Lynne Malcolm: Loneliness, it's a growing concern globally and it can have a profound impact on our health and wellbeing.

Michelle Lim: Loneliness is defined as a subjective sense of social isolation. You could be around people but you still feel you do not have those meaningful connections with others, perhaps kind of feel like you're speaking the same language but not really quite understanding people around you or not really relating fully to those that you interact with on a daily basis.

Nick Duerden: Loneliness can be incredibly toxic, it's a toxic way to live. So the more we remove ourselves from society, the less we take care of ourselves, and that can lead long-term to all sorts of illness. It's as deadly as smoking, as deadly as cancer.

Lynne Malcolm: UK author Nick Duerden and, before him, Dr Michelle Lim from Swinburne University.

Hi, it's All in the Mind on RN, I'm Lynne Malcolm.

Most of us feel lonely to some extent, some time in our lives. It's a distressing way to be, and we find it difficult to talk about. It's surrounded by stigma, but according to a large survey exploring the loneliness levels of Australians, one in four of us are lonely.

Today we'll hear about the possible causes, and the strategies which could ease this social pain.

Dr Michelle Lim is the Scientific Chair for the Australian Coalition to End Loneliness. She'd previously done a large longitudinal study in the US on loneliness and social anxiety. Now she's working on the Australian Loneliness Report. It's a collaboration between Swinburne University and the Australian Psychological Society. The initial findings were released at the end of 2018, and a scientific paper from it is expected later this year.

Michelle Lim: When we kind of measured Australians in a sample of almost 2,000 across the nation, one in four Australians actually report quite problematic levels, so they are really on the higher end, way above what we call population norm. That's a bit worrying I think in my opinion. And what we do find is that loneliness is very much associate of lower quality of life for our health, and things like physical health symptoms which we never really quite got our heads around, so things like higher loneliness is associated with things like more nausea, more headaches, more stomach problems, and also depression, that increases your risk of depression and social anxiety.

One thing that we do know and definitely from my research in the US is that loneliness actually is an antecedent for more problematic mental health symptoms. That's not to say that just because you're lonely you definitely have a mental health problem, but if you are reporting loneliness, you're more likely to experience higher levels of, say, depression or social anxiety, or paranoia in non-clinical levels maybe in the next six months. So we do see this predictive relationship when we actually track these symptoms over time.

Lynne Malcolm: So when it comes to physical health, what's the mechanism between physical health and loneliness?

Michelle Lim: So there's a lot of research that looks at how loneliness shares the same neural pathways as physical pain, it's almost like if you want to think of loneliness as a social pain. So when we feel pain we process more stress in our body, so we have higher levels of cortisol and things like that, and those then actually affect our health. So if you think of loneliness a little bit as a social pain, sharing the same neural correlates as physical pain, it's no wonder that it stresses our body if we feel lonely. And it kind of makes sense, because if you think about the way humans function, we are almost safer as a group, but if you feel like no one has your back, even the way you survey your social environment is quite different.

So say, for example, if I am walking down a dark street with a stranger by myself versus someone I trust and I care about, the physiology of our bodies actually functions quite differently. So the context might be the same but who we are with actually depends on how we actually process whether that's actually a stressful task or not.

So I think we are just scratching the surface of actually the impact of loneliness on Australians, and this particular report is just giving us a hint as to where we should be investing our energies into, and understanding the true impact of loneliness on Australian health.

Lynne Malcolm: So what has this survey told us about who in our society are most affected by loneliness?

Michelle Lim: For this particular report it was fairly even. From other countries they are noting it's a spike at the start of life, adolescents to young adulthood, and another spike in the older adults, over 65 or 75, they are in the more vulnerable range. And I think it's because there's a loss of control of both of these age groups. One is trying to find their identity and trying to find who they are and they're going through life transitions of starting new schools, perhaps making new friendship groups, going out to work, those are huge challenges for young people. And then you have the other end which is marked with loss, loss of health, loss of partners, perhaps a bereavement or maybe a transition into aged care. So I think both ends really are vulnerable.

Lynne Malcolm: And how important is being in a relationship or having close connection with family?

