Loneliness

There is a strong social narrative that pregnancy and parenthood should be a time filled with new connection, a strong sense of community, and abundant social support. In reality many parents can feel incredibly lonely and disconnected. 

In this episode, Lynsey and Chrissy are joined by Dr Kate Adlington to discuss the emotional, social, and existential facets of loneliness and the specific issue of loneliness in the perinatal period. What drives it? What is the relationship between loneliness and mental illness? And what can be done about it?

Key references and resources:

• Loneliness Conceptual Review (What Works Centre for Wellbeing, 2019)
• “Juts snap out of it” - the experience of loneliness in women with perinatal depression: a meta synthesis of qualitative studies (Adlington et al, 2023)
• Solutions to perinatal loneliness (Naughton-Doe, 2024)
• Video - Where is the village that was promised? (Naughton-Doe, 2024) *content warning - reference to perinatal loss*
• Guardian article - It felt shameful: the profound loneliness of modern motherhood (Jones, 2024)

If you or someone you know is struggling with mental health difficulties, there is lots of help available. You can contact your primary care provider in the first instance, or if you are based in the UK the NHS perinatal mental health website will help you to find support in your local area.

Transcript

​ Hello and welcome to our podcast, Beyond Baby Blues. My name is Dr Chrissy Jayarajah. I'm a consultant perinatal psychiatrist working in London.

 And I'm Dr. Lynsey McAlpine. I'm a trainee psychiatrist also based in London.

 And today we're going to be talking about a really interesting topic, which is loneliness. in the perinatal period. And we know that loneliness is something that is experienced by lots of women, and we know this clinically, but we thought today we'll have a real deep dive into into loneliness and what it means and what we can do about it.

And we're really delighted to have our guest today, Dr. Katherine Adlington. 

Hi, Kate, welcome to the podcast. Thanks so much for joining us.

Thank you so much for inviting me.

 so Kate, can you tell our listeners a little bit about yourself?

Yeah, course. So I'm an ST5 registrar, academic trainee in general adult psychiatry, and I'm living and working in East London. 

And really I got interested in perinatal psychiatry when I was working on a mother and baby unit, um, during my early core training. yeah, I suppose I was really motivated by seeing The impact of poor mental health on mothers and, you know, more widely on their children and families, so since then I've kind of pursued some research around the perinatal period. 

 So I've worked less than full time for about eight years, and, um, done other stuff alongside my psychiatry training, And one of the things I did was a master's in mental health sciences research. And as part of that, I, did this research, into kind of loneliness, in the perinatal period alongside perinatal depression. 

 And what was it that drew you to that topic in particular?

Yes, so, i, um, I had two periods of maternity leave, um, in the last few years and, um, my first child was actually born in March 2020. 

So it's just a few days before the COVID pandemic and obviously the lockdown. And, it was obviously a time that was quite scary and, um, Very lonely in a way. My partner worked as a medical registrar. So I was on my own for long stretches and no one else really held my daughter for the first four months.

And so I spent a lot of time thinking about how that impacted my experience. And so when it came to choosing a master's project, it was really front and center of my mind. I was very lucky that my supervisor at UCL was a very experienced researcher as well in loneliness. So we decided to kind of explore its impact on perinatal mental health. 

Yeah, gosh, I meant to say earlier, congratulations on completing your master's and somehow fitting it around psychiatry training and two pregnancies and all of the other things that I know you're involved with.

 So last year, Kate, you published an excellent paper about your research into the perinatal loneliness, and I'll share the link to that paper in the show notes for any of our listeners that wants to take a look. We've also drawn from some other fantastic resources and in particular, I wanted to mention. Um, when I was preparing for this episode, I came across some brilliant stuff from the perinatal loneliness study based at the university of York, which included some great visual summaries of some of their findings. And again, I'll share the link to those resources in the show notes.

 So loneliness is something it's probably fair to say that most people will experience it at some point in their lives. But it's one of those things that's experienced differently by different people. And there are various different ways of defining it and conceptualizing it. So we should probably start with the basics. 

