Jansson, Anu

Pitkala, K. H.

English

Helsingin yliopiston digitaalinen arkisto

         Circle of Friends, an encouraging intervention for alleviating loneliness Anu Jansson, Kaisu Pitkälä    Anu Jansson, PhD 1) University of Helsinki, Department of General Practice and Helsinki University Hospital, Unit of Primary Health Care, Helsinki, Finland, 2)The Finnish Association for the Welfare of Older People, Helsinki, Finland. anu.jansson@vtkl.fi (Corresponding author) Orcid ID: 0000-0001-6531-2054  Kaisu Pitkälä, MD, PhD, Professor University of Helsinki, Department of General Practice and Helsinki University Hospital, Unit of Primary Health Care, Helsinki, Finland.  kaisu.pitkala@helsinki.fi  Orcid ID: 0000-0001-9659-6985              “Loneliness is like you have been dropped down   into an empty, dark room. And you can only hear your own voice   echoing off the walls.”  This poem was written by an older person and describes his miserable feelings of loneliness at the beginning of the “Circle of Friends” group intervention. The COVID-19 pandemic and lockdown have highlighted how important social relationships are to all of us. We have also seen and been worried about older people in social isolation, separated from their meaningful others [1]. However, people may also still feel lonely when surrounded by a social network. Loneliness derives from the gap between the desired and actual level of social interaction [2].   In recent decades, aging research has consistently shown that loneliness has many adverse health outcomes. It predicts cognitive and functional decline [3,4,5], chronic diseases [6], the use of health services [7] and mortality [6,8]. Loneliness impairs quality of life (QOL) [9] and psychological wellbeing [10].  Although loneliness is a health risk, it is also part of normal human life and almost every one of us occasionally suffers from it. Thus, loneliness may be transient, and people often cope with it on their own [11]. Reading, walking, having pets, and gardening have been suggested as appropriate means of self-management for lonely older people [2]. Older adults also maintain many relationships in later life, which prevents loneliness [12]. However, about 20–30% of older people in developed countries suffer from loneliness and about 5–10% suffer constantly [13]. A large proportion of these people are unable to use appropriate means for coping or alleviating their loneliness. Furthermore, although many of them express a wish to escape their loneliness, they may be ashamed to express their feelings [14]. In this situation, loneliness can become chronic and harmful if not addressed in time. The social and health care sector needs to become more aware and recognize loneliness among older people and, in particular, offer effective interventions [15].  Addressing older people’s loneliness can be difficult for many reasons. Firstly, we have to trace older people who suffer from loneliness and who may benefit from interventions. Asking about loneliness is challenging for professionals [15]. Secondly, recruiting lonely older people for interventions is problematic. Admitting and expressing feelings of loneliness may be difficult for older people because of its stigmatizing, undesirable nature [16]. Thirdly, the results concerning the effectiveness of loneliness interventions are conflicting. Those offering social activity with peers in a group format, in which older people play an active role have shown efficacy [17]. When intervening in loneliness, three approaches are useful [18] increasing contacts and reducing the perceived discrepancy between actual and desired relationships 2) decreasing relationship standards to meet realities, or 3) reducing the effect of the discrepancy by accepting and coping with feelings of loneliness. An effective intervention using these approaches to improve the well-being of lonely older people is the “Circle of Friends” [7, 19] developed and run by The Finnish Association for the Welfare of Older People. According to Hawkley & Cacioppo [6], it may be the only form of intervention that is also effective for preventing adverse health outcomes of loneliness. Savikko et al. [20] presented the essential, predetermined elements required of the participants and facilitators, favourable processes among and within the group, and the mediating factors that occurred during the group process and promoted the alleviation of loneliness. In the randomized controlled trial, the Circle of Friends improved lonely older people’s health and cognition, reduced the use of health care services and reduced mortality among the participants [7, 19, 21]. The Circle of Friends is a