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Patterns of loneliness in an immigrant population
Patterns of Loneliness in an Immigrant Population Alexander M. Ponizovsky and Michael S. Ritsner Loneliness has been recognized as a public health problem that requires the attention of clinicians and researchers both as a condition in itself and in its relation to other conditions. This study sought to examine the relationship between self-reported loneliness, psychological distress, and social support among immigrants. A community survey of 386 recent immigrants to Israel from the former Soviet Union was conducted using the Revised UCLA Loneliness Scale (R-UCLA-LS), Talbieh Brief Distress Inventory (TBDI), and Multidimensional Scale of Perceived Social Support (MSPSS). A cross-sectional design, and correlation and factor analyses were used to study the relationship between the studied variables.
The distress-related and distress-free patterns of loneliness were distinguished as independent constructs, each with a specific sphere of influence. Distress-related loneliness accounted for 56.3% and distress-free for 18.2% of the total variance in individual loneliness scores. Distress-related loneliness is a generalized negative experience embedded in an array of distress symptoms, while distress-free loneliness appears to be a normal psychological reaction to dissatisfaction with current friend support. An important implication of this study in mental health practice is the sensitivity to these differences when treating recent immigrants. © 2004 Elsevier Inc. All rights reserved.
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safety and security, and a spouse often provides it. Friends provide social integration, in which people share common interests and values. Reliable alliance, the assurance that tangible assistance will be available if needed, is generally available from the family. Guidance, including advice and information, is provided by significant persons in position of authority. Differential contribution of the unfulfilled social needs and provisions to loneliness of social isolation had not been explored to date. The symptomatic loneliness has been described often as a secondary symptom or a component of depression, not a condition in its own right.12-14 As a high correlation between measures of both constructs exists, not surprisingly some researchers define loneliness as a specific type of depression in the interpersonal domain or “interpersonal depression.”15-21 In contrast to those studies, the relationship of loneliness to psychological distress and its symptomatology22-26 has not been adequately explored. Immigration offers a unique opportunity to investigate the different types of loneliness reactions. Newly immigrated persons find themselves in a drastically different network of social relationships and experience multiple stressors, including losses.27-29 Indeed, studies have consistently found elevated levels of stress-related malaise and broad-based morbidity, along with decreased levels of social support, among immigrant groups when compared to native populations.24-34 Moreover, there is clear evidence that being a immigrant is a risk factor for the development of psychological disturbances and that this is related to social isolation.35 However,
ONELINESS, a pervasive feeling that undermines the health and quality of life of individuals, requires the attention of community-based mental health workers both as a condition in itself and as a component of other conditions.1-3 Loneliness is generally understood as the unpleasant feeling that takes place when one’s network of social relations is deficient in some important way, either quantitatively or qualitatively.4 The most typical situations precipitating loneliness include, among others, social uninvolvement of students,5,6 solitary living of the elderly,7,8 and cultural isolation of immigrants.9,10 Two major concepts of loneliness are discussed in the literature: loneliness resulting from social isolation and symptomatic loneliness. The former describes loneliness as a natural reaction of individuals to specific circumstances of life, such as loss, abandonment, and lack of social support11 resulting from dissatisfaction with current social relation provisions. According to Weiss,12 these relationships fulfill different interpersonal needs. Attachment confers a sense of From the Mental Health Services, Department of Research and Planning, Ministry of Health, Jerusalem, Israel; Sha’ar Menashe Mental Health Center, Hadera, Israel; and the Bruce Rappaport Faculty of Medicine, Technion, Haifa, Israel. Supported in part by the Ministry of Absorption (A.M.P.). Address reprint requests to Alexander Ponizovsky, M.D., Ph.D., Mental Health Services, Department of Research and Planning, Ministry of Health, 2 Ben Tabai St, Jerusalem 93591, Israel. © 2004 Elsevier Inc. All rights reserved. 0010-440X/04/4505-0026$30.00/0 doi:10.1016/j.comppsych.2004.03.011 408
Comprehensive Psychiatry, Vol. 45, No. 5 (September/October), 2004: pp 408-414
PATTERNS OF LONELINESS IN IMMIGRANTS
knowledge on the relationship among immigrant populations is lacking. In the present study, we investigated the above relationships among a large group of relatively recent immigrants to Israel from the former Soviet Union (FSU). The recent mass wave of Jewish immigration from the FSU brought more than 820,000 immigrants to Israel between 1990 and 1998 (Statistical Abstract of Israel 1997, Central Bureau of Statistics). Many of these immigrants obtained advanced education in their home country and are reasonably familiar with Western culture. Their arrival in relatively large numbers has provided most individuals with a common set of values. Moreover, the group relied on the former immigrants from the USSR that arrived during the 1970s as sociocultural facilitators. These factors may have contributed to buffer the untoward effects of the immigrant process. This study aimed (1) to examine the relationship among self-reported loneliness, symptoms of psychological distress, and sources of social support; and (2) to outline differential patterns of loneliness among Russian-born immigrants. We hypothesized there were two patterns of loneliness in this population: one related to distress and another not related. Knowledge of these patterns and influencing factors would enhance the sensitivity to these differences when treating recent immigrants.
409 Table 1. Sex and Age Distribution in Immigrant Population and Sample Population* Variable
Sex† Male Female Age (yr)‡ 18-24 25-34 35-44 45-59 60-74 Total
Sample
N
%
N
%
128,937 151,700
46.0 54.0
175 225
43.8 56.2
31,505 62,810 68,813 56,408 58,181 280,637
11.2 22.3 24.5 20.3 20.7 100.0
41 77 114 95 65 386
10.3 19.3 28.3 23.8 16.3 100.0
*Immigrant population: all adult immigrants from the FSU who arrived to Israel between 1989 and 1992 (State Statistics, 1993) †Population v Sample: 2 ⫽ 0.006, df ⫽ 1, not significant (NS). ‡Population v Sample: 2 ⫽ 6.41, df ⫽ 4, NS.