Michelle Lim: I believe that is actually quite important. There's some indications that being married…of course we know the quality of those relationships do need to be measured as well, but living with someone or a spouse or a partner can buffer you, definitely not a guarantee, and also having not so much actually a number of people around you but meaningful family relationships.

We did find in this report that Australians are actually also really bad at having relationships with their neighbours. They may fare fairly well with friends and family but then when it comes to the community they are actually showing really very, very poor connections with those neighbours that they live with.

Lynne Malcolm: One of Michelle Lim's goals is to develop evidence based solutions for people who are lonely. Here are some of the strategies they're exploring:

Michelle Lim: One thing that we found within theoretical models of loneliness is that asking a lonely person to just join a group is not always helpful and that's because we do see an increase in hypervigilance in their brains, for example, and they have the skills, they have the social skills, they have access to these interactions but perhaps they might be feeling more threatened. So a lot of the interventions or solutions or programs that are designed to correct negative beliefs about others, perhaps correcting assumptions about those interactions may be quite helpful. But that's not to say that everyone will benefit from that, so there's not really a one-size-fits-all.

For example, perhaps if someone has what we call cognitive decline or perhaps they have poor memory, then a solution like that is not going to help because it's just going to put more stress on them. So what we often ask or try to figure out is the context in which a person sits in. Again, asking someone to join a group, for example, when they are not mobile isn't helpful either. So in this case I think solutions have to be I guess appropriate to the person receiving help or assistance or an intervention. So perhaps what we are looking at is not so much a one-size-fits-all, but we could look at a one-size-fits-most perhaps and go from there.

Lynne Malcolm: Dr Michelle Lim also runs Swinburne's Social Health and Wellbeing Laboratory. At this lab they help young people who are consumers of youth mental health services and who experience loneliness. Many of these young people have also gone through serious mental illness, or severe depression and anxiety.

Michelle Lim: The concept really is based on working on the strengths of the young person, getting them to identify those strengths, but also getting them to then build on their social confidence, to do what we call relationship hygiene skills, things that we know we should be doing but we don't, and keeping in mind as well that these young people that we work with have gone through significant trauma, so they have been also ostracised by their peers because maybe perhaps they've developed a serious mental illness. Often they have almost no friends or just one or two meaningful relationships and usually the family.

And so what we were trying to do here is to even just getting them to focus on increasing the meaning of one relationship as opposed to making new friends. And some of these mental health conditions do also come with significant social difficulties and what we call social cognition difficulties. What we did find though, that wasn't the barrier, I think what was the barrier was for them to also realise that they are an active participant in the way they interact with people and actually teach them how to build intimacy between two people, like showing gratitude to someone. How do you show support when someone tells you a piece of good news? How do you use your body to signal positive emotions, because we do know that lonely people, for example, they show lower positive emotion, and that's actually telling the other person that you're not ready to connect. So we are teaching them to show overtly those signs, so a willingness to connect with people.

Lynne Malcolm: So it's a series of social skills that you are helping them with.

Michelle Lim: I wouldn't call it social skills so much because they do know these things, I think it's more social confidence. And a lot of these things we know. If I tell you we should be expressing gratitude and saying more than thank you to the people that we love, that makes sense, but we just don't do those things. So getting them to identify their strengths and how to build on those strengths to then harness those relationships, those are really important skills that I think we all should be doing and we probably all do have the skills but we don't do them.

Lynne Malcolm: It's about nurturing relationships.

Michelle Lim: That's correct, and I think people often have this assumption that relationships are too hard and they hate things like small talk. But small talk has a function, for example. You know, I often hear people who are lonely saying 'I can't be bothered to make friends' or 'it's too hard because people are going to be non-receptive', or 'it's too hard to do small talk'. But actually the lonely person themselves can take control and actually can initiate those interactions that are positive and healthy, but it takes for them to actually put in some effort. And so things like making small talk might be not a natural thing that some people want to do but it's an opener for more meaningful interactions in the future. And you could have brief positive social interactions that can lead to something a bit more meaningful at the end of it. And people hold these assumptions on what friendships are. So a lot of it is trying to educate them around those things.

