All The Lonely Clients

by Tim Clark

“So many people are shut up tight inside themselves like boxes, yet they would open up, unfolding quite wonderfully, if only you were interested in them.”

Sylvia Plath, Johnny Panic and the Bible of Dreams

Max* came to see me about some low back pain but it soon became clear the problem was more than just physical.

He couldn’t relax on the massage table. If I tried to move his arm or leg for him, the limb would invariably stiffen. He could not relinquish that much control.  

He loved to talk during his massages. Not just chitchat but real in-depth conversation about politics, art, music, current affairs, society at large. Talking with Max was intellectually stimulating but, for a bad multitasker like me, pretty exhausting. I sensed that he saw his time on the table as an opportunity to get out all the things he’d had on his mind but had no one to tell.

I, on the other hand, was hoping to offer him an opportunity to switch off what seemed to be an over-active mind, to give his nervous system a break from what I thought was hypervigilance.

After a treatment one day, I suggested that it might be easier for him to relax if we talked less while he was on the table. We discussed it. He didn’t like the idea. Said he could get all the silence he wanted at home.

What I thought I was saying to him was: “This is how I want to help you.” What I think he had heard was: “Shut up.” We said an amiable goodbye but he never came back.

That was about five years ago. I was just starting out as a massage therapist.

Though I can still understand why I said what I said, I look back at my experience with Max with some regret as an opportunity lost.

I wish I’d known then what I know now about loneliness.

What is Loneliness?

Loneliness is “the discrepancy between a person’s desired and actual social relationships”.[1]

This is very different to simply ‘being alone’. We can be alone and be perfectly content with our social relationships. Conversely, we can be surrounded by people and still feel completely cut off, even those who are objectively closest to us.

Therefore, it’s about our perception of the quality, not quantity, of our relationships. Researchers on loneliness use specific terms like ‘perceived social isolation’ or ‘subjective social isolation’ to distinguish it from ‘objective social isolation’, which simply means not having people around you.

I believe Max felt stifled by the silence of living alone but it’s hard to know if he would have openly identified as ‘lonely’; the social stigma around loneliness is pretty strong.

PD reflection idea: How would you feel if a client admitted to you that they were feeling lonely? What prejudices might come to the surface? Might you want to tell them to stop feeling sorry for themselves and just get out more? Might you move to ‘rescue’ or even befriend them yourself? What are your attitudes towards loneliness? Do you allow yourself to feel lonely? Where do you think your beliefs about loneliness come from?

Also, loneliness can be short-term or ongoing. Research suggests that most episodes of loneliness last less than one year but those that last longer tend to last for three years or more.[2] When it’s short-lived, it serves as a healthy motivator for us to re-establish social connections. When it hangs around, it becomes problematic and can lead to serious health problems.

Is Loneliness Prevalent?

The subjective nature of loneliness makes quantifying it a bit slippery. The stigma around loneliness may lead survey respondents to report not feeling lonely when they do. Still, there are some consistent patterns in the research.

Prior to the COVID-19 pandemic, the prevalence of ‘problematic’ loneliness in Australia was typically estimated at around 25-30%[3][4] and figures from the UK at that time are comparable.[5]

A study made during the first wave of COVID-19 lockdowns in 2020 suggested that 54% of Australians felt lonelier during COVID-19, compared with 61% of Britons and 66% of Americans.[6] It remains to be seen how the enforced social isolation of lockdowns will impact loneliness in the long term but, at any given time, we can assume about a quarter of the population is experiencing some degree of loneliness.

Who Does Loneliness Affect?

Research has consistently shown that loneliness is particularly widespread among young adults aged 18-25[7] [8] [9] [10] and least common in those aged over 65. In young people, loneliness is often associated with social anxiety and depression.[11][12]

In Australia, the groups that are most likely to experience ongoing, problematic loneliness are:

  • Single parents
  • People with a disability
  • Carers
  • Those from low-socio-economic backgrounds
  • Those with a migrant background
  • Those from non-english speaking backgrounds.[13]

Loneliness Vs Overall Health

Some of the most widely researched associated effects of loneliness are:

  • Increased blood pressure
  • Fragmented sleep
  • Increased hypothalamic pituitary adrenocortical activity (dysfunctional stress response)
  • Decreased inflammatory control
  • Diminished immunity
  • Depressive symptoms
  • Impaired cognitive performance.[14]

Loneliness Breeds Loneliness

Lonely people can have just as much ‘social capital’ as non-lonely people, which is to say they can be attractive, wealthy and intelligent. The difference is: they don’t make use of that capital because of what their experience of loneliness has taught them. The more time they spend feeling alienated from people, the less likely they are to seek out new social connections. They become distrustful, expecting to be negatively judged by others, and start to forget that they can actually cope with the challenges that accompany greater social connection.[15] It’s a “self-reinforcing loneliness loop”,[16] and hard to break out of once entrenched.