(SD ⫽ 2.7; range, 8 to 18 years); more than 65% of respondents had a university education and 7% had a Ph.D. degree. At the time of the survey, 59% of the respondents were employed, 10% were unemployed, 23% were housewives or retired, and 8% were students. Twelve percent of the respondents were single, 68% married, and 20% separated/divorced or widowed. Regarding family composition at arrival to Israel, 9% of the subjects were single, 12% were single-parent families, 55% had nuclear families, and 24% were members of three-generation families.
Measures METHOD
Sampling The sample consisted of Russian-born Jewish immigrants living in two cities with relatively high concentrations of immigrant residents (Jerusalem and Ashkelon). A list of immigrants’ addresses was obtained from the Ministry of Absorption. A random sample of 400 adult subjects was drawn from this list. In terms of gender and age, the sample did not differed from the adult immigrants that arrived in Israel from the FSU between 1989 and 1992 (Table 1). During a 6-month period in 1995, four trained research assistants visited the subjects on a “door to door” basis. The response rate was high: 96.5% of the subjects (N ⫽ 386) gave written informed consent after confidentiality was assured. The respondents completed self-administered questionnaires in their native language.
Subjects The sample included 56.5% women, with a mean age of 43.4 years (SD ⫽ 14.7; range, 18 to 80 years). Thirty percent of the participants came from the Ukraine and a similar proportion from Moscow. Ninety percent of the respondents had resided in Israel less than 5 years (mean ⫾ SD, 42.1 ⫾ 15.3 months; range, 6 to 66 months). Average years of education was 14.9
The Revised UCLA-Loneliness Scale (R-UCLA-LS). The R-UCLA-LS5 was administered to evaluate loneliness. It consists of 20 items where the respondent is requested to rate on a 1- to 4-point scale his/her situation for the past month. The range of potential scores is 20 to 80, with higher scores indicating a higher level of perceived loneliness. The reliability and validity of the scale have been well documented.36 In the present study, the Cronbach’s alpha reliability coefficient was 0.88. The R-UCLA-LS mean scores for no clinical population (college students, teachers, nurses, and elderly) were estimated in past studies5,36-40 and ranged from 39.9 to 50.4 (SD ⫽ 5.1 to 9.5). For suicide and accident survivors, the R-UCLA-LS means reported were 39.9 and 45.0, respectively,39 while for psychiatric inpatients it was 50.4.38 The Talbieh Brief Distress Inventory (TBDI). Psychological distress was assessed using the TBDI,41 a self-report questionnaire consisting of 24 items drawn from two previously developed scales: the Psychiatric Epidemiology Research Inventory– Demoralization Scale (PERI-D)42 and the Brief Symptom Inventory (BSI).43 General TBDI index and obsessive, hostility, sensitivity, depression, anxiety, and paranoid ideation symptom subscales were computed. Responses are scored on a 0- to 4-point scale, with higher scores indicating a higher level of distress and symptoms. Internal consistency and validity of the scale have been reported elsewhere.33 Three levels of psycho-
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PONIZOVSKY AND RITSNER Table 2. Correlation Matrix, Means, and Standard Deviations: Psychological Distress Symptoms, Depression Severity, Social Support From Family, Friends, and Significant Others, and Loneliness Measures
1
2
3
1. TBDI index 2. Obsessiveness 3. Hostility 4. Sensitivity 5. Depression 6. Anxiety 7. Paranoid ideation 8. MSPSS total 9. Family 10. Friends 11. Significant others 12. R-UCLA-LS
— .79 .72 .86 .91 .83 .68 ⫺.42 ⫺.34 ⫺.33 ⫺.36 .55
— .56 .66 .66 .59 .42 ⫺.27 ⫺.21 ⫺.18 ⫺.25 .34
— .59 .53 .55 .42 ⫺.30 ⫺.25 ⫺.24 ⫺.24 .35
Mean score SD
1.16 .70
1.13 .83
1.20 .87
4
5
6
7
8
9
10
11
12
— .74 .66 .55 ⫺.31 ⫺.26 ⫺.23 ⫺.27 .49
— .73 .54 ⫺.42 ⫺.32 ⫺.34 ⫺.37 .50
— .49 ⫺.32 ⫺.25 ⫺.25 ⫺.28 .46
— ⫺.31 ⫺.26 ⫺.27 ⫺.23 .56
— .80 .78 .86 ⫺.48
— .35 .59 ⫺.30
— .54 ⫺.51
— ⫺.36
—
.87 .79
1.21 .89
1.48 .90
1.77 .65
63.0 16.6
21.4 7.0
19.3 6.9
22.3 6.4
43.2 11.3
NOTE. All correlations are based on a sample size of 386 (correlation’s in excess of .14 are significant at P ⬍ .05). Abbreviations: TBDI, Talbieh Brief Distress Inventory; MSPSS, Multidimensional Scale of Perceived Social Support (Family, Friend and Significant other subscales); R-UCLA-LS, Revised UCLA Loneliness Scale.