Lynne Malcolm: Dr Michelle Lim from Swinburne University.

You're with All in the Mind on RN, I'm Lynne Malcolm. We're discussing the growing concern around the world about the levels of loneliness people are feeling and the impact it can have on our physical and mental wellbeing.

Nick Duerden: This was the shocking thing. I have to be honest and say that I wasn't really aware of loneliness. I suppose I was aware but in the same way that we all are, without really recognising it or labelling it. And then as I started to research it more and more I realised that it can affect anyone, irrespective of age, race or class, it really can affect all of us at any time of our lives for all sorts of different reasons.

Lynne Malcolm: Nick Duerden, UK author of the book A Life Less lonely: What we can all do to lead more connected, kinder lives.

Nick Duerdan was asked to research and write about solutions to loneliness and social isolation after the senseless murder of British MP Jo Cox in 2016. Before her death, Jo Cox had set up a Commission on Loneliness.

Nick Duerden: Essentially we wanted to continue to shine a light on some of the work that she had started and could obviously no longer carry out. At first I started looking at all of the initiatives and charities around the country that she had been working to highlight, and then I took it worldwide because obviously the more people I spoke to, the more I learned on the subject and who loneliness and social isolation affects and why.

Lynne Malcolm: Amongst the scientists Nick Duerden spoke to was Steve Cole from the University of LA. He studies how loneliness affects our brains and our bodies, and here's what he found:

Nick Duerden: Essentially that loneliness kills, that loneliness can be incredibly toxic, it's a toxic way to live, he told me. His work involves looking at how psychological, social and economic conditions can turn into disease and death. So the more we remove ourselves from society, the less we take care of ourselves, and that can lead long-term to all sorts of illness. He was saying it's as deadly as smoking, as deadly as cancer, as deadly as anything else.

Lynne Malcolm: And you also spoke to John Cacioppo from the University of Chicago, and he demonstrated in his work just how much we need each other.

Nick Duerden: Yes, historically we've lived in communities for very good reasons. If we ever wanted to punish people in centuries gone by we would expel them from the community and they would be alone, and the suggestion there is when you are alone you're in danger. And that continues to this day, but the way in which we live today, we are all living alone more and more. We leave our towns and villages for cities, we have to start again. More and more people now are living in their own flats by themselves as single people than I think at any point in history. So this removes us from society, it destroys our human connections and that can have, John Cacioppo writes, a really negative effect on our outlook, on our health prospects, all areas of our life, and negatively it seems.

Lynne Malcolm: So what sort of a mindset can a lonely person develop over time, and how does that exacerbate the problem?

Nick Duerden: Steve Cole told me that there are two types of loneliness, one is transient and one is chronic. Transient loneliness is something that we can all feel whenever we have had a change in life. So if we do move from that small town to the city, if we do leave secondary school for university, or even if we move across town and have children, you can lose your social circle. If you are the first in that social circle to have children, you have to start again and you will feel transient loneliness. What the book strives to highlight is that there are lots of things that we can do if we are suffering transient loneliness, and most of us at some point in life will experience transient loneliness, but by its very meaning, it's fleeting.

Chronic loneliness is when we've been alone for a long time and we've developed a certain mindset because of it. We start to distrust the people around us, we believe that people are inherently if not evil then unfriendly. So we cocoon ourselves from them, and that's the point at which loneliness can feed into a deterioration of health, and it affects the blood cells, it affects the brain cells. And so the efforts of psychologists like Steve Cole and John Cacioppo is to rescue people while they are still just transiently lonely, before they tip into chronic.

Lynne Malcolm: And there are particular points that you can keep in mind in order to break out of that transient loneliness, aren't there.

Nick Duerden: There are. It's perhaps easier said than done. For the course of the book I spent many months speaking to all sorts of people who are really struggling with loneliness, and I was very aware it's all very well to say to them, 'Look, just reach out and talk to someone, connect to someone, join a group,' because they have to be ready for it. But really that's the only thing that we can do, is to try to reintroduce ourselves into a community. And at first that can seem quite a big ask. But I got the sense from everybody I talked to that everybody really does want to reach out and connect, we do want to talk, it is inherent in us still to be part of that community. And it only takes a little bit of effort to realise that others around us want to make just as much effort, and in that way you rebuild social connections one at a time, and slowly you will start to feel better about your situation. And crucially I guess you will learn that you're not alone, that none of us are alone, even if we feel we are, we're not.