Kate, what do you mean when you're talking about loneliness?

So, loneliness is often defined as a kind of perceptual gap between someone's actual social relationships and what they desire and what they want. It's very much a personal experience, it is a person's perception, so whilst we can actually measure social isolation, so the number of social contacts, or the size of their social network, when it comes to loneliness, it is very much about a person's personal experience. So, you know, we talk about how someone can be in a room full of people, but still feel lonely. 

Yeah, that makes sense. And I guess conversely, then someone can have quite a limited number of social contacts, but still feel content with both the quantity and the quality of their social relationships in which case they might not feel lonely at all.

yeah, and there are different ways that we can Conceptualize different types of loneliness that people have talked about so there's emotional loneliness social loneliness or existential loneliness.

Emotional loneliness is thought about as this kind of disconnection from your significant others. So it's thinking about those close personal relationships, that perhaps you rely on day to day, where maybe you feel cared for or recognized or understood. And there's a sense that when you're emotionally lonely, that you don't have that close, personal connection with people around you. 

Whereas social loneliness is more about Your sense of belonging to a wider group or network. So the sense that you kind of don't fit into wider society. Maybe you don't feel like you've got opportunities to socialize, or you don't have social groups that you fit into. And I suppose, you know, as a new parent, a sense that you're disconnected from other, maybe, parent groups or networks. 

And then existential loneliness, I guess, is a bit more of a kind of philosophical idea that you perhaps fundamentally feel alone in the world. This sense that, you're born alone and maybe you die alone. And, for some people that's felt really strongly that you fundamentally kind of feel perhaps invisible or excluded, or that you don't really have a belonging or a purpose in the world.

Yeah, that's quite a helpful way of thinking about it. And the other thing that really struck me is that loneliness is not just an emotional experience. So we know that it's also got these cognitive elements and behavioral elements as well. So when people feel lonely, they're more likely to interpret the world in a certain way. 

And they can sometimes get trapped in what we'd call a vicious cycle, where their feelings and their thinking patterns will drive behaviors that make them more likely to be isolated. And more lonely, if that makes sense. So people can get trapped in a cycle of loneliness. 

I was thinking, um, Kate, about the social loneliness and that community and sense of belonging and how, I guess we might think that, oh, if you're a mum now, that's it. And you're going to be, you're going to be part of that mum group. In reality, there might be a conflict or feelings of loneliness arising because you don't feel you fit in with those mum groups or you're sort of mourning the loss of your old friendships, before you became a parent and may feel that, you know, your friends are going out and having a great time and doing the things you used to enjoy doing, but now you can't because you've got this baby to look after and that in itself can, almost feel like you're stuck between a rock and a hard place sometimes as a new parent.

I think you picked on a really important point that there's not really anything else like it where you get such a sudden and immediate overnight fracture between your old self and, and a new self, that loss of work identity, financial security, social identity, and it's up to you to create those social networks and those social groups, and actually it isn't a given that you're going to suddenly feel connection to them.

I think you're right that just because you're going along to parenting groups or, you know, you sign up for things, that, you might suddenly feel a part of these, um, new networks, but actually you can be going, you know, thinking, look how well everyone else is doing, and I'm not doing as well as them, or how are they managing this, and I'm not, and, it can actually make you feel worse, and more lonely, so, yeah, it's a really complicated time.

And that brings me to my next question is loneliness a common issue in the perinatal period. What do we know about the scale of the problem? 

So, um, there isn't a lot of research and there haven't been a lot of studies measuring parental or perinatal loneliness. So there are few polls, that had been published by charities. So there was a recent UK poll showed. Over half of parents had experienced loneliness since becoming a parent, and a fifth have felt lonely in the past week. And it seems to be that it's worse if you are younger or your children are younger, so another UK poll found that as many as a third of mothers under 25 a young child have felt lonely. And a bigger study in Finland found about a third of pregnant women felt lonely. And this is certainly higher than the general population. 

