Experiences of Loneliness Among Persons With Mental Ill-health

Looking at the world through a frosted window:experiences of loneliness among persons withmental ill-healthB . - M . L I N D G R E N 1 R N P h D , J . S U N D B A U M 2 R N M S c , M . E R I K S S O N 2 R N M S c &U . H . G R A N E H E I M 3 R N T P h D1Senior Lecturer, 2Clinical Nurse Specialist, 3Associate Professor, Department of Nursing, Ume University, Ume,Sweden

Keywords: community-based psychiatry,

emotional and social exclusion,

experiences of loneliness, mental

ill-health, qualitative content analysis

Correspondence:

B.-M. Lindgren

Department of Nursing

Ume University

SE-90187 Ume

Sweden

E-mail: [email protected]

Accepted for publication: 17 February

2013

doi: 10.1111/jpm.12053

Accessible summary

Experiences of loneliness among people with mental ill-health can be metaphori-cally described as looking at the world through a frosted window.

The experiences are multifaceted and developing as well as emotionally andsocially excluding.

People suffering from mental ill-health and loneliness carry a twofolded stigma.They feel socially undesirable, and the social perceptions of lonely people aregenerally unfavourable.

Abstract

Mental ill-health is reported to be of major concern in public health. Persons sufferingfrom mental ill-health are a vulnerable group, and loneliness influences the perceptionof physical, social, and emotional well-being. However, there are few studies explor-ing lived experiences of loneliness among people with mental ill-health. This qualita-tive study aimed to illuminate experiences of loneliness among people with mentalill-health. Five individual, informal conversational interviews were performed andsubjected to qualitative content analysis. The main findings showed that experiencesof loneliness could be metaphorically described as looking at the world through afrosted window. The experiences of loneliness were multifaceted and altering as wellas emotionally and socially excluding. The findings are discussed in relation to Tillichdimensions of loneliness: loneliness as a painful dimension of being alone, andsolitude as the enriching dimension of being alone. People suffering from mentalill-health carry a twofolded stigma. They feel socially undesirable because of theirmental ill-health, and the social perceptions of lonely people are generally unfavour-able. We believe that mental health nurses can support the developing and creativedimension of loneliness through a confirming approach, where people with mentalill-health feel seen, heard, and respected as human beings.

Introduction

Loneliness is considered to be a multidimensional phenom-enon (de Jong Giervald 1998, Nilsson et al. 2006); it is apersonal and subjective experience related to the individu-als gender, age, marital status, and social relations, as wellas to the aspects of the cultural and religious context. Ofsignificance are the individuals values, self-image, desires,

and needs, as well as personal opinions about social rela-tions and the phenomenon of loneliness (Wiseman et al.2005, Cacioppo et al. 2006, Mellor et al. 2008, Civitci &Civitci 2009, de Jong-Giervald et al. 2009).

There is no clear consensual definition of loneliness(Karnick 2005). The concepts of feeling lonely, being alone,and living alone are often used interchangeably; althoughthey are distinct concepts (Routasalo & Pitkala 2003), they

Journal of Psychiatric and Mental Health Nursing, 2013, ,

2013 Blackwell Publishing 1

are related and constitute dimensions of loneliness. In thispaper, we refrain from defining loneliness, as our mainfocus was to illuminate the experiences of loneliness asdescribed by persons with mental ill-health.

People experience and describe loneliness in multipleways. Thesen (2001) described loneliness as a continual,painful companion that causes people to regard theiraffliction as a personal defect or deficiency. Dahlberg(2007) reported on loneliness from a life-world perspec-tive among women and men aged between 12 and 82years. She described the essence of loneliness as lonelinesswithout others; loneliness with others; loneliness as astrange, wrong, ugly, or even shameful thing; and loneli-ness as a restful and creative thing. Eshbaugh (2008)described negative, neutral, and positive experiences ofloneliness among older adult women living alone. Theirutterances concerning their experiences of lonelinessvaried between I hate it, Im used to it now and I love it.According to Graneheim & Lundman (2010), the experi-ences of loneliness among the very old were twofold; onthe one hand, living with losses and feeling abandonedrepresented the limitations imposed by loneliness; and onthe other hand, living in confidence and feeling free rep-resented the opportunities of loneliness.