closed face-to-face group of six to eight participants suffering from loneliness, who meet with their peers 12 times, once a week, for three months. A closed group means that a facilitated group process has a clear beginning and end. New participants are not added after the intervention has started, even if some group participant(s) drop(s) out [22]. The main idea of the group is to value older people’s active agency, empower them to take mastery over their own lives, and to allow them to gradually take over the responsibility of interaction in the group. A properly facilitated group process and group dynamics are used as means to empower participants to confront their loneliness, to support their peers in the group and to start keeping in touch with each other on their own without the facilitators [23]. Each group always has two facilitators. Their competence in favourable group processes and group dynamics is important, and skills in empowering and supporting interaction among the participants is essential. The facilitators’ working approach is objective oriented and client centred. They receive thorough training and work supervision [22]. The Circle of Friends it is not about more frequent social relationships, but how these relationships really meet the participant’s own expectations. Nor is it important that the group members have a diverse program: The main objective is that the group process progresses well and that it is in line with the pace of the participants. The facilitators guide the group towards self-direction and the participants’ own empowering leadership. The facilitators’ final goal is to step back when it is time, and to gradually become unnecessary and encourage the participants to continue the group meetings on their own [24]. According to the ten-year (2006−2016) follow-up, nine out of ten Circle of Friends participants felt their loneliness had been alleviated in the group, and over 60% of the participants had continued the meetings after the facilitated group [22]. “Give a man a fish and you feed him for a day; teach a man to fish and you feed him for a lifetime” is very much true of the Circle of Friends.  “Now it’s been three years since our group started and this gang still meets at the café nearby. Our “coffee moments” are something that all of us look forward to…they are moments among friends that really don’t lack talking and laughter.” Over the last two decades, the Circle of Friends has been widely disseminated in Finland [22]. More than 10 000 lonely older people have participated in these groups. The Circle of Friends is feasible in long-term care facilities and among people with cognitive decline [24]. The model has also been modified and exported to some other countries [25]. At the beginning of the COVID-19 pandemic, The Finnish Association for the Welfare of Older People started to modify the original Circle of Friends model into online group sessions. These online groups are on an electronic platform which is easy and safe to use, and its virtual meeting room is free of charge for the participants. The online version of the Circle of Friends has the elements of the original group model. Of the first online groups, all the participants have kept in touch with each other independently.  References 1. Kotwal AA, Holt-Lunstad J, Newmark RL, Cenzer I, Smith AK, Covinsky KE, Escueta DP, Lee JM, Perissinotto CM. Social Isolation and Loneliness Among San Francisco Bay Area Older Adults During the COVID-19 Shelter-in-Place Orders. J Am Geriatr Soc. 2021;69:20-29. doi: 10.1111/jgs.16865.  2. Victor C, Scambler S, Bond J (2009) The social world of older people. Understanding loneliness and social isolation in later life. Open university press, England.  3. Tilvis RS, Pitkala KH, Jolkkonen J, Strandberg TE. Social networks and dementia. Lancet. 2000;356:77-8. doi: 10.1016/s0140-6736(05)73414-0.  4. Boss L, Kang DH, Branson S. Loneliness and cognitive function in the older adult: a systematic review. Int Psychogeriatr. 2015;27:541-53. doi: 10.1017/S1041610214002749. 5. Perissinotto CM, Stijacic Cenzer I, Covinsky KE. Loneliness in older persons: a predictor of functional decline and death. Arch Intern Med. 2012;172:1078-83. doi: 10.1001/archinternmed.2012.1993.  6. Hawkley LC, Cacioppo JT. Loneliness Matters: A Theoretical and Empirical Review of Consequences and mechanisms. Ann Behav Med. 2010;40:218-27. doi: 10.1007/s12160-010-9210-8. 7. Pitkala KH, Routasalo P, Kautiainen H, Tilvis RS. Effects of psychosocial group rehabilitation on health, use of health care services, and mortality of older persons suffering from loneliness: a randomized, controlled trial. J Gerontol A Biol Sci Med Sci. 2009;64:792-800. doi: 10.1093/gerona/glp011. 