Daniel Palamara and Professor Margaret Anne Carter

Introduction

Loneliness is an enduring public health concern.1 In Australia, over 100 organisations formed the Endling Loneliness Together collaboration in 2016 with the goal of halving loneliness in Australia by 2030.2 Their State of the Nation Report on Social Connection found that, in 2023, 15 per cent of adults were often or always lonely, with a further 25 per cent lonely some of the time.3

Loneliness is profoundly detrimental to both physical and mental health; and is strongly linked to both morbidity and mortality.4 It is also both a contributor to and consequence of many mental health conditions, especially depression,5 and is implicated in suicide.6 In fact, the impact of social relationships on health is greater than that of obesity or inadequate physical exercise and rivals that of smoking and alcohol consumption across all ages, sexes, and initial health status.7

Generally thought to broadly consist of social isolation and emotional isolation,8 and manifesting as a subjective and painful sense of lack, loneliness is difficult to quantify and even harder to address.9 While public health measures often focus on reducing social isolation through increasing opportunities for interactions, improving social skills or providing social support,10 it potentially falls to therapeutic interventions to help people resolve issues with emotional isolation. This is because loneliness is not, after all, synonymous with social isolation11 and is not necessarily ameliorated by more social relationships; it is more a question of quality than quantity.12

Because of this, loneliness and emotional isolation can derive from issues that are more relevant to counselling, such as problematic schema,13 social anxiety,14 maladaptive social cognitions,15 existential concerns and more.16

This semi-systematic narrative review examines how counselling engages with loneliness by asking how the professional literature understands and addresses this pervasive condition.

Methods and Results

A hybrid narrative17 and semi-systematic literature review18 was undertaken to develop a broad understanding (narrative review) of the concept of loneliness in a counselling context but in a reproducible way (semi-systematic review). Parameters for the single search term are shown in Table 1 and a PRISMA flow diagram is shown in Figure 1.

Figure 1. PRISMA 2020 flow diagram

The final review contained 38 peer-reviewed articles. Key characteristics of the studies are summarised in Table 2.

Eight studies did not define loneliness. Twenty-eight studies proposed definitions derived (in varying degrees) from the concept of loneliness originally proposed by Weiss (1973) which described loneliness as a combination of social isolation, stemming from a subjective lack of engagement with a satisfying social network, and emotional loneliness, stemming from a subjective lack of satisfactory relationships.19

Most of those 28 studies described loneliness as an affective state; a subjective experience arising from the felt or perceived gap between one’s actual versus their desired relationships. These studies largely rely on Peplau and Perlman's synthesis (1982), which extracted three key components of loneliness: it is unpleasant, stems from social insufficiency, and is subjective and therefore “not synonymous with social isolation”.20

Modalities

Fifteen counselling-relevant modalities were described in the studies, as shown in Table 2.

Not all studies presented a rationale for choosing a particular modality. When provided, rationales for choosing particular modalities generally focused on either their demonstrated effectiveness for working with loneliness or the plausible mechanisms by which the modality might address loneliness.

For instance, cognitive behavioural therapy was often selected because research shows it to be more effective than non-therapeutic interventions.21 Existential therapy treats loneliness and existential isolation as one of its core concerns,22 and reality therapy considers social relationships as fundamental to psychological flourishing23 The rationale for working with loneliness is therefore somewhat integral to these therapies.

Overall, the results suggest that – based on a consistent definition of loneliness and with the use of pre- and post-test measures – most counselling modalities resulted in statistically significant reductions in loneliness, though few studies included follow-up measurements of loneliness.

Discussion and Conclusion

Generally, loneliness was conceptualised in a consistent way within the studies in this review. This “standard” view of loneliness accords with the broadly accepted definition common in loneliness research. Arguably, this definition is insufficient in a counselling context.

Although the subjective element accords with the phenomenological aspect of person-centred counselling,29 a client’s subjective experience of loneliness is not always the best or final determiner of loneliness. For example, clients with a “social exclusion life trap”30 may not report loneliness despite objectively poor social connectedness.