Mental ill-health is reported to be of major concern inpublic health. Persons suffering from mental ill-health are avulnerable group, and loneliness influences the perceptionof physical, social, and emotional well-being (Nilsson et al.2008). Loneliness is significantly associated with mentalill-health (Syrn 2010), especially depression (Victor &Yang 2012), and living with mental ill-health influencesphysical and psychological prerequisites to creating socialnetworks and close relations. Thus, mental ill-health cancontribute to experiences of being unwanted, unimportant,stigmatized, and lonely (Erdner et al. 2005). People withmental ill-health reported a sense of loneliness, from havingno friends and experiencing a huge vacuum, to havingcontact with family and friends, but still experiencing lone-liness (Granerud & Severinsson 2006).

In summary, people with mental ill-health are stigma-tized (Erdner et al. 2005), and their experiences are seldomaddressed, and if so, their experiences are often neglectedand referred to their mental ill-health (Lindgren et al.2004). Even though it is evident that experiences of lone-liness influence mental ill-health, there are few studiesconcerning these experiences among persons with mentalill-health. Today, a large number of people suffering frommental ill-health are cared for in their own homes andoffered support by the community. In order to open up adialogue about loneliness in this context, it is important toknow how they experience their situation and loneliness asa part of their lives.

Aim

This study aimed to illuminate the experiences of lonelinessas described by people with mental ill-health.

Methods

This is a qualitative study based on individual, informalconversational interviews, using qualitative content analy-sis, to derive the experiences of loneliness among peoplewith mental ill-health. The epistemology of qualitativecontent analysis has been considered unclear (Lundman &Graneheim 2012). However, we argue that qualitativecontent analysis comprises phenomenological descriptionsof the manifest concrete content, close to the text, as well ashermeneutic interpretations of the latent abstractedmessage, yet still close to the subjects experiences. Thus,different stages in the analysis process can be referred tovarious scientific approaches (Schreier 2012). In this study,we both described the manifest content and interpreted thelatent message.

Context

In order to facilitate recovery and rehabilitation for peoplewith mental ill-health, the community offer various kindsof support, for example, support at home, special housing,and assistance finding something meaningful to do. Withinthe area of personal support, the community offers helpconcerning daily living, relations, finances, and contactswith authorities. Concerning employment, meaningfulactivities, and studies, there are adapted and structuredworkplaces and work-oriented rehabilitation, with accessto individual supervision (counselling) as well as opportu-nities to study with special pedagogical support. There arealso social meeting centres and opportunities to participatein cultural activities. The study was performed amongpersons visiting two social meeting centres in a midsizedcity in northern Sweden. These houses are part of a socialcooperative run by the users and next-of-kin organizations.The cooperative is mainly a social meeting centre, openevery day during the year, where influence and participa-tion are key concepts. Besides the opportunity to just be,they offer activities such as playing music, watchingmovies, painting, working with computers, and makingpottery.

Participants

For our study, we contacted the managers at two socialmeeting centres for people with mental ill-health and gotpermission to arrange an information meeting. The second

B.-M. Lindgren et al.

2 2013 Blackwell Publishing

(JS) and third (ME) authors provided information aboutthe project, and those attendees who were willing to par-ticipate could signify their interest. The inclusion criteriawere having lived experiences of mental ill-health, notbeing admitted to inpatient care, visiting the social meetingcentres on a regular basis, and being willing to share theirexperiences verbally. Eight persons were interested in par-ticipating. However, three of them were not able to fulfiltheir participation because of personal reasons. The fiveremaining participants were three men and two women,between 25 and 57 years of age. Self-reported diagnoseswere, for example, depression, anxiety, and psychosis.Their length of experience of living with mental ill-healthranged between 7 and 30 years. Three participants werecohabiting, and two had children.

Informal conversational interviews

Aiming to illuminate the experiences of loneliness, thesecond and the third authors performed informal conver-sational interviews, during November 2009 and February2010, with five persons who met the inclusion criteria. Aninformal conversational interview has an open-endedapproach and is both unstructured and focused (Patton2002, pp. 342343). The focus of the current interviewswas on the participants experiences of loneliness, withexamples of questions asked being, Could you please tellme about your experiences of loneliness? The responseswere followed up with clarifying and exploratory ques-tions, such as How do you mean? Can you tell us moreabout that? Whenever the interviewees did not spontane-ously reflect on their descriptions, their reflections weresolicited. The interviewees told about their experiences ofloneliness throughout life.