logical distress according to the TBDI mean scores were determined: low distress (⬍1.2 for men and ⬍1.4 for women), moderate distress (1.21 to 1.95 and 1.41 to 1.96), and high distress (⬎1.95 and 1.96, respectively). The lower threshold was adopted from PERI-D and BSI normative rates for both sexes, while the upper one we developed empirically based on a sample of 125 immigrants with mental disorders seeking help in psychiatric outpatient clinics.44 For the given sample, the Cronbach’s alpha of the TBDI index and subscales ranged from 0.61 (for paranoid ideation) to 0.92 (general TBDI index). The Multidimensional Scale of Perceived Social Support (MSPSS). The MSPSS is a self-report instrument that assesses satisfaction with the support provided by family, friends, and significant others.45 It consists of 12 items, each of which describes those to whom the respondent would turn if he/she had any problems. Responses are scored on a 7-point scale from 1 (“completely disagree”) to 7 (“completely agree”). Scores ranged from 12 to 84, with a higher score indicating greater satisfaction with the total support network. The MSPSS cutoff point of 73 was empirically developed in our previous study of immigrants33 to distinguish subjects with significant support (⬎73) from those who did not have adequate support. This threshold was established by varying magnitude of the MSPSS total score to maximize simultaneously two proportions: (1) of those who had both a high social support and distress, and (2) of those who had neither social support nor distress. A magnitude of mean score as cutoff point for a social support was accepted when the balance between these two proportions had been reached. For the given sample, Cronbach’s alpha of the MSPSS dimensions ranged from 0.75 to 0.83. We used Russian versions of all the instruments, which were translated and culturally validated in our previous studies of immigrants.33,34,36 The time frame was the month preceding the survey. In addition, six sociodemographic variables—gender, age, marital status, family composition at arrival to Israel (single, single-parent family, nuclear family, and three-generation
family), years of education, and length of residence in Israel— were registered.
Data Analysis All analyses were performed using the Number Cruncher Statistical System (NCSS-2000; NCSS Statistical Software, Kaysville, UT). Analysis of covariance (ANCOVA) was employed to evaluate the main effects of the demographic variables on the variation in the loneliness scores after controlling for covariates. Two-tailed ttest and chi-square statistics were used to test the significance of differences in means and standard deviations, and proportions, respectively. A factor analysis by the principal axis method with varimax rotated factor matrix was performed to identify underlying factors (subsets of variables) from nine variables. Of the 12 initial variables, three (MSPSS total score, TBDI index, and paranoid ideation including loneliness item) were removed to avoid augmenting scores. The communality is the proportion of the variation of the variable that is accounted for by the factors that are retained. For all analyses, the level of statistical significance was defined as an alpha less than 0.05.
RESULTS
For the entire sample, the mean R-UCLA-LS score was moderate in magnitude, and the mean TBDI score was in the low range. The most prominent symptoms of psychological distress were paranoid ideation and anxiety. The mean MSPSS total score was under the threshold distinguishing subjects with and without appropriate social support (Table 2). As can be seen from Table 2, the loneliness score is moderately and positively associated with
PATTERNS OF LONELINESS IN IMMIGRANTS
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Table 3. Factor Analysis of Distress Symptoms, Social Support Sources, and Loneliness Measures Factor Loadings* Variable
Distress symptoms (TBDI) Obsessiveness Hostility Sensitivity Depression Anxiety Social support (MSPSS) Family Friends Significant others Loneliness (R-UCLA-LS) Eigenvalue Variance accounted for (%)
Distress-Related Loneliness
Social Support
Distress-Free Loneliness
Communality
⫺.770 ⫺.646 ⫺.829 ⫺.800 ⫺.762
.140 .154 .118 .223 .127
⫺.048 ⫺.134 ⫺.192 ⫺.251 ⫺.212
.615 .459 .739 .754 .643
.183 .104 .152 ⫺.385 3.14 56.3
⫺.641 ⫺.430 ⫺.816 .193 1.42 25.5
.141 .613 .249 ⫺.628 1.01 18.2
.464 .572 .750 .579 5.57 100.0
NOTE. Number in bold identity the highest factor loadings. *Rotated factor matrix ⬎0.4.
distress index and symptom scores, and moderately but negatively with social support scores. In turn, the negative correlations between distress symptoms and sources of social support are relatively low in magnitude. The results suggest distinctiveness of the loneliness, psychological distress, and social support constructs. ANCOVA was used to assess the main effects of gender, age (⬍45 v ⬎45 years), and family composition on the loneliness scores controlling for covariance sources (TBDI and MSPSS scores). The main effects were revealed for gender (F ⫽ 3.93, df ⫽ 1, 386, P ⫽ .002), family composition (F ⫽ 4.96, df ⫽ 2, 386, P ⫽ .007), and for the interaction between the two (F ⫽ 6.59, df ⫽ 2, 386, P ⫽ .0015), as well as for their interaction with age (F ⫽ 3.29, df ⫽ 4, 386, P ⫽ .011). The results suggest that older female subjects who arrived in Israel without a spouse perceive themselves as lonelier than their younger male counterparts from complete or three-generation families (F ⫽ 10.00, df ⫽ 1, 386, P ⫽ .002). Patterns of Loneliness To identify the main factors associated with loneliness, we performed an exploratory factor analysis for the entire sample. Tables 3 presents variables with an absolute loading greater than the amount set in the minimum loading option (⬎0.4). Three factors were identified on the highest eigenvalues. The first factor was constructed with loneliness and symptoms of psychological distress. The
second factor included neither loneliness nor distress, but only social support from family and significant others. Finally, the third factor included loneliness and social support from friends. Accordingly, the first factor was labeled a distress-related loneliness factor, the second a social support factor, and the third a distress-free loneliness factor. Correspondingly, the factors accounted for 56.3%, 25.5%, and 18.2% of the total variance among the nine measures. DISCUSSION