Can A Massage Therapist Help?

What could I have done differently if Max had admitted to feeling lonely?

It’s tricky to posit an evidence-based approach because generally there is inadequate research on the efficacy of interventions for loneliness.[17]

Also, we’re limited by our scope of practice and our professional ethics. We’re neither counsellors for our clients nor are we their friends but there are some common-sense things we can do to help:

Focus on the things we know massage can help with

Though the evidence base isn’t there for massage as a loneliness intervention per se, it is there for some of the symptoms, so treat what you know is treatable.

Give them an experience of trust

Lonely clients won’t trust easily, so a massage can help to remind them that connection and safety can coexist. (I harped on about how we can do this not long ago in this blog post.)

Encourage positive health behaviours…carefully

Lonely people may not be exposed to the kind of ‘social control’ that non-lonely people are exposed to, which is to say they might not have people around them to remind them of the things they could be doing to improve their health. It’s tricky, though, because there’s a risk of seeming intrusive or dominating which will only reinforce their resistance to change.[18] Gentle approaches like motivational interviewing could certainly be helpful, especially around basics like good sleep behaviours, diet and exercise.

Encourage clients to sustain social connections

Motivational approaches might also be useful to help clients consider ways to connect with the local community. Who knows? You might help your client think of something they wouldn’t have thought of on their own. Volunteer work or joining a group whose purpose is not solely ‘social’ seem to be the most helpful at reducing feelings of loneliness.[19] You might be able to help less mobile clients connect with a local ‘befriending’ service. Find out what is available in your local area so you can suggest it if the opportunity arises.

Be open to a chat, especially about the little things

Chatting with your client about the ordinary, day-to-day things they’ve been doing or challenges they’ve been facing can help to give them a sense that they are seen and that they matter, which can have positive flow-on effects for their health.[20] This is especially the case for people who live alone or don’t have someone to debrief with on a regular basis.

Be open to shows of appreciation

Prominent loneliness researcher John Cacioppo once said:

“Just getting support doesn’t actually make you feel very good. This is one of the reasons why when we do something for others, we tend to feel good.”[21]

Although the massage therapist/client relationship does not require reciprocity beyond payment, we can still accept gratitude, compliments or even small gifts from our clients without concern that a boundary has been crossed. Of course, we need to remain alert to potential manipulation but there are benefits for the client if we can show them that we have received their genuine gratitude and that it makes a positive difference to us.[22]

Refer for counselling

Because self-perpetuating client beliefs are so entwined with feelings of isolation, the best chance lonely people may have to get to the root of their loneliness is through counselling or psychology, where they can bring their beliefs to consciousness, then challenge them.[23] (If you’re unsure about referring for counselling, you might want to read this blog post from a couple of years back.)

So…

If I had my time again with Max, I would put empathy, warmth and unconditional positive regard at the top of my agenda. If he wanted to chat, I would chat. I would be interested. I would notice him.

It would leave me dealing with a tension between the quality of my massage and the quality of my interpersonal skills but sometimes we just have to get comfortable with those tensions and trust that our clients will find what they need in their own time.

While I may not have been ‘perfect’ for Max (whatever that means), chances are I’ve already helped other clients with their loneliness without even knowing it. That’s part of the magic of being a massage therapist.  

* not his real name

Further Reading

If you attended the AMT 2020 Virtual Conference, you’ll remember the terrific presentation from Alison Sim on motivational interviewing. Alison recommended Miller and Rollnick’s book, Motivational Interviewing (2012), and I notice that Miller and Rollnick (and Butler) also have a book specifically on Motivational Interviewing in Health Care (2007).

About the Author

Tim Clark is a massage therapist and psychotherapist in Melbourne. He wrote a great bio for this article but his dog ate it.

References


[1] Russell D., Peplau L.A., Cutrona C.E. (1980) The revised UCLA Loneliness Scale: Concurrent and discriminant validity evidence. Journal of Personality and Social Psychology 39(3), 472–480.

[2] Baker, D. (2012). All the lonely people: Loneliness in Australia, 2001–2009. The Australia Institute.

[3] Abbott, J., Lim, M., Eres, R., Long, K., & Mathews, R. (2018). The impact of loneliness on the health and wellbeing of Australians. InPsych, 40.