And so why is that experience so widespread, what's driving this loneliness or rather what are the barriers to connection?

it can be broken down into kind of cultural drivers and then structural drivers. And, um, we've talked a little bit about expectations, judgment, We already know there's a huge expectation on, on people around parenthood.

And there's an expectation in society that this, should be the happiest time of your life. And, and people should be, from the moment they find out they're pregnant, they should be jumping for joy. And we know within mental health, this often people from coming forward and talking about their mental health because they are already feeling stigmatized, that maybe they're not, feeling the way that they should be feeling, and this is true for loneliness as well.

So, you know, people, worry that they're feeling alone and lonely because, you know, they're thinking that they should, this should be the happiest time. Um, And I think it's true as well, you know, um, for, um, there are different kind of cultural expectations as well.

Yeah, absolutely. So I suppose just thinking a bit more about these cultural factors that that might drive loneliness, I guess there are some groups that might be more affected than others, or might be affected differently than other groups. Um, and there has been a little bit of research in recent years, thinking about fathers and non-birthing parents, and their experiences of loneliness. They sometimes describe feeling invisible or just not feeling as valued as a parent, which can be really hard.

And another group that might experience loneliness differently is LGBTQ parents who can sometimes have very different journeys to parenthood. Um, broadly speaking, our society can still be pretty heteronormative at times, especially in places like maternity services and parenting groups. And I think as a result of that, people can feel like these services are not designed for people like them. Which can lead to them, feeling excluded or feeling like they don't belong. 

Absolutely. And then they're obviously very practical structural drivers. So if you are experiencing poverty, then it's going to be more difficult to access support or social opportunities within your community. There's often a cost associated with these. 

We know in terms of welfare policies, there's, you know, women are often discriminated against. There is limited parental leave. Childcare is extremely expensive. Um, and if you're, if you're wanting to go back to work, actually there are huge barriers to that. There's the two child benefits cap. Um, Transport suddenly so much more difficult you're trying also transport a pram and a child um, and just spaces, are spaces accessible for, for people with children are the nappy changing facilities, is it breastfeeding friendly, is there somewhere to warm your milk, you know, all of these things can be barriers to finding meaningful connection

 one of the things, mentioned, in our show notes was digital exclusion. Can you tell us a little bit more about that? I've not heard about that before. 

So we, we live in a society that's very much online. Don't we. And I think increasingly if you want to connect with people or use healthcare services or any services, really, um, if you want to access anything, then you need to have a smartphone or a computer. And you need to be digitally literate. And that can be a real barrier for some people. 

So, for example, in some places you need to have a special app to book a GP appointment or request a repeat prescription from your pharmacy. Or you need to have a webcam and a good internet connection in order to access online support groups. And nowadays some parenting groups, antenatal classes are done online too.

And it's not just about having access to the technology. It's also about being able to use it effectively. So for example, with some of the psychiatric conditions that we work with, Um, people can develop paranoid beliefs about technology to the extent that they don't want to use it at all. Or, um, if someone has difficulties with executive function, for example, Um, things like apps and websites and logins can be really stressful and hard to navigate. 

 It's something that we sometimes miss as professionals. I think because a lot of this technology is so pervasive. We can be guilty of just assuming that everyone has similar levels of access, which is not always the case. 

And I was also thinking about the perinatal period where, it, it might be a plus, having support on social media if you can't get out of the house. That could be seen as a plus or you feel like digitally included, I guess, in an online community.

However, you could also flip that and feel quite digitally excluded if you maybe, for example, don't want to share yourself or your baby on social media, but other people do, or you're struggling to get onto groups or apps or whatever it is, um, if you don't have access. 

And I think even if things are online, they're not necessarily universally going to be experienced positively because I think that we were touching on kind of stigma and shaming and comparing, social media is the worst for, you know, influencers have had a baby two weeks ago and they're out and about or they're exercising or, talking about their body or whatever.