This is the first report on the relationship between self-reported loneliness, psychological distress, and social support in a large-scale sample of recent immigrants with major real-life stressors. We have many reasons to assume that people who immigrated to Israel will feel less lonely that those immigrating to other asylum countries. Unfortunately, due to the absence of published data on the subject, we could not directly test this assumption. Nevertheless, indirect comparisons have shown that the immigrants as a whole exhibit a higher level of experienced loneliness (43.2 mean score) than those in most no clinical population surveyed using the same loneliness instrument (RUCLA-LS). It was comparable with mean reporting for accident survivors—45.0,39 although it did not approach mean reported for psychiatric inpatients—50.4.40 Although we suggest that the differences are due to immigrant status, the effects of other cultural factors on the R-UCLA-LS scores
412
cannot be excluded. In contrast to previous studies in which greater feelings of loneliness were reported among older adults,8,15,46,47 we did not find a significant association with age when considered in isolation. However, combination of age with gender and family composition exerts the significant effect on the variation in the loneliness scores when psychological distress and social support variables were controlled. This finding suggests that the effects of distress and social support in producing profound experiences of loneliness are more salient than the impact of demographic factors. Because loneliness and distress share some characteristics, we tried to differentiate the loneliness patterns associated or not associated with components of general psychological malaise. The results of factor analysis confirm the hypothesized patterns of loneliness. For loneliness that is not associated with distress (factor 3), the main area of dissatisfaction focuses on social support from friends. This type of loneliness experience may be considered a normal psychological response defending an individual from distress. Experiencing loss of his/her friend support, such an individual is probably successful in keeping “perhaps the most important of all relationships—the relationship with the self.”48 Being connected to one’s inner feelings promotes a sense of self-identity and knowledge of how much one can rely on one’s own abilities in a self-sufficient and autonomic manner. The inability to maintain such inner connections has a tendency to dissolve positive self-esteem, to lower self-confidence, and to diminish trust in others even in the presence of external support systems. In severe instances, one’s bonds with reality may be severed, and replaced by withdrawal into a profound distress. This picture may be seen in the distress-related loneliness that seems to be a component (symptom) of an array of distress symptoms (factor 1). In general, the results of this study concerning symptomatic loneliness support and supplement earlier studies that have cited affective descriptions and correlates of loneliness.14,19,22 However, our findings demonstrate that not only symptoms specific for depression, but also other symptoms of general psychological distress are markedly associated with feelings of loneliness. Of particular interest is the relationship of loneliness to interpersonal sensitivity (low self-esteem) including feel-
PONIZOVSKY AND RITSNER
ings of personal inadequacy and inferiority, especially in comparison with others, negative expectations concerning communication and interpersonal behavior. However, not only self-depreciation, but also criticism of others plays an important role in symptomatic loneliness. The strong correlation of loneliness with paranoid ideation involving projective thought, hostility, suspiciousness, and fear of loss of autonomy supports this assumption. This pattern of psychological symptoms reflects the immigrants’ way of evaluating themselves as lonely, through separation from relationships or group memberships, and a trend toward self-isolation, avoidance, and rejection of others. Overall, the findings concerning symptomatic loneliness support Silove et al.’s18 conclusion that loneliness appears to be an integral aspect of general psychological distress rather than an independent determinant of such condition. It was shown that satisfaction with social support is the largest predictor of loneliness in elderly Korean immigrants in the United States, although the types of social support were not differentiated in that study.10 Our results also demonstrate the role of specific types of social support in the development of loneliness of social isolation. Comparing the two factors, one containing loneliness and one not (factor 3 and 2), we find that only dissatisfaction with support from friends (high positive loading on factor 3) precipitates loneliness experiences, while lack of social support from family and significant others (high negative loading on factor 2) does not. The results suggest that among the different interpersonal needs, satisfaction of need in social integration providing by friends could prevent an individual from loneliness of social isolation in the same degree as fulfilled needs in attachment, reliable alliance, and guidance providing by family and significant others. Several limitations of the present study should be addressed. Few self-report variables assessing no pathological phenomenon of loneliness were included in the design, e.g., having a non-Jewish spouse, number of friends among Israelis, leaving behind significant others, or companionship in the workplace. We suggest, however, that using social support instrument measuring emotional help and satisfaction with the support provided from family, friends, and significant others covers at least some of these important factors. Since the present study relies entirely on self-report measures, our findings
PATTERNS OF LONELINESS IN IMMIGRANTS
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are inevitably limited to the immigrants’ subjective experience of psychological symptoms, not diagnosable psychiatric disorders. Because of the uniqueness of the given immigrant population, we cannot generalize our findings to include other immigrant groups to Israel and worldwide. Nonetheless, we suggest that the findings of this study have important implications for health care providers by showing the differential patterns of loneliness. One is a sufficiently consistent and salient component of general psychological distress requiring appropriate intervention. Another repre-
senting a natural response to dissatisfaction with current social provisions may serve as a defensive mechanism from psychological distress. Sensitivity to these differences is needed in practice with recent immigrants. Further prospective investigations of this important issue should include more stress and coping measures to extend the perspectives of the present findings. ACKNOWLEDGMENT The authors acknowledge with appreciation the assistance of Dr. S. Safro and Dr. M.C. Ryan.