The informal conversational interviews were performedat the social meeting centres, except for one that took placein the participants home. The tape-recorded interviewslasted between 30 and 90 min (median = 45 min) and weretranscribed verbatim.

Analysis

The transcribed text was subjected to qualitative contentanalysis (Graneheim & Lundman 2004). Content analysissystematically analyses written or verbal communication(Krippendorff 2004), focusing on differences between, andsimilarities within, parts of the text, and the interpretationprocess results in categories and/or themes (Graneheim &Lundman 2004).

The analysis was performed in several steps. First, thetext was read several times to get a sense of the whole. Thenthe text was divided into meaning units, for example,

words, sentences, and paragraphs related to each otherthrough their content and context. The meaning units werecondensed, while still preserving their core meaning, andlabelled with a code. Codes that deviated from the aimwere excluded, for example, comments on the weather,actual television programmes, and other visitors to thecentre. The remaining codes were sorted into four subcate-gories, and eventually abstracted to two categories at amanifest level. Finally, the categories were reflected on, anda theme, that is, a thread of latent meaning runningthrough codes on an interpretative level, was formulated(Graneheim & Lundman 2004).

To enhance trustworthiness, the codes, subcategories,categories, and theme were reflected on and discussed inthe research team throughout the analysis process, result-ing in consolidation of the findings.

Ethical considerations

This study was accomplished according to the ethicalguideline described in the Helsinki Declaration (WorldMedical Association 2008). Furthermore, the study wasapproved by the managers at the social meeting centres.Participants received verbal and written information aboutthe aim of the study, and they decided on their ownwhether they wanted to participate. Nonetheless, therewere risks that need to be taken into consideration. Partici-pants can feel violated by close questioning. However, theparticipants in our study could choose what they wanted totell and were informed that they could end their participa-tion whenever they wished. They were also assured ofconfidentiality. Furthermore, expressing their experiencesmay provide relief for the participants (Gaydos 2005).

Findings

The participants experienced loneliness as multifaceted andaltering, and as emotionally and socially excluding, whichwas interpreted as an experience of looking upon the worldthrough a frosted window.

Looking upon the world through a frosted window

The picture that emerged from the participants descrip-tions about experiences of loneliness could be understoodas being on one side of a frosted window. Through thiswindow, covered in crystals of ice, the persons with mentalill-health viewed people in the surrounding world and theirsolidarity, and this reminded them of their loneliness.Whether participants perceived themselves to be on theinside looking out or on the outside looking in, the con-tours of the surroundings, fellow beings, and phenomena

Looking at the world through a frosted window


were shattered, looked somewhat diffuse, were hard tounderstand and achieve, but were yet considered somethingworth striving to be a part of. The ice crystals made thelight reflect in various ways that symbolized the multifac-eted and altering experiences of loneliness. Furthermore,the frosted window became a symbol for emotional andsocial exclusion, from the world and society, as sharedthrough the participants descriptions. Thus, the experienceof ones own existence, the world in relation to others, andones social context, could change and alter the experienceof loneliness. Because of shifting seasons, the frost couldmelt away, and if the conditions were right, lonelinesscould be experienced as developing. However, the windowwas still there as a reminder of being excluded and hin-dered from participating in social life. Categories that con-stitute the theme are presented later and illuminated byquotations.

Multifaceted and altering

The experiences of loneliness were multifaceted and alter-ing, described as varying with situation in life and endless,but also as a developing experience.

The multifaceted nature of loneliness reflected the par-ticipants life situation, health status, memories from thepast, and expectations and worries for the future. One ofthe participants described how emotional difficulties suchas anxiety could drain energy and stamina, resulting in aninability to maintain social relationships, in the long runleading to loneliness. She stated, Anxiety and other stuffhindered, and sort of kept me from . . . I just did not havethe energy to maintain social relationships and that, ofcourse, creates loneliness (P3).