[4] Lim, M., Eres, R., & Peck, C. (2019). The young Australian loneliness survey: Understanding loneliness in adolescence and young adulthood.

[5] Office of National Statistics, UK (2018). Loneliness – What characteristics and circumstances are associated with feeling lonely?

[6] Lim, M., Lambert, G., Thurston, L., Argent, T., Eres, R., Qualter, P., Panayiotou, M., Hennessey, A., Badcock, J., Holt-Lunstad, J. (2020). Survey of Health and Wellbeing – Monitoring the Impact of COVID-19.

[7] Australian Loneliness Report (2018).

[8] Office of National Statistics, UK (2018). Loneliness – What characteristics and circumstances are associated with feeling lonely?

[9] Mullen, R.A., Tong, S., Sabo, R.T., Liaw, W.R., Marshall, J., Nease, D.E., Krist, A.H. & Frey, J.J. (2019). Loneliness in primary care patients: a prevalence study. The Annals of Family Medicine17(2), 108-115.

[10] Groarke, J.M., Berry, E., Graham-Wisener, L., McKenna-Plumley, P.E., McGlinchey, E. & Armour, C.(2020) Loneliness in the UK during the COVID-19 pandemic: Cross-sectional results from the COVID- 19 Psychological Wellbeing Study. PLoS ONE 15(9): e0239698.

[11] Australian Loneliness Report (2018) (see 7 for link)

[12] Lim, M., Eres, R., & Peck, C. (2019). The young Australian loneliness survey: Understanding loneliness in adolescence and young adulthood.

[13] Ending Loneliness Together (2020). Ending Loneliness Together in Australia.

[14] Cacioppo, J.T. & Cacioppo, S. (2014). Social Relationships and Health: The Toxic Effects of Perceived Social Isolation. Soc Personal Psychol Compass 8(2): 58–72. doi:10.1111/spc3.12087

[15] Cacioppo, J.T., Ernst, J.M., Burleson, M.H., McClintock, M.K., Malarkey, W.B., Hawkley, L.C., … & Berntson, G.G. (2000). Lonely traits and concomitant physiological processes: The MacArthur social neuroscience studies. International Journal of Psychophysiology35(2-3), 143-154. doi: 10.1016/S0167-8760(99)00049-5

[16] Hawkley, L. & Cacioppo, J.T. (2010). Loneliness Matters: A Theoretical and Empirical Review of Consequences and Mechanisms. Ann Behav Med 40(2). doi: 10.1007/s12160-010-9210-8

[17] Courtin, E. & Knapp, M. (2017). Social isolation, loneliness and health in old age: a scoping review. Health and Social Care in the Community 25(3), 799–812. doi: 10.1111/hsc.12311

[18] Thoits, P.A. (2011). Mechanisms Linking Social Ties and Support to Physical and Mental Health. Journal of Health and Social Behavior 52(2) 145 –161. doi: 10.1177/0022146510395592

[19] Jopling, K. (2020). Promising Approaches Revisited: Effective action on loneliness in later life. Campaign to End Loneliness.

[20] Thoits, P.A. (2011). Mechanisms Linking Social Ties and Support to Physical and Mental Health. Journal of Health and Social Behavior 52(2) 145 –161. doi: 10.1177/0022146510395592 (link at 18)

[21] Khazan, O. (2017). How Loneliness Begets Loneliness. The Atlantic.

[22] Thoits, P.A. (2011). Mechanisms Linking Social Ties and Support to Physical and Mental Health. Journal of Health and Social Behavior 52(2) 145 –161. doi: 10.1177/0022146510395592 (link at 18)

[23] Hawkley, L. & Cacioppo, J.T. (2010). Loneliness Matters: A Theoretical and Empirical Review of Consequences and Mechanisms. Ann Behav Med 40(2). doi: 10.1007/s12160-010-9210-8 (link at 16)

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Comments

  1. As always, great post. Thank you Tim.

  2. Excellent piece! Such a hard thing to evaluate and yet we face it so often so should be constantly looking at our management and coping strategies. Thanks!
    Love the suggested PD reflection too!

  3. Thanks so much Pavel and Michelle! Glad you found it helpful.

  4. Thank you Tim for another very timely and great post.
    G
    🙏🏽

  5. Awesome, in depth, and supportive read for therapists. So happy to have confirmed what often isnt spoken about. Great work Tim!!

  6. Great thought provoking read Tim. I myself, in the past, have had thoughts of ‘silence would be bliss’ with many clients, but your article highlights loneliness as one of the unspoken reasons people embrace massage as a therapy, regardless of how we perceive the benefits we bestow.

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