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ness, and suicide ideation in an Asian student population: a test of a model. Suicide Life Threat Behav 1990;24:127-139. 15. Ryan MC. The relationship between loneliness, social support, and decline in cognitive function in the hospitalized elderly. J Gerontol Nurs 1998;24:19-27. 16. Curtona CE. Transition to college: loneliness and the process of social adjustment. Loneliness: A Sourcebook of Current Research, Theory, and Therapy. In: Peplau LA, Perlman D. New York, NY: Wiley, 1982:291-309. 17. Rockach A. Antecedents of loneliness: factorial analysis. J Psychol 1989;123:269-384. 18. Silove D, Sinnerbrink I, Field A, Manicavasagar V, Steel Z. Anxiety, depression and PTSD in asylum-seekers: associations with pre-migration trauma and post-migration stressors. Br J Psychiatry 1997;170:351-357. 19. Blatt SJ, Zuroff DC. Interpersonal relatedness and selfdefinition: two prototypes for depression. Clin Psychol Rev 1992;12:527-562. 20. Jones WH. Loneliness and social behavior. In: Peplau LA, Perlman D (eds). Loneliness: A Sourcebook of Current Research, Theory, and Therapy. New York, NY: Wiley, 1982: 238-252. 21. Horowitz LM, de Sales French R. Interpersonal problems of people who describe themselves as lonely. J Consult Clin Psychol 1982;47:762-764. 22. Schachter EP, Zlotogorsky Z. Self-critical and dependent aspects of loneliness. Isr J Psychiatry Relat Sci 1995;32:205211. 23. Joiner TE Jr. Shyness and low social support as interactive diatheses, with loneliness as mediator: testing an interpersonal-personality view of vulnerability to depressive symptoms. J Abnorm Psychol 1997;106:386-394. 24. Penninx BW, van Tilburg T, Kriegsman DM, et al. Effects of social support and personal coping resources on mortality in older age: the longitudinal aging study in Amsterdam. Am J Epidemiol 1997;146:510-519. 25. Coyne JC. Self-reported distress: analog or Ersatz depression? Psychol Bull 1994;116:29-45. 26. Hsu LR, Hailey BJ, Range LM. Cultural and emotional components of loneliness and depression. J Psychol 1987;121: 61-70. 27. Ginter EL, Glauser A, Richmond BO. Loneliness, social support and anxiety among two South Pacific cultures. Psychol Rep 1994;74:875-879.
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The distress-related and distress-free patterns of loneliness were distinguished as independent constructs, each with a specific sphere of influence. Distress-related loneliness accounted for 56.3% and distress-free for 18.2% of the total variance in individual loneliness scores. Distress-related loneliness is a generalized negative experience embedded in an array of distress symptoms, while distress-free loneliness appears to be a normal psychological reaction to dissatisfaction with current friend support. An important implication of this study in mental health practice is the sensitivity to these differences when treating recent immigrants. © 2004 Elsevier Inc. All rights reserved.
L
safety and security, and a spouse often provides it. Friends provide social integration, in which people share common interests and values. Reliable alliance, the assurance that tangible assistance will be available if needed, is generally available from the family. Guidance, including advice and information, is provided by significant persons in position of authority. Differential contribution of the unfulfilled social needs and provisions to loneliness of social isolation had not been explored to date. The symptomatic loneliness has been described often as a secondary symptom or a component of depression, not a condition in its own right.12-14 As a high correlation between measures of both constructs exists, not surprisingly some researchers define loneliness as a specific type of depression in the interpersonal domain or “interpersonal depression.”15-21 In contrast to those studies, the relationship of loneliness to psychological distress and its symptomatology22-26 has not been adequately explored. Immigration offers a unique opportunity to investigate the different types of loneliness reactions. Newly immigrated persons find themselves in a drastically different network of social relationships and experience multiple stressors, including losses.27-29 Indeed, studies have consistently found elevated levels of stress-related malaise and broad-based morbidity, along with decreased levels of social support, among immigrant groups when compared to native populations.24-34 Moreover, there is clear evidence that being a immigrant is a risk factor for the development of psychological disturbances and that this is related to social isolation.35 However,
ONELINESS, a pervasive feeling that undermines the health and quality of life of individuals, requires the attention of community-based mental health workers both as a condition in itself and as a component of other conditions.1-3 Loneliness is generally understood as the unpleasant feeling that takes place when one’s network of social relations is deficient in some important way, either quantitatively or qualitatively.4 The most typical situations precipitating loneliness include, among others, social uninvolvement of students,5,6 solitary living of the elderly,7,8 and cultural isolation of immigrants.9,10 Two major concepts of loneliness are discussed in the literature: loneliness resulting from social isolation and symptomatic loneliness. The former describes loneliness as a natural reaction of individuals to specific circumstances of life, such as loss, abandonment, and lack of social support11 resulting from dissatisfaction with current social relation provisions. According to Weiss,12 these relationships fulfill different interpersonal needs. Attachment confers a sense of From the Mental Health Services, Department of Research and Planning, Ministry of Health, Jerusalem, Israel; Sha’ar Menashe Mental Health Center, Hadera, Israel; and the Bruce Rappaport Faculty of Medicine, Technion, Haifa, Israel. Supported in part by the Ministry of Absorption (A.M.P.). Address reprint requests to Alexander Ponizovsky, M.D., Ph.D., Mental Health Services, Department of Research and Planning, Ministry of Health, 2 Ben Tabai St, Jerusalem 93591, Israel. © 2004 Elsevier Inc. All rights reserved. 0010-440X/04/4505-0026$30.00/0 doi:10.1016/j.comppsych.2004.03.011 408
Comprehensive Psychiatry, Vol. 45, No. 5 (September/October), 2004: pp 408-414
PATTERNS OF LONELINESS IN IMMIGRANTS
knowledge on the relationship among immigrant populations is lacking. In the present study, we investigated the above relationships among a large group of relatively recent immigrants to Israel from the former Soviet Union (FSU). The recent mass wave of Jewish immigration from the FSU brought more than 820,000 immigrants to Israel between 1990 and 1998 (Statistical Abstract of Israel 1997, Central Bureau of Statistics). Many of these immigrants obtained advanced education in their home country and are reasonably familiar with Western culture. Their arrival in relatively large numbers has provided most individuals with a common set of values. Moreover, the group relied on the former immigrants from the USSR that arrived during the 1970s as sociocultural facilitators. These factors may have contributed to buffer the untoward effects of the immigrant process. This study aimed (1) to examine the relationship among self-reported loneliness, symptoms of psychological distress, and sources of social support; and (2) to outline differential patterns of loneliness among Russian-born immigrants. We hypothesized there were two patterns of loneliness in this population: one related to distress and another not related. Knowledge of these patterns and influencing factors would enhance the sensitivity to these differences when treating recent immigrants.