The experiences of loneliness shifted over the course oftime. The participants described that the experiences ofloneliness varied throughout life and were related to theindividual social situation, such as the quality of relation-ships and whether the person had the ability, will, andopportunity to express the emotions that loneliness brings.One man said, Apparently there are a lot of different ways;it depends on where you are in life, your relationships, andif you have the ability to talk about it (P1).

Varying with life situations, loneliness could be involun-tary as well as voluntary. The participants expressed thatinvoluntary loneliness could be a necessity, when it becamedifficult to handle social relationships in everyday life.However, even though loneliness was not by choice, itcould be experienced as beneficial. One woman reported, Icould not cope with having to work alongside others . . . soI chose to work by myself most of the time (P2). Involun-tary loneliness was also described as an experience thatalmost everyone, at some point in life, had experienced,

especially when relationships with others failed, changed,or was ended. The same woman said, If your relationshipfails, loneliness will be present and there is nothing strangeabout that (P2).

Sometimes, the experience of loneliness was continu-ously present and endless, and created a sense of emptinessand hopelessness, and of life being meaningless. The expe-riences of loneliness became a vicious circle, and ongoingphenomena in life that never seemed to end. As one womantold, I could wake up and there was no end to it . . . I justthought that the only thing of worth today was to pull upthe blinds (P2). The participants described loneliness aslatent and a constant reminder of how life can be, evenwhen loneliness no longer was present. A man said, But itskind of still present and guides you in life . . . because youkind of put it behind you, but yet the feeling is present . . .Its latent . . . so that you wont forget (P5). This contrib-uted to the experiences of loneliness as an inevitable partof, or as a lot in, life. One woman told, . . . I thought itwas what Ive been given in life, my lot in life . . . (P2).

The experiences of loneliness were also described asvoluntarily chosen and developing, meaning that lonelinesscould be a relief from the hardships of social interactionand sometimes a necessity. The participants described thatloneliness could be beneficial, existentially rewarding, anda driving force in life, because the experiences of lonelinesswill create a reference to the experience itself, from whichdesires and striving for future social situations could beshaped. One man said, Well, you need time for yourselftoo . . . but that is a positive loneliness. You can be byyourself without it being negative. Before, I did not see itlike that . . . that loneliness can be beneficial (P5).

Emotionally and socially excluding

The experiences of loneliness, as shared by the participants,could bring a sense of emotional and social exclusion,described as lack of belonging and feeling set aside. Lack ofbelonging fostered feelings of being insignificant and inad-equate. The participants related that when they and theiremotions were unimportant to their close family, it createda fundamental feeling of exclusion. Furthermore, lack ofbelonging was intensified when there was an inability toreturn to, maintain, and/or create social networks. As oneman said, Its not easy to rebuild your social network orfriendships when you dont have the ability to (P4).

Feeling set aside included feelings of not being acknowl-edged, that is, not being heard, seen, or understood byothers. This could be due to a physical lack of someone toopen ones heart to, as well as lack of feeling understood onan emotional level and not being allowed to express emo-tions or experiences.



The lack of belonging as well as feeling set aside influ-enced the experiences of loneliness and affected the per-ceived self-confidence and self-image, which createdambivalence, confusion, and insecurity, when it came toself-worth and individual importance. One woman said,Not having relationships or someone that reflects who youare as a person . . . well, someone to validate you and youractions . . . you will feel that youre not of importance as aperson (P3).

Discussion

The aim of this study was to illuminate the experiences ofloneliness among people with mental ill-health. The find-ings showed that the experiences of loneliness were multi-faceted and altering as well as emotionally and sociallyexcluding. The latent meaning of these categories formedthe theme looking upon the world through a frostedwindow.

Tillich (1963) suggests using two words for the multi-faceted experience of loneliness, loneliness to express thepainful dimension of being alone and solitude to expressthe developing dimension of being alone.

Similar to Tillichs (1963) dimension of solitude as theglory of being alone, we found that the experience ofloneliness could be enriching, a driving force towardstogetherness and belonging of a larger social context. Expe-riences of loneliness were considered as a source of wisdomand personal growth. Tillich described that solitude can befound in music, literature, and art, and he stated that onehour in conscious solitude does more for your creativitythan many hours of learning how to become creative(p 553). This is echoed in Dahlberg (2007), who describedvoluntary loneliness to be a powerful and creative experi-ence, which offered inner peace and calm. Furthermore,Graneheim & Lundman (2010) described the opportunitiesoffered by loneliness among the very old as living in con-fidence and feeling free.