And actually that can really drive sense of shame, sense of, feeling not good enough. So it, that gets this amazing tool for kind of connection and finding your tribe online, but also, uh, it could also drive loneliness as well. 

And then alongside all of those structural factors that we've talked about. There's also individual risk factors that we knew kind of increase people's risk of loneliness. I suppose one group that comes to mind is parents whose babies need admissions to neonatal units. They can often have a completely different parenting journey. And of course they're spending a lot of time on the neonatal unit themselves, which can make it a lot harder to connect with other parents.

 I'd agree with you. And I think say if your baby is born premature and then, you're in hospital weeks before your actual due date it can be really, disjointed particularly if you say we're part of a group. Who were all expecting their baby at around the same time and then your baby comes earlier or late or is in hospital and that can be quite isolating and difficult. 

yeah, If you're a solo parent, if you're a refugee or migrant, if you're experiencing domestic abuse, if there's a language barrier, You know, if you're a younger patient or an older patient, and of these are also risk factors for, experiencing mental health difficulties. 

I think, It's really important to think about intersectionality here as well, so, you know, different forms of oppression and discrimination, such as racism, sexism, ableism, homophobia, they all intersect and overlap. And exacerbate each other. So it's really important, that we think about these when we're seeing people in our clinics and thinking about how, people from marginalized groups are probably experiencing, Discrimination and disadvantage in lots of different areas and this is increasing their risk of both loneliness and mental health difficulties.

So that brings us on to thinking a bit more about the relationship between loneliness and mental health. What's the link there.

 So there has been, you know, increasing interest in research into loneliness and mental illness over the past few years. And lots of the research has kind of focused on depression so far. And so there have been larger longitudinal studies that have shown that there is, uh, a very complex bi directional relationship between loneliness and depression. Um, so we know that, if you're depressed, you're ten times more likely to feel lonely. Similarly, if you are already lonely, you're more likely to become depressed. And if you're already depressed, if you're also lonely, the, the symptoms depression will be worse. 

But we don't really know why, and it's thought it's kind of complex, multifactorial, we've already, talked lots about the different, factors that, influence loneliness, and we know that's the case for mental illness as well. 

In terms of loneliness and perinatal depression, there's much less research and evidence. There is emerging evidence that women with perinatal depression are more likely to feel lonely, um, but we don't really know very much so there's more we need to look into and understand about this relationship.

And I imagine that was the sort of thinking behind your research then, which focused on the experience of loneliness specifically in women with perinatal depression.

Yeah. So, previously there were qualitative studies that were broadly exploring perinatal depression and, researchers found that loneliness experiences were coming up a lot, but there hadn't really been studies that exclusively looked at loneliness and perinatal depression. And there certainly haven't been any sort of overarching reviews on the topic. 

So with your research then, what were you trying to find out?

We wanted to explore kind of, what are these experiences of loneliness for women with perinatal depression in their own words and think, maybe, a little bit about what they felt was making the loneliness worse, what was causing loneliness and perhaps, also, what helped

and really take stock of what research is out there and try and get an overview of what studies have already been done to then perhaps guide future research in this area.

So, I guess the idea is that if we have a much more robust understanding of what's actually going on with perinatal loneliness, Um, that will help to inform any treatments or interventions or policy changes. So, how did you do this then? What did you do?

So we did a qualitative metasynthesis, is essentially a systematic review of qualitative papers. So you do a systematic search looking for all papers where women with perinatal depression have talked at some point about their experience of loneliness.

And then once you've gathered all those papers you systematically go through and you gather all that primary information mostly from women's own words, and then try and synthesize it and find themes. So it's finding kind of overarching themes that women have talked about when they're describing their experience of loneliness, and this is exclusively women with perinatal depression.

So, yeah, in lay terms, then what you've done is you've taken all of the qualitative research on this particular subject. And we should probably explain that qualitative research focuses on understanding people's experiences and their behaviors and opinions. It's all about getting an in depth understanding based on people's direct experiences. 