409 Table 1. Sex and Age Distribution in Immigrant Population and Sample Population* Variable
Sex† Male Female Age (yr)‡ 18-24 25-34 35-44 45-59 60-74 Total
Sample
N
%
N
%
128,937 151,700
46.0 54.0
175 225
43.8 56.2
31,505 62,810 68,813 56,408 58,181 280,637
11.2 22.3 24.5 20.3 20.7 100.0
41 77 114 95 65 386
10.3 19.3 28.3 23.8 16.3 100.0
*Immigrant population: all adult immigrants from the FSU who arrived to Israel between 1989 and 1992 (State Statistics, 1993) †Population v Sample: 2 ⫽ 0.006, df ⫽ 1, not significant (NS). ‡Population v Sample: 2 ⫽ 6.41, df ⫽ 4, NS.
(SD ⫽ 2.7; range, 8 to 18 years); more than 65% of respondents had a university education and 7% had a Ph.D. degree. At the time of the survey, 59% of the respondents were employed, 10% were unemployed, 23% were housewives or retired, and 8% were students. Twelve percent of the respondents were single, 68% married, and 20% separated/divorced or widowed. Regarding family composition at arrival to Israel, 9% of the subjects were single, 12% were single-parent families, 55% had nuclear families, and 24% were members of three-generation families.
Measures METHOD
Sampling The sample consisted of Russian-born Jewish immigrants living in two cities with relatively high concentrations of immigrant residents (Jerusalem and Ashkelon). A list of immigrants’ addresses was obtained from the Ministry of Absorption. A random sample of 400 adult subjects was drawn from this list. In terms of gender and age, the sample did not differed from the adult immigrants that arrived in Israel from the FSU between 1989 and 1992 (Table 1). During a 6-month period in 1995, four trained research assistants visited the subjects on a “door to door” basis. The response rate was high: 96.5% of the subjects (N ⫽ 386) gave written informed consent after confidentiality was assured. The respondents completed self-administered questionnaires in their native language.
Subjects The sample included 56.5% women, with a mean age of 43.4 years (SD ⫽ 14.7; range, 18 to 80 years). Thirty percent of the participants came from the Ukraine and a similar proportion from Moscow. Ninety percent of the respondents had resided in Israel less than 5 years (mean ⫾ SD, 42.1 ⫾ 15.3 months; range, 6 to 66 months). Average years of education was 14.9
The Revised UCLA-Loneliness Scale (R-UCLA-LS). The R-UCLA-LS5 was administered to evaluate loneliness. It consists of 20 items where the respondent is requested to rate on a 1- to 4-point scale his/her situation for the past month. The range of potential scores is 20 to 80, with higher scores indicating a higher level of perceived loneliness. The reliability and validity of the scale have been well documented.36 In the present study, the Cronbach’s alpha reliability coefficient was 0.88. The R-UCLA-LS mean scores for no clinical population (college students, teachers, nurses, and elderly) were estimated in past studies5,36-40 and ranged from 39.9 to 50.4 (SD ⫽ 5.1 to 9.5). For suicide and accident survivors, the R-UCLA-LS means reported were 39.9 and 45.0, respectively,39 while for psychiatric inpatients it was 50.4.38 The Talbieh Brief Distress Inventory (TBDI). Psychological distress was assessed using the TBDI,41 a self-report questionnaire consisting of 24 items drawn from two previously developed scales: the Psychiatric Epidemiology Research Inventory– Demoralization Scale (PERI-D)42 and the Brief Symptom Inventory (BSI).43 General TBDI index and obsessive, hostility, sensitivity, depression, anxiety, and paranoid ideation symptom subscales were computed. Responses are scored on a 0- to 4-point scale, with higher scores indicating a higher level of distress and symptoms. Internal consistency and validity of the scale have been reported elsewhere.33 Three levels of psycho-
410
PONIZOVSKY AND RITSNER Table 2. Correlation Matrix, Means, and Standard Deviations: Psychological Distress Symptoms, Depression Severity, Social Support From Family, Friends, and Significant Others, and Loneliness Measures
1
2
3
1. TBDI index 2. Obsessiveness 3. Hostility 4. Sensitivity 5. Depression 6. Anxiety 7. Paranoid ideation 8. MSPSS total 9. Family 10. Friends 11. Significant others 12. R-UCLA-LS
— .79 .72 .86 .91 .83 .68 ⫺.42 ⫺.34 ⫺.33 ⫺.36 .55
— .56 .66 .66 .59 .42 ⫺.27 ⫺.21 ⫺.18 ⫺.25 .34
— .59 .53 .55 .42 ⫺.30 ⫺.25 ⫺.24 ⫺.24 .35
Mean score SD
1.16 .70
1.13 .83
1.20 .87
4
5
6
7
8
9
10
11
12
— .74 .66 .55 ⫺.31 ⫺.26 ⫺.23 ⫺.27 .49
— .73 .54 ⫺.42 ⫺.32 ⫺.34 ⫺.37 .50
— .49 ⫺.32 ⫺.25 ⫺.25 ⫺.28 .46
— ⫺.31 ⫺.26 ⫺.27 ⫺.23 .56
— .80 .78 .86 ⫺.48
— .35 .59 ⫺.30
— .54 ⫺.51
— ⫺.36
—
.87 .79
1.21 .89
1.48 .90
1.77 .65
63.0 16.6
21.4 7.0
19.3 6.9
22.3 6.4
43.2 11.3
NOTE. All correlations are based on a sample size of 386 (correlation’s in excess of .14 are significant at P ⬍ .05). Abbreviations: TBDI, Talbieh Brief Distress Inventory; MSPSS, Multidimensional Scale of Perceived Social Support (Family, Friend and Significant other subscales); R-UCLA-LS, Revised UCLA Loneliness Scale.