There is a strong relation between loneliness and per-ceived physical and mental health status over time. Therelation is two-sided: a decrease in experience of lonelinessincreases perceived physical and mental health at the sametime as a deterioration of physical and mental healthincreases the experience of loneliness (Nummela et al.2011). Our study shows that even though the experience ofloneliness varies throughout life and by the influence of anumber of factors, such as phase of life, social situation,and the presence of friends, the experience of loneliness stillis continuously present. In a literature review on existentialloneliness Ettema et al. (2010), the authors found threedimensions of existential loneliness, as a basic condition ofhuman existence, as a specific experience, and as a process

in which the negative experience of a mans lonely nature istransformed into a positive one. Tillich (1963) advocatedthat human beings have always suffered from experiencesof loneliness and thereby had a wish to escape this loneli-ness. With other words, lonely is not something youbecome; it is something you are, which echoes our findingsthat experiences of loneliness are continuously present.

The experience of loneliness was described as notbelonging and being set aside. It was a social and emotionalexclusion that throughout life fostered feelings of hopeless-ness and was perceived as endless. Unfulfilled wishes andexpectations of life and social relations contributed to dis-appointment and pain. This is supported by Peplau &Perlman (1982), who reported that loneliness occurs whenindividuals perceive a difference between their desired andactual levels of social involvement. Furthermore, we foundthat feeling set aside, including not being heard, seen, orunderstood, fostered experiences of loneliness even whenbeing surrounded by people. These feelings of exclusioncontributed to resignation, frustration, and desperation.According to Tillich (1963), the experience loneliness andisolation could be present among family members, neigh-bours, co-workers, and friends. This contributes to a needto retire from the group in order to be alone with theloneliness. Buber (1957, 1994) suggests that you becomesomeone in relation to others, and a persons identity ispromoted by confirmation. Feeling emotionally andsocially excluded can derive from experiences of disconfir-mation. According to Cissna & Seaburg (1981), disconfir-mation means To me, you do not exist, We are notrelating, To me, you are not significant, and Your way ofexperiencing your world is invalid. The participants in ourstudy expressed this by saying that they and their emotionswere insignificant to their close relatives, and there was noone around who could validate them and their actions.

People suffering from mental ill-health are stigmatized(Erdner et al. 2005). Furthermore, loneliness carries a sig-nificant social stigma, as lack of friendship and social ties issocially undesirable, and the social perceptions of lonelypeople are generally unfavourable (Rokach 2012). Knightet al. (2003) describe social exclusion as not only a conse-quence of mental ill-health but also an experience of stig-matization. The ideological foundation of the developmentfrom institutionalized to decentralized psychiatry wassocial integration (National Board on Health and Welfare1992). Modern community health-care views social inte-gration as vital for improving mental health (Granerud &Severinsson 2006). However, without active interventionsin the form of community participation and individualsupport, people with mental ill-health who move intoprivate housing can find themselves excluded from thesocial network (Hardiman & Segal 2003).



Methodological discussion

The number of participants in this study is small. However,the interviews conducted resulted in a large amount ofmaterial, illuminating differences and similarities in theparticipants experiences of loneliness. Thus, five partici-pants were assessed to be enough, as trustworthiness in aqualitative study is gained more by the richness of eachinterview than by sample size (Sandelowski 1995).

Conducting informal conversational interviews, withtwo authors present, can be considered as both a weaknessand a strength. On the one hand, it can create an unnaturaland inhibiting atmosphere for all involved because theparticipants are sharing private and intimate thoughts andexperiences, which are sometimes very emotional. It couldbe argued that an already unfamiliar situation for the inter-viewees could be even more exposing with a three-wayconversation. On the other hand, the presence of bothauthors created a setting for a more active conversationconcerning the participants experiences of loneliness andthus a greater variation in data.

Some of the results and quotations of this study mayreflect not only the experiences of loneliness, but also theexperiences of suffering from mental ill-health. One reasonfor this may be the complex nature of human experiences.It is not always possible to separate intertwined feelingsfrom each other, that is, experiences of loneliness and livingwith mental ill-health cannot always be isolated from eachother.