So you've taken all of this research and you've appraised and reviewed all of the evidence from these different studies and then try to pull it all together to understand what these studies, when they're taken together can tell us about loneliness and perinatal depression. 

Yeah, absolutely then, you say, try and interpret that and think, what does that mean for us in clinical practice? there any lessons we can learn from what women are saying about how their care could be better? Or are we doing, anything, that's helping them already? And what, maybe across society could be changed that might make their experience less lonely? 

Yeah. And I suppose a lot of the value in doing this sort of study is that. As we've mentioned before, there's lots of little bits of research all over the place in quite a scattered way. 

And I think as clinicians, it can be really tricky when there's lots of small pieces of research out there, that all touch on the same subject. It can be hard to know how to use all that information in our clinical practice, but doing something like this matter synthesis brings all together in a much more cohesive way that helps us to see how all this research fits together.

And particularly with qualitative research, studies often are quite small you know, by their nature, you can only really speak to and get rich feedback from a small number of women. And so you can kind of amplify the quality of the quality of research by trying to draw as many voices together as possible.

And one of the things that's really wonderful about qualitative research is that you get this incredibly rich depth of information and all comes from people's lived experience, which is so valuable in making sense of these complex issues.

Absolutely. And being able to use quotes in your results is just so powerful, actually, so, um, one woman said I remember going to a postnatal group and I thought you shouldn't be here. I just felt everyone else seemed so happy and so really pleased. So I just didn't go there again. Um, And another woman said, Although I had a lot of support from a lot of people, which should have made me ecstatic, I couldn't actually connect with it. Um, so it's quotes like this that we would gather and together, would build up into the themes that we found in the results

so when you went through all of these studies, what did you find out?

We ultimately ended up with 27 studies where women with perinatal depression had talked a lot about loneliness. Only one of those studies was exclusively focused on loneliness, so that goes to show that it hasn't been a huge focus of research and perhaps there is room for more studies that are exclusively looking at that.

But, interestingly, even though women weren't specifically being asked about loneliness. It was coming up when they, you know, when they were talking about their experience of perinatal depression. Most studies were looking at Postnatal depression, so there was not very much in pregnancy, which is another, perhaps a gap. And as I've touched on as well, 11 the 27 exclusively were exploring the experiences of women from marginalized groups. So loneliness was coming up, a lot for those women. 

So, when we were looking at what the experiences of loneliness and perinatal depression were, we came up with three kind of key themes. 

Um, so the first theme was around the interaction between depression and loneliness and stigma, really. And what we found is that women were experiencing stigma and judgment about their depression. And this fear judgment of being a bad mother made them feel very alone, and they linked that to loneliness. And then that also was quite self perpetuating, because it would mean that they self isolated, hid their depressive symptoms, and that would compound the feeling of loneliness. 

The second key theme we found was around a sense of emotional disconnection that was associated with their depression, but really fueled the loneliness.

So we've talked about that kind difficulty connecting with other mothers and there was this feeling that they were having quite kind of fake and inauthentic relationships with other mothers because they were having a very different experience to other mothers. Because they were often hiding it there was a disconnect and that made them feel more lonely. 

But that sense of disconnection was talked about in relation to their baby as well, that sense that they're with their baby all the time, but they can't feel a connection to it could make women feel very lonely. 

And that feels very relevant to our clinical practice because one of the symptoms that we often see is difficulty developing that bond with their baby. You know, it's part of the illness and it's something that gets better with treatment, but at the time, it's a really difficult and upsetting thing to experience.

Absolutely. And finally, also this disconnection with themselves that we talked about, kind of their past self, their past life, and not really being able to connect with past friendships, perhaps their work, you know, this, this total kind of change in their identity meant there was a sense of loss and loneliness as well.

And finally, I guess the third is a bit more about the lack of emotional support, lack of practical support, that made them feel lonely. So, if there wasn't support from their wider family, there wasn't support from their partner, if there was a gender imbalance in the caring That made them feel much more lonely as well.