logical distress according to the TBDI mean scores were determined: low distress (⬍1.2 for men and ⬍1.4 for women), moderate distress (1.21 to 1.95 and 1.41 to 1.96), and high distress (⬎1.95 and 1.96, respectively). The lower threshold was adopted from PERI-D and BSI normative rates for both sexes, while the upper one we developed empirically based on a sample of 125 immigrants with mental disorders seeking help in psychiatric outpatient clinics.44 For the given sample, the Cronbach’s alpha of the TBDI index and subscales ranged from 0.61 (for paranoid ideation) to 0.92 (general TBDI index). The Multidimensional Scale of Perceived Social Support (MSPSS). The MSPSS is a self-report instrument that assesses satisfaction with the support provided by family, friends, and significant others.45 It consists of 12 items, each of which describes those to whom the respondent would turn if he/she had any problems. Responses are scored on a 7-point scale from 1 (“completely disagree”) to 7 (“completely agree”). Scores ranged from 12 to 84, with a higher score indicating greater satisfaction with the total support network. The MSPSS cutoff point of 73 was empirically developed in our previous study of immigrants33 to distinguish subjects with significant support (⬎73) from those who did not have adequate support. This threshold was established by varying magnitude of the MSPSS total score to maximize simultaneously two proportions: (1) of those who had both a high social support and distress, and (2) of those who had neither social support nor distress. A magnitude of mean score as cutoff point for a social support was accepted when the balance between these two proportions had been reached. For the given sample, Cronbach’s alpha of the MSPSS dimensions ranged from 0.75 to 0.83. We used Russian versions of all the instruments, which were translated and culturally validated in our previous studies of immigrants.33,34,36 The time frame was the month preceding the survey. In addition, six sociodemographic variables—gender, age, marital status, family composition at arrival to Israel (single, single-parent family, nuclear family, and three-generation
family), years of education, and length of residence in Israel— were registered.
Data Analysis All analyses were performed using the Number Cruncher Statistical System (NCSS-2000; NCSS Statistical Software, Kaysville, UT). Analysis of covariance (ANCOVA) was employed to evaluate the main effects of the demographic variables on the variation in the loneliness scores after controlling for covariates. Two-tailed ttest and chi-square statistics were used to test the significance of differences in means and standard deviations, and proportions, respectively. A factor analysis by the principal axis method with varimax rotated factor matrix was performed to identify underlying factors (subsets of variables) from nine variables. Of the 12 initial variables, three (MSPSS total score, TBDI index, and paranoid ideation including loneliness item) were removed to avoid augmenting scores. The communality is the proportion of the variation of the variable that is accounted for by the factors that are retained. For all analyses, the level of statistical significance was defined as an alpha less than 0.05.
RESULTS
For the entire sample, the mean R-UCLA-LS score was moderate in magnitude, and the mean TBDI score was in the low range. The most prominent symptoms of psychological distress were paranoid ideation and anxiety. The mean MSPSS total score was under the threshold distinguishing subjects with and without appropriate social support (Table 2). As can be seen from Table 2, the loneliness score is moderately and positively associated with
PATTERNS OF LONELINESS IN IMMIGRANTS
411
Table 3. Factor Analysis of Distress Symptoms, Social Support Sources, and Loneliness Measures Factor Loadings* Variable
Distress symptoms (TBDI) Obsessiveness Hostility Sensitivity Depression Anxiety Social support (MSPSS) Family Friends Significant others Loneliness (R-UCLA-LS) Eigenvalue Variance accounted for (%)
Distress-Related Loneliness
Social Support
Distress-Free Loneliness
Communality
⫺.770 ⫺.646 ⫺.829 ⫺.800 ⫺.762
.140 .154 .118 .223 .127
⫺.048 ⫺.134 ⫺.192 ⫺.251 ⫺.212
.615 .459 .739 .754 .643
.183 .104 .152 ⫺.385 3.14 56.3
⫺.641 ⫺.430 ⫺.816 .193 1.42 25.5
.141 .613 .249 ⫺.628 1.01 18.2
.464 .572 .750 .579 5.57 100.0
NOTE. Number in bold identity the highest factor loadings. *Rotated factor matrix ⬎0.4.