Our interpretation should be considered as one possibleunderstanding of the experiences of loneliness amongpeople with mental ill-health. According to Krippendorff(2004), a text never implies one single meaning, just the

most probable meaning from a particular perspective. Inorder to enhance trustworthiness, the authors discussedevery step in the analysis process, until consensus about theinterpretation was achieved. We also reflected on our find-ings in relation to the text and relevant literature.

Conclusions and relevance for practice

Our study showed that experiences of loneliness amongpeople with mental ill-health can be metaphoricallydescribed as looking at the world through a frostedwindow. Furthermore, people suffering from mental ill-health and loneliness carry a twofolded stigma. They feelsocially undesirable because of their mental ill-health, andthe social perceptions of lonely people are generally unfa-vourable. Loneliness was described as an inevitable part of,or as a lot, in life. This is in accordance with Tillich (1963)who argues that the fundamental issues of loneliness is thefact that being alive means being in a body, separated fromall other bodies, and being separated means being alone. Byaddressing these issues, we believe that mental healthnurses can reduce the experiences of loneliness and supportthe developing and creative dimension of loneliness that is,solitude. This can be achieved through a confirmingperson-centred approach, where people with mental ill-health feel seen, heard, and respected as human beings.Furthermore, by encouraging solitude, people with mentalill-health may come to peace with loneliness.

Acknowledgement

We would like to thank the participants who shared theirstories with us.

References

Buber M. (1957) Distance and relation. Psychiatry

20, 97104.

Buber M. (1994) Jag Och Du. [I and Thou].

(German Original, 1923, Ich Und Du). Dualis,

Ludvika.

Cacioppo J.T., Hawkley L.K., Ernst J.M., et al.

(2006) Loneliness within a nomological net: an

evolutionary perspective. Journal of Research in

Personality 40, 10541085.

Cissna K.N.L. & Seaburg E. (1981) Patterns of

interactional confirmation and disconfirmation.

In: Rigor & Imagination: Essays from the

Legacy ofGregory Bateson (eds Wilder-Mott, C.

& Weakland, J.H.), pp. 253282. Praeger, New

York.

Civitci N. & Civitci A. (2009) Self-esteem as

mediator and moderator of the relationship

between loneliness and life satisfaction in ado-

lescents. Journal of Personality and Individual

Differences 47, 954958.

Dahlberg K. (2007) The enigmatic phenomenon of

loneliness. International Journal of Qualitative

Studies on Health and Well-Being 2, 195

207.

Erdner A., Magnusson A., Nystrm M., et al.

(2005) Social and existential alienation experi-

enced by people with long-term mental illness.

Scandinavian Journal of Caring Sciences 19,

373380.

Eshbaugh E.M. (2008) Perceptions of living

alone among older adult women. Journal

of Community Health Nursing 25, 125

137.

Ettema E.J., Derksen L.D. & van Leeuwen E.

(2010) Existential loneliness and end-of-life

care: a systematic review. Theoretical Medicine

& Bioethics 31, 141169.

Gaydos H.L. (2005) Understanding personal

narratives: an approach to practice.

Journal of Advanced Nursing 49, 254

259.

Graneheim U.H. & Lundman B. (2004) Qualita-

tive content analysis in nursing research: con-

cepts, procedures and measures to achieve

trustworthiness. Nurse Education Today 24,

105112.

Graneheim U.H. & Lundman B. (2010) Experi-

ences of loneliness among the very old: the

Umea 85+ project. Aging & Mental Health 14,433438.

Granerud A. & Severinsson E. (2006) The struggle

for social integration in the community the

experiences of people with mental health prob-

lems. Journal of Psychiatric and Mental Health

Nursing 13, 288293.

Hardiman E.R. & Segal S.P. (2003) Community

membership and social networks in mental



health self-help agencies. Psychiatric Rehabilita-

tion Journal 27, 2533.

de Jong Giervald J. (1998) A review of loneliness:

concept and definitions, determinants and con-

sequences. Reviews in Clinical Gerontology 8,

7380.

de Jong-Giervald J., Broese van Groenou M.,

Hoogendoorn A.W., et al. (2009) Quality of

marriages in later life and emotional and social

loneliness. Journal of Gerontology: Social

Sciences 64B, 497506.