And having gone through all of those themes, what were your reflections on what all of this means?

One of the things I found most interesting, quite often women had talked about healthcare professionals, and there was something around validation about their mental health and their depression and feeling listened to and feeling valued by the healthcare professionals that made them feel less lonely and conversely, if they felt they weren't being listened to, or they weren't able to access healthcare because of, a language barrier, or if they felt dismissed by the healthcare professional, that made them feel more lonely.

So for me, a big reflection was, you know, we do have the opportunity to make people feel listened to, to validate their experiences and feel less alone for that moment. And actually we can't underestimate the power that can have.

I think the other is around support groups and peer support groups and how it can be a slightly double edged sword because Women did talk about what could make loneliness better and peer support with mothers who understood their experience could be really powerful. So one woman said, Groups are a safe place to say this isn't the greatest time of my life, and getting some support that you're a good mum and that your baby does feel loved, even though you're not like, jumping up and down for joy and that it will get better. So there's this sense that, if, you have that meaningful connection where people understand and you don't feel judged and that they get your experience can be really powerful. 

But conversely, we just had before the quote from the woman where they said, Actually, I went there and I didn't feel understood and I just felt like I couldn't go back there. So there's something about how we are able to support women and connect them with other people who get their experience is really important. And it's quite a tricky question, really, when we're thinking about designing services and interventions is how we can meet that need.

Yeah. And I think it really speaks to the, the very personal and individual ways that people experienced loneliness that can be unique to every different person. So there's not going to be a one size fits all approach. And I suppose my reflection from listening to all of this is about the need to take a really nuanced and individualized approach to understanding how someone experiences loneliness. And what their own personal barriers to connection are rather than just trying to create generic interventions that are meant for everyone.

Yeah, and think that's particularly, important at the moment as there isn't a lot of research around interventions for loneliness in mental health populations. And you know, there's early evidence that suggests that some intervention can help with loneliness, but that doesn't necessarily mean it improves their mental health and vice versa.

 So actually in the absence of really any evidence base, what we have to do is listen to women, speak to them about what their experience of loneliness is, what they're experiencing as, barriers and trying to think about what you can offer and what there is available to help them create connections. 

So thinking about our own perinatal services, then I mean, bearing in mind the lack of evidence that we currently have for interventions. What do you think we should be doing to try to address loneliness?

I think just having a really good understanding of what kind support is available in the local community. What can you recommend, what would be right for them, maybe you're having a conversation with them about what they feel would be helpful.

I think one of the things I've taken from our conversation today is not to make assumptions about people's support networks and their subjective experience of that support. 

And another thought was about how people tend to get stuck in these cycles of loneliness. And there were various thinking patterns and feelings and behaviors that can then perpetuate that loneliness. And I suppose thinking about my own clinical practice, it really struck me that things like cognitive behavioral strategies could be really helpful in addressing that cycle. And those internal barriers to connection. 

And I was also thinking about the compassion focused approaches that we often use in perinatal mental health as well, which could be really valuable in addressing that negative self view and the self criticism. That can fuel a lot of the social and emotional loneliness that we talked about earlier.

 So I guess I totally agree with what you were saying earlier, Kate. Um, there's a real need to see the policy changes that will tackle those structural barriers and systemic problems that are really contributing to this widespread problem of loneliness but I'd also love to see more research looking at how we can help patients to address their own personal barriers. And I think there's a lot of scope for developing really positive interventions that that can make a huge difference.

Yeah, I really couldn't agree more

 So on that note, Kate, I just wanted to say, thank you so much for joining us today. It's been a really interesting chat and it's given us all a lot to think about

thank you so much. Thank you for inviting me. It's been so interesting talking to you both and I'd just like to say thank you as well to, the supervisor of this research, Professor Sonia Johnson, and also all of, um, the researchers I work with, and especially the patient advisory group who I worked with throughout.

So, yeah, thank you

and also thank you for the Royal College of Psychiatrists perinatal faculty for their support with the podcast as always, 

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