• Lonely for Different Reasons: Talking to Vivek H. Murthy

    When do our feelings of loneliness symptomize broader societal problems? When does loneliness itself cause acute challenges in individual lives? When I want to ask such questions, I pose them to Dr. Vivek H. Murthy. This present conversation focuses on Murthy’s book Together: The Healing Power of Human Connection in a Sometimes Lonely World. Murthy served as the 19th Surgeon General of the United States, appointed by President Obama. During his tenure, Murthy launched the TurnTheTide campaign, catalyzing a movement among health professionals to address the nation’s opioid crisis. He issued the first Surgeon General’s Report on Alcohol, Drugs, and Health — calling for expanded access to prevention and treatment, and for recognizing addiction as a chronic illness. An internal-medicine physician and entrepreneur, Murthy has co-founded a number of organizations, including: VISIONS (an HIV-/AIDS-education program in India), Swasthya (a community partnership in rural India, training women as health providers and educators), the software company TrialNetworks, and Doctors for America.

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    ANDY FITCH: Could we start with your sinking feeling when getting dropped off each morning of grade school? Retrospectively, could you articulate what this sense of loneliness signaled quite accurately about your emotional needs in that situation? But could you also describe how this loneliness felt in the moment more like an accusation?

    VIVEK H. MURTHY: I can first remember feeling lonely in elementary school. I’d have this physical sensation, this sinking in the pit of my stomach, as my parents pulled up in front of school to drop me off. I didn’t worry about exams, or answering teachers’ questions. I worried about feeling lonely during the day. I worried about heading out to the playground and not getting chosen for a team. I worried that if we did small-group activities in class, I’d be the one left without a partner. Lunchtime worried me most of all. Walking into the cafeteria, I’d wonder if I would have anybody to sit next to that day. Those feelings, they weighed on me throughout so much of elementary school. I just couldn’t wait for the three-o’clock bell to ring. I would just rush out to my parents’ car, so that I could get back to the safety, security, and comfort of a home where I knew I was loved — where I knew I belonged.

    Looking back on all of that now, Andy, gives me perspective in a couple ways. First, I can recognize that I wasn’t really alone in this experience, that many people around me felt the same. I just didn’t realize it then. I didn’t notice most of the loneliness around me, even though I felt it myself. And second, I now can grasp how enduring that loneliness for a prolonged period chipped away at my self-esteem, and kept me stuck in this lonely state. Longstanding loneliness erodes our sense of self-worth, which makes it even harder to reach out to people.

    You can become quite self-conscious and hypervigilant when it comes to interactions with other people. In retrospect, I understand how that played out in my own experience. I kept putting too much pressure on interactions with other kids, trying to come across as likable, trying to give them the person I thought they wanted me to be — but probably coming off as forced and unnatural and actually less likable. Though again I should make clear: this all remained just utterly baffling to me for a long time.

    And then I also should mention the shame that came with this loneliness. Even while still really young, I could sense this embarrassment about being lonely and feeling somehow incapable of making friends. The loneliness felt like proof that I must be broken or deficient in some way. So I never talked about it with my parents, for example. Again that just seemed too embarrassing. I’ve still never mentioned it to them, actually. I mean, these days, that conversation wouldn’t embarrass me. But I still don’t want them to feel like they did something wrong, or failed to notice this big challenge I faced — because the truth is that they were extraordinary parents, and still are. They’ve done so much to support me and give me the love that I needed, which still in many ways operates as the foundation for me moving forward in my life an adult.

    To further develop then this book’s definitional account, could you frame loneliness as a subjective sense that we lack the social connection we need (whether or not we have others around us)? Along the way, could you differentiate (and also show possibilities for overlap) among intimate, relational, and collective loneliness?

    Loneliness exists in that gap between the social connection we need and the social connection we feel is available to us. The social connection we need really differs from person to person, especially from extroverts to introverts. But we all need high-quality social connection in life, regardless of how much these connections occupy our days. And we can’t overlook the fact that our perceptions of quality social connection again remain highly subjective. Even when surrounded by people, we can feel quite lonely. We don’t inevitably feel connected to them. Or conversely, we might have very few people around us, yet feel profoundly connected through our strong relationships with them. In either case, the quality of the relationship matters most. In our strongest relationships (with a partner or spouse or certain very close family members or friends) we sense that we can show up as ourselves, that we can share without judgment, that we can be vulnerable without coming across as weak. To me, all strong relationships have these qualities.

    Though then, as you suggested, we also can distinguish among different types of relationships. We don’t need many of those most intimate connections. In fact, in all likelihood, we only sustain a handful of them in our lives. But they’re essential for our well-being. Relational connections also play a crucial role. These come from certain friendships we have, the people we spend time with on evenings and weekends, the people we meet for dinner or go to ball games with. When we lack those important ties, we experience relational loneliness. And collective loneliness comes from not having a community to which you feel connected (through some shared sense of identity). This shared identity might come out of a common mission that you take up with work colleagues. It might come from a community of parents volunteering at their children’s school. It might come through a shared faith institution or volunteer organization.