Lynne Malcolm: There seems to be more and more of us now living alone too, and we are turning to our phones and technology for connection. Is this necessarily a bad thing? I mean, can't these technologies also be an invaluable tool for connection?

Nick Duerden: They absolutely can. Obviously it's not particularly healthy if we live exclusively on our phones, if we never look up to the world around us. But during the researching of the book I realised that technology can actually help us in all sorts of ways. It can be ways in which we connect with one another and introduce one another to everybody else around us, to the wider community. For those who are long-term unwell and are unable to leave the house, technology can be nothing less than a lifesaver really, it can keep you connected to the world in ways in which otherwise you simply couldn't do.

Lynne Malcolm: But you also suggest that conversation has fallen silent, as you put it. What do you mean by that?

Nick Duerden: Well, we talk with our thumbs now. If we are not sending texts or WhatsApps, we are simply sending an emoji in place of a discussion. So it has largely taken away the impulse that we have to communicate with one another. I took a train and a tube into the studio today, and everybody is on their phones. Just looking into our phones because our phones are purportedly more interesting than anything else or anybody else around us really takes us away from social connection itself. It makes us fall out of the habit of talking to people. And then sometimes there will be occasions when we will want to talk to people, perhaps even need to, but we don't know how to do it anymore because we are so used to communicating with our thumbs.

Lynne Malcolm: I was interested in a concept that you came across which originally I think has occurred in Japan, hikikomori. You found that Japan is particularly fixated on living through technology. Can you explain this concept of hikikomori?

Nick Duerden: I thought that was fascinating and it was something I had no concept of at all until I started researching the book. It's now a recognised term in Japan for people who haven't been out of the house and don't interact on a social level for more than six months at a time. And technology has facilitated that, so they've elected to do their studies online, they communicate with their friends online. So they can have parties but they do so via WhatsApp. So they are all in their own homes and really don't see anybody at all.

I spoke to some psychologists about it to get kind of an overview, and they told me that this is in many ways a very modern condition because they are enabled to do it firstly by technology but also a lot of the people who are hikikomori tend to still live at home with their parents and their parents have facilitated that sense of isolation, for whatever reason. And yes, they all do their shopping online, they file their homework online, they do their exams online, they talk to friends online. It was something that's identified in Japan, but this kind of thing goes on all over the world now.

So for the book I spoke to a young woman in New Jersey who was 24 years old, incredibly intelligent, very, very eloquent, who very rarely goes out of the house for all sorts of I guess complicated psychological reasons, but there are also a multitude of health issues that she is going through at the moment, and she consequently feels that going out into the outside world isn't safe for her anymore, and so she stays at home. But she doesn't want to become, in her words, a vegetable, she wants to be as socially engaged and switched on and informed as anybody else, and social media has allowed that, and the internet has allowed that.

So she could speak to me incredibly honestly via Skype. So we were looking at each other in the eye and she was telling me all sorts of personal information about her situation, but she wouldn't have been able to do that had we been face-to-face. She's become so comfortable with her screen that that is the only way that she can communicate. But she talks to people all over the world. She has a boyfriend in Taiwan whom she's never met but they are very close, they have co-written books of poetry together. She has friends in Australia and I think she said Poland, and she has psychological discussions with them. So what she was trying to tell me was that she was very, very engaged, but she understood that she had an issue but that she wasn't just forgotten and languishing at home beneath her duvet, she was still an active member of the world, just a modern member of the world and she could do it remotely.

And when I gently tried to press her on where she saw herself in five years she talked about at some point are re-entering the world. It seems that she loves her Taiwanese boyfriend very much and that at some theoretical level at the moment she would love to go and see him in Taiwan and re-join the world but at her own pace.

