practice should further explore the needs of the PTSD-diagnosed veteran community, seek to explore and identify potential common routes toward the development of PTSD within this community and consider bespoke interventions for tackling loneliness.
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