distress index and symptom scores, and moderately but negatively with social support scores. In turn, the negative correlations between distress symptoms and sources of social support are relatively low in magnitude. The results suggest distinctiveness of the loneliness, psychological distress, and social support constructs. ANCOVA was used to assess the main effects of gender, age (⬍45 v ⬎45 years), and family composition on the loneliness scores controlling for covariance sources (TBDI and MSPSS scores). The main effects were revealed for gender (F ⫽ 3.93, df ⫽ 1, 386, P ⫽ .002), family composition (F ⫽ 4.96, df ⫽ 2, 386, P ⫽ .007), and for the interaction between the two (F ⫽ 6.59, df ⫽ 2, 386, P ⫽ .0015), as well as for their interaction with age (F ⫽ 3.29, df ⫽ 4, 386, P ⫽ .011). The results suggest that older female subjects who arrived in Israel without a spouse perceive themselves as lonelier than their younger male counterparts from complete or three-generation families (F ⫽ 10.00, df ⫽ 1, 386, P ⫽ .002). Patterns of Loneliness To identify the main factors associated with loneliness, we performed an exploratory factor analysis for the entire sample. Tables 3 presents variables with an absolute loading greater than the amount set in the minimum loading option (⬎0.4). Three factors were identified on the highest eigenvalues. The first factor was constructed with loneliness and symptoms of psychological distress. The
second factor included neither loneliness nor distress, but only social support from family and significant others. Finally, the third factor included loneliness and social support from friends. Accordingly, the first factor was labeled a distress-related loneliness factor, the second a social support factor, and the third a distress-free loneliness factor. Correspondingly, the factors accounted for 56.3%, 25.5%, and 18.2% of the total variance among the nine measures. DISCUSSION
This is the first report on the relationship between self-reported loneliness, psychological distress, and social support in a large-scale sample of recent immigrants with major real-life stressors. We have many reasons to assume that people who immigrated to Israel will feel less lonely that those immigrating to other asylum countries. Unfortunately, due to the absence of published data on the subject, we could not directly test this assumption. Nevertheless, indirect comparisons have shown that the immigrants as a whole exhibit a higher level of experienced loneliness (43.2 mean score) than those in most no clinical population surveyed using the same loneliness instrument (RUCLA-LS). It was comparable with mean reporting for accident survivors—45.0,39 although it did not approach mean reported for psychiatric inpatients—50.4.40 Although we suggest that the differences are due to immigrant status, the effects of other cultural factors on the R-UCLA-LS scores
412
cannot be excluded. In contrast to previous studies in which greater feelings of loneliness were reported among older adults,8,15,46,47 we did not find a significant association with age when considered in isolation. However, combination of age with gender and family composition exerts the significant effect on the variation in the loneliness scores when psychological distress and social support variables were controlled. This finding suggests that the effects of distress and social support in producing profound experiences of loneliness are more salient than the impact of demographic factors. Because loneliness and distress share some characteristics, we tried to differentiate the loneliness patterns associated or not associated with components of general psychological malaise. The results of factor analysis confirm the hypothesized patterns of loneliness. For loneliness that is not associated with distress (factor 3), the main area of dissatisfaction focuses on social support from friends. This type of loneliness experience may be considered a normal psychological response defending an individual from distress. Experiencing loss of his/her friend support, such an individual is probably successful in keeping “perhaps the most important of all relationships—the relationship with the self.”48 Being connected to one’s inner feelings promotes a sense of self-identity and knowledge of how much one can rely on one’s own abilities in a self-sufficient and autonomic manner. The inability to maintain such inner connections has a tendency to dissolve positive self-esteem, to lower self-confidence, and to diminish trust in others even in the presence of external support systems. In severe instances, one’s bonds with reality may be severed, and replaced by withdrawal into a profound distress. This picture may be seen in the distress-related loneliness that seems to be a component (symptom) of an array of distress symptoms (factor 1). In general, the results of this study concerning symptomatic loneliness support and supplement earlier studies that have cited affective descriptions and correlates of loneliness.14,19,22 However, our findings demonstrate that not only symptoms specific for depression, but also other symptoms of general psychological distress are markedly associated with feelings of loneliness. Of particular interest is the relationship of loneliness to interpersonal sensitivity (low self-esteem) including feel-
PONIZOVSKY AND RITSNER
ings of personal inadequacy and inferiority, especially in comparison with others, negative expectations concerning communication and interpersonal behavior. However, not only self-depreciation, but also criticism of others plays an important role in symptomatic loneliness. The strong correlation of loneliness with paranoid ideation involving projective thought, hostility, suspiciousness, and fear of loss of autonomy supports this assumption. This pattern of psychological symptoms reflects the immigrants’ way of evaluating themselves as lonely, through separation from relationships or group memberships, and a trend toward self-isolation, avoidance, and rejection of others. Overall, the findings concerning symptomatic loneliness support Silove et al.’s18 conclusion that loneliness appears to be an integral aspect of general psychological distress rather than an independent determinant of such condition. It was shown that satisfaction with social support is the largest predictor of loneliness in elderly Korean immigrants in the United States, although the types of social support were not differentiated in that study.10 Our results also demonstrate the role of specific types of social support in the development of loneliness of social isolation. Comparing the two factors, one containing loneliness and one not (factor 3 and 2), we find that only dissatisfaction with support from friends (high positive loading on factor 3) precipitates loneliness experiences, while lack of social support from family and significant others (high negative loading on factor 2) does not. The results suggest that among the different interpersonal needs, satisfaction of need in social integration providing by friends could prevent an individual from loneliness of social isolation in the same degree as fulfilled needs in attachment, reliable alliance, and guidance providing by family and significant others. Several limitations of the present study should be addressed. Few self-report variables assessing no pathological phenomenon of loneliness were included in the design, e.g., having a non-Jewish spouse, number of friends among Israelis, leaving behind significant others, or companionship in the workplace. We suggest, however, that using social support instrument measuring emotional help and satisfaction with the support provided from family, friends, and significant others covers at least some of these important factors. Since the present study relies entirely on self-report measures, our findings
PATTERNS OF LONELINESS IN IMMIGRANTS
413
are inevitably limited to the immigrants’ subjective experience of psychological symptoms, not diagnosable psychiatric disorders. Because of the uniqueness of the given immigrant population, we cannot generalize our findings to include other immigrant groups to Israel and worldwide. Nonetheless, we suggest that the findings of this study have important implications for health care providers by showing the differential patterns of loneliness. One is a sufficiently consistent and salient component of general psychological distress requiring appropriate intervention. Another repre-
senting a natural response to dissatisfaction with current social provisions may serve as a defensive mechanism from psychological distress. Sensitivity to these differences is needed in practice with recent immigrants. Further prospective investigations of this important issue should include more stress and coping measures to extend the perspectives of the present findings. ACKNOWLEDGMENT The authors acknowledge with appreciation the assistance of Dr. S. Safro and Dr. M.C. Ryan.
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