Lynne Malcolm: Whilst investigating some of the community initiatives which are set up to help connect people, Nick Duerden came across a number of call services which seemed to be quite effective for some people, such as 96-year-old Bob Lowe.

Nick Duerden: Bob Lowe was terrific. As you said, he is 96 years old. He lost his wife to dementia several years before I spoke to him, and he never entirely got over it, and I got the sense that he didn't particularly want to, he didn't want to forget his wife and move on. He didn't want to remarry, as certain friends suggested he do. His whole life was his wife. She died, she had dementia before and so he nursed her diligently for I think five years. And then suddenly the world as he knew it had closed off. He had children but they had their own lives, and even though they came to see him most weekends he found himself sitting at home surrounded by photographs on the mantelpiece of his wife whom he missed and mourned after every day. And for a while at least he felt very sorry for himself.

At one point I think he'd hurt his leg or his knee, and so he had to go to the doctor anyway, and he spoke to the nurse and he talked about how lonely he was. And the nurse said, 'Well look, what are you going to do about it? You can't just sit at home moaning, you have to do something, get up and do something about it.' And she commented on how nice his voice was and she said there are reading services for the blind, so he could read newspapers for the blind. And he thought, well, I've got nothing to lose, why not. So he did it, he found he really enjoyed it. If nothing else, it passed the time for him.

And then he started working in the studio as a studio manager, and suddenly he found himself gainfully employed again. And he was also I think the recipient of some of these phone calls that you mentioned earlier where people of all different ages from all different sorts of backgrounds have volunteered to talk to older lonely people in the community, so they don't meet, they just speak on the phone once every few weeks, maybe once a month, and they just share news. And the more Bob did this, the more he found that his loneliness was decreasing, and he became, in a way, a kind of poster boy for the whole initiative. So he's now been on TV a few times, he's given lots of talks in elder communities where he says that most of his audience are women because men are pretty much like he was, just staying at home and closing the door. Men tend to fall off the social map far easier than women, and he was trying to encourage both men and women to get out there and reengage. And he found the more he talked about it the better he felt. The hours in the day passed. He missed his wife no less, but it helped him get past day after day after day without her.

Lynne Malcolm: And did you get a sense overall that there are particular human qualities that we need to nurture more in our society to decrease the level of loneliness?

Nick Duerden: I know it sounds like a pat answer but I really got the sense that if we look up more, that would help an awful lot. But what I really found out is that everybody does want to connect, even if we only want to take a little step ourselves, if we all do it, that connection comes up again. And in the many months I spent research showing and writing the book, I just came across endless random acts of kindness, people just reaching out because they wanted to, because they felt it would make a difference. And it didn't just make a difference to the people they were trying to help, it helped them as well. It just reminds you that people are inherently good, and perhaps we need those reminders from time to time.

Lynne Malcolm: Nick Duerden, author of A Life Less Lonely: What we can all do to lead more connected, kinder lives.

Michelle Lim: What really saddens me I think is that sometimes when lonely people try to reach out, they may not reach out in very direct ways because they don't want to be a burden to other people. There is a stigma around loneliness that, you know, 'I shouldn't feel this way', or 'I'm lonely because I'm a loser', or some people conflate it with being depressed when they're not actually depressed. So that's really sad. And in many ways I feel that really to combat loneliness is not just with the person who's lonely but also to the people around them, to be more open, because saying hi and spending five minutes, yes, it might take up your time but it actually means a lot to that person. So I do think that we just need to be more compassionate as well with people who are trying to reach out, or just be a little bit more mindful. If your neighbour is asking you for a small little chat, hey, maybe she hasn't had that chat with anyone for the last two weeks. And it's really important for us to look out for other people around us as well, even if we are not feeling lonely.

Lynne Malcolm: Dr Michelle Lim, the Scientific Chair for the Australian Coalition to End Loneliness, from Swinburne University.

If anything raised in this program has caused you concern, contact Lifeline on 13 11 14, and head to the All in the Mind website where you'll find more support and links.

Thanks to producer Diane Dean and sound engineer Joe Wallace. I'm Lynne Malcolm, thanks for your company, bye for now.