Alternatively, clients may feel lonely simply because of their expectations and not because of their objective circumstances. For example, in the study of Aydın and Yasemin Kutlu31, older people in aged care with children living in the same city were subjectively lonelier than those who had never had children; potentially, the existence of absent children generates more loneliness than the non-existence of children. This is even more relevant to the existential reality of loneliness; as Ratanashevorn and Brown described in their case study,32 sometimes we can feel lonely because we aren’t aware of or will not accept the limits of intimacy. Loneliness is, after all, an existential reality33 and therefore our subjective response may reflect a lack of acceptance and responsibility more than a lack of connection.

In exploring the shortcomings of the “standard” definition of loneliness from a philosophical perspective, Seemann34 suggests that loneliness is actually poorly understood. For example, they ask whether it is possible to deny that someone is lonely if that is how they subjectively feel. This question is highly pertinent to a counselling setting and one that is not addressed by either the definition of or the measures of loneliness encountered in this review.

Therefore, although “…interventions must be grounded in an understanding of the lived experience of loneliness”,35 the therapist must also have an objective understanding of loneliness. A systematic review and thematic synthesis of 29 studies in non-clinical settings found that loneliness is experienced in a much more nuanced way than simply a lack of emotional connection; it is both psychological and contextual, involves feelings of meaningful connection and painful disconnection, and can be a general phenomenon or targeted at a specific person or specific relationship type.36 These insights are critical for counsellors attempting to understand the scope of loneliness in their clients and deploy suitable interventions as part of the necessary case conceptualisation process.

This narrative/semi-systematic review confirmed that a wide variety of counselling modalities have some effect on loneliness. A notable gap in the literature is the lack of a coherent rationale for modality selection; few studies empirically demonstrate how or why a particular intervention reduces loneliness.37

A further question relates to integration. Effective therapy often rests on the successful integration of multiple modalities.38 Few studies in the review integrated multiple modalities.39 Given that the effect of single psychological interventions on loneliness can be somewhat limited,40 future research is required to develop the integrative or even eclectic approaches that are likely to be critical for achieving enduring success.

Conclusion

Ethical and effective counselling hinges on suitable case conceptualisation, necessary for generating a map for the therapist to plan and implement interventions.41 Loneliness interventions are unlikely to be effective without “accurate definitions and understandings”,42 and so the first part of case conceptualisation hinges on counsellors recognising loneliness. To support effective and personalised treatment plans, case conceptualisation needs to be theoretical rich and integrate multiple theoretical perspectives.43

In conclusion, while a variety of counselling modalities appear to reduce loneliness, further research is needed to clarify their mechanisms and to support integrative approaches. Enhanced case conceptualisation that draws on multiple theoretical perspectives will be key to developing effective, personalised treatment plans for loneliness, as well as more research into how counselling understands and addresses loneliness. This also requires a better understanding of how clients experience loneliness – ultimately leading to a revised, counselling-specific definition of loneliness, and professional development opportunities for counsellors for working to address it.

Table 2. Studies reviewed in the context of counselling for loneliness.
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Notes: 1. Q-E – quasi-experimental design, RCT – randomised controlled trial, SCED – single-case experimental design.

Biography

Daniel Palamara is a diploma-qualified, ACA Level 1 member current completing a Master of Guidance in Counselling and working casually in private practice. Daniel also holds a Master of Arts in Sociology, a PhD in Earth Sciences, and is trained in Logotherapy.

Contact details: 0478 452 479 daniel.palamara@my.jcu.edu.au

Professor Margaret Anne Carter is highly respected within the counsellor education field as an academic, researcher and practitioner. Currently Margaret Anne is the discipline lead and coordinator of the postgraduate Guidance and Counselling course with James Cook University [Australia and Singapore].

Contact details: 0419 035 181 E: Margaret.carter@jcu.edu.au

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