Karnick P.M. (2005) Feeling lonely: theoretical

perspectives. Nursing Science Quarterly 18,

712.

Knight M., Wykes T. & Hayward P. (2003)

People dont understand: an investigation of

stigma in schizophrenia using interpretative

phenomenological analysis (IPA). Journal of

Mental Health 12, 209222.

Krippendorff K. (2004) Content Analysis An

Introduction to Its Methodology. Sage, Thou-

sand Oaks, CA.

Lindgren B.-M., Wilstrand C., Gilje F., et al.

(2004) Struggling for hopefulness: a qualitative

study of Swedish women who self-harm.

Journal of Psychiatric and Mental Health

Nursing 11, 284291.

Lundman B. & Graneheim U.H. (2012)

Kvalitativ innehllsanalys (Qualitative

content analysis. In: Tillmpad Kvalitativ

Forskning Inom Hlso- Och Sjukvrd

(Applied qualitative research in health care).

(eds Granskr, M., Hglund-Nielsen, B.)

Studentlitteratur AB, Lund.

Mellor D., Stokes M., Firth L., et al. (2008) Need

for belonging, relationship satisfaction,

loneliness and life satisfaction. Journal of Per-

sonality and Individual Differences 40, 213

218.

National Board on Health and Welfare (1992)

Vlfrd Och Valfrihet Service, Std Och Vrd

Fr Psykiskt Strda. (SOU 1992:73) [Prosperity

and Freedom of Choice Service, Support and

Care for the Mentally Ill.]. Allmnna Frlaget,

Stockholm.

Nilsson B., Lindstrm U. & Nden D. (2006) Is

loneliness a psychological dysfunction? A liter-

ary study of the phenomenon of loneliness.

Scandinavian Journal of Caring Sciences 20,

93101.

Nilsson B., Nden D. & Lindstrm U. (2008) The

tune of want on the loneliness melody loneli-

ness experienced by people with serious mental

suffering. Scandinavian Journal of Caring

Sciences 22, 161169.

Nummela O., Seppnen M. & Uutela A. (2011)

The effect of loneliness and change in loneliness

on self-rated health (SRH): a longitudinal study

among aging people. Archives of Gerontology

and Geriatrics 53, 163167.

Patton M.Q. (2002) Qualitative Research and

Evaluation Methods. Sage, London.

Peplau L.A. & Perlman D. (1982) Loneliness:

A Sourcebook of Current Theory, Research

and Therapy. Wiley-Interscience, New

York.

Rokach A. (2012) Loneliness updated: an intro-

duction. The Journal of Psychology 146,

16.

Routasalo P. & Pitkala K.H. (2003) Loneliness

among older people. Reviews in Clinical Geron-

tology 13, 303311.

Sandelowski M. (1995) Focus on qualitative

methods. Sample size in qualitative research.

Research in Nursing and Health 18, 479482.

Schreier M. (2012) Qualitative Content Analysis

in Practice. Sage, London.

Syrn S. (2010) Being in the World with Long-

Term Psychotic Illness the Unspoken and

Unheard Suffering. Doctoral Dissertation (No

6/2010). Linnaeus University Press, Vxj.

Thesen J. (2001) Being a psychiatric patient in the

community reclassified as the stigmatized

other. Scandinavian Journal of Public Health

29, 248255.

Tillich P. (1963) The Eternal Now. Charles Scrib-

ners Sons, New York. Reprinted in Hartog, J.

(eds) (1980) The anatomy of loneliness. Inter-

national Universities Press, New York.

Victor C.R. & Yang K. (2012) The prevalence of

loneliness among adults: a case study of the

United Kingdom. The Journal of Psychology:

Interdisciplinary and Applied 146, 85104.

Wiseman H., Mayseless O. & Sharabany R. (2005)

Why are they lonely? Perceived quality of early

relationships with parents, attachment, person-

ality predispositions and loneliness in first- year

university students. Journal of Personality and

Individual Differences 40, 237248.

World Medical Association (2008) Declaration of

Helsinki. Ethical Principles for Medical

Research Involving Human Subjects. Available

at: http://www.wma.net/en/30publications/

10policies/b3 (accessed 13 March 2013).



Documents

Experiences of Loneliness Among Persons With Mental Ill-health