8. Tilvis RS, Routasalo P, Karppinen H, Strandberg TE, Pitkälä KH. Social isolation, social activity and loneliness as survival indicators in old age; a nationwide survey with a 7-year follow-up. Eur Geriatr Med. 2012;3:18-22. https://doi.org/10.1016/j.eurger.2011.08.004 3:18–22. 9. Musich S, Wang SS, Hawkins K, Yeh CS (2015)The Impact of Loneliness on Quality of Life and Patient Satisfaction Among Older, Sicker Adults. Gerontol Geriatr Med. doi: 10.1177/2333721415582119.  10. Golden J, Conroy RM, Bruce I, Denihan A, Greene E, Kirby M, Lawlor BA (2009) Loneliness, social support networks, mood and wellbeing in community-dwelling elderly. Int J Geriatr Psychiatry. doi: 10.1002/gps.2181 11. Rook KS, Peplau LA (1982) Perspectives on helping the lonely. In: Peplau LA, Perlman D. Loneliness: a sourcebook of current theory, research and therapy. John Wiley & Sons, New York, pp. 351−378. 12. Victor C, Scharf T (2005) Social isolation and loneliness. In: Walker A. Growing older. Understanding quality of life in old age. Open university press, England, pp. 100−116  13. Yang K, Victor C. Age and loneliness in 25 European nations. Ageing Soc 2011;31:1368−1388. doi: 10.1017/S0144686X1000139X 14. de Jong Gierveld J, Fokkema T (2015) Strategies to prevent loneliness. In Sha’ked A, Rokach A (eds.) Addressing loneliness. Coping, prevention and clinical interventions. Routledge, London and New York, pp. 218−230. 15. Perissinotto C, Holt-Lunstad J, Periyakoil VS, Covinsky K. A Practical Approach to Assessing and Mitigating Loneliness and Isolation in Older Adults. J Am Geriatr Soc 2019;67:657–662. 16. Victor C, Grenade L, Boldy D. Measuring loneliness in later life: A comparison of differing measures. Rev Clin Gerontol 2005;15:63−70. doi: 10.1017/S0959259805001723 17. Cohen-Mansfield J, Perach R. Interventions for alleviating loneliness among older persons: a critical review. Am J Health Promot 2015;29:e109–e125 18. de Jong-Gierveld J, Fokkema T, van Tilburg TG (2011) Alleviating loneliness among older adults: Possibilities and constraints of interventions. Safeguarding the convoy: A call to action from the campaign to end loneliness. Oxon, UK. Age UK Oxfordshire, pp. 41−45 19. Routasalo PE, Tilvis RS, Kautiainen H, Pitkälä KH. Effects of psychosocial group rehabilitation on social functioning, loneliness and well-being of lonely, older people: randomized controlled trial. J Adv Nurs 2009;65:297–305. doi: 10.1111/j.1365-2648.2008.04837.x. 20. Savikko N, Routasalo P, Tilvis R, Pitkälä K. Psychosocial group rehabilitation for lonely older people: favourable processes and mediating factors of the intervention leading to alleviated loneliness. Int J Older People Nurs 2010;5:16-24 21. Pitkälä KH, Routasalo P, Kautiainen H, Sintonen H, Tilvis RS. Effects of socially stimulating group intervention on lonely, older people's cognition: a randomized, controlled trial. Am J Geriatr Psychiatry 2011;19:654−663 22. Jansson A, Savikko N, Pitkälä K. Training professionals to implement a group model for alleviating loneliness among older people – 10-year follow-up study, Educ Gerontol 2018;44:119–127 23. Pitkälä KH, Savikko N, Routasalo P (2015) Group Dynamics in Older People’s Closed Groups: findings from Finnish psychosocial group rehabilitation for lonely older people. In Derrickson H (eds.), Group Therapy. Nova Science Publishers, pp. 39–73. 24. Jansson A, Karisto A, Pitkälä K. Loneliness in assisted living facilities: An exploration of the group process. Scand J Occup Ther. 2019;12:1-12. doi: 10.1080/11038128.2019.1690043.  25. Zubatsky M, Berg-Weger M, Morley J. Using Telehealth Groups to Combat Loneliness in Older Adults Through COVID-19. J Am Geriatr Soc. 2020;68:1678-1679   Narrative abstract  COVID-19 has crystalized the significance of older people’s loneliness. This editorial defines loneliness and its adverse effects on the health and wellbeing of older adults. It describes how professionals in the health and social care sector can recognize and address older people’s loneliness and how to offer them appropriate interventions. The Circle of Friends is a group intervention developed specifically for lonely, older people and has shown to effectively improve their health and wellbeing. We present the essential elements and current state of Circle of Friends.   

Circle of Friends, an Encouraging Intervention for Alleviating Loneliness

https://helda.helsinki.fi/bitstream/10138/353334/1/friends.pdf

Circle of Friends, an Encouraging Intervention for Alleviating Loneliness

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Helsingin yliopiston digitaalinen arkisto