    Each of these different kinds of relationships plays its own distinct role in making us feel fully connected. Some of us might find ourselves in a deeply fulfilling marriage, but still feel lonely from a lack of good friends or strong community connections. Some of us see our spouse feeling lonely, and blame ourselves for somehow failing to provide the kind of fulfillment our partner needs. But sometimes loneliness happens within a strong romantic relationship, and points to other challenges in our personal and social lives.

    For one example now of a fused personal, social, and collective concern, could we look at today’s opioids-addiction epidemic, and discuss how it illustrates the diagnostic difficulties of clarifying cause and effect when it comes to loneliness? And then, in more practical or prescriptive terms, could you sketch what this book characterizes as the “seesaw relationship between loneliness and togetherness”?

    Yeah, I kept getting stuck on some of those questions as I delved deeper into writing this book, particularly around cause and effect. Addiction really does bring out these tensions. When I would speak to people around the country struggling with substance-use disorders, I’d so often hear threads of loneliness. People would speak quite directly to loneliness playing such a big part in their day-to-day experience, and in the pain they were enduring.

    Only over many conversations did I begin to recognize how consistently emotional pain correlates with loneliness. And when human beings feel pain, we seek to relieve it. So what options do we have, and what do we end up reaching for, during those moments of pain? If we can respond to this pain of loneliness by connecting authentically, and openly, and with vulnerability to another person, that might truly help us. But when emotional pain brings on one of those downward cycles of loneliness, characterized by diminished self-esteem, increased threat level, hypervigilance, that makes reaching out to others even harder.

    Still we somehow need to relieve this pain, and how we relieve it often directly shapes whether the loneliness persists, and whether it brings on further problems. If we reach for alcohol or drugs to numb this pain of loneliness, that creates increased risk for a substance-use disorder. If we reach for food, or for cigarettes, or if we lash out at others (because moments of aggression give us some sense of control), all of that can have detrimental consequences for ourselves and people around us.

    So that gives some sense of what I learned about how loneliness had emerged as a symptom of this deep emotional pain felt by many Americans. And then I also began to see how loneliness itself could cause so much pain, and bring on its own challenges. In communities across the country, people told me about their struggles with addiction: how they had lost friends, how they lost family. Loved ones had often lost faith in them, and so they too lost faith in themselves, and ended up even more alone. Of course this doesn’t only happen with addiction. Many people struggling with depression or anxiety likewise find themselves withdrawing from social contact — often when they need it most. So the seesaw effect you mentioned comes from loneliness sometimes operating as a cause, sometimes as a consequence, of these difficult conditions.

    But in either case, we should recognize the role that social togetherness plays in starting to address these issues. That especially stood out with people I met who had managed to get through this dark tunnel of addiction, and emerge on the other side in recovery. To a T, every single one of them could point to somebody or some group who served as a key source of support during their recovery. Maybe it was their mom. Maybe it was their spouse. Maybe it was their Alcoholics Anonymous or Narcotics Anonymous group. But some essential healing took place through these social connections, which seemed just pivotal to the process of recovery. So I came to learn that focusing solely on medical dimensions of care for people with substance-use disorders, talking exclusively about the medications they should receive or the clinical counseling they need, might take them one step forward — but that we could significantly increase the likelihood of successful treatment by also helping them to strengthen social connections in their life, and enabling them to find sources of support.

    So now to further flesh out loneliness as a subjective state, established when possibilities for connectedness fall below our loneliness threshold (as determined by cultural norms and/or individual expectations), what kind of continuum might you personally sketch that could include isolation, solitude, loneliness? And when does being alone not necessarily equate to being lonely?

    Well, being somewhat of a math nerd, could I first reorganize this on an axis?

    For sure.

    If you picture both X and Y axes, I would think of the horizontal axis as having loneliness on one end, social connection on the other. And then on the Y axis, I’d place a high need for solitude at the top, a low need for solitude at the bottom. From a definitional perspective, I’d frame solitude as time spent joyfully or purposefully alone. Solitude doesn’t suggest that we lack desired social connection. When we experience solitude, we feel good. And the amount of solitude we as individuals need would show up on that Y axis. Again, this need for solitude depends much on our individual personalities. For me personally, as someone inclined towards introversion, I have a higher need for solitude than I receive in my day-to-day life. So one specific challenge for me involves how to create this time, while still fulfilling my responsibilities to family and friends and community, and while still getting my work done.

    But returning now to the X axis: people definitely exist on a spectrum of loneliness and social connection. An introverted person still can end up quite lonely. An extroverted person can end up lonely for different reasons. Again it depends on where this gap arises between the social connections you need and the social connections you have.

    And even for those less inclined to seek out solitude, how might solitude help all of us in fact to develop comfort with ourselves — enhancing our capacities to connect with others?

    Right, we may differ in how much solitude we need, but we all do need some of it. And here we also should recognize how our modern lives have increasingly etched out opportunities for solitude. To access solitude today, we might need to proactively set aside time to meditate, to pray, to be in nature, to simply sit outside on the porch or park bench and feel the wind against our face, and remember what we’re most grateful for.

    We also experience unintended moments of solitude, when a friend gets delayed five minutes in meeting you at a restaurant, or as you wait at the station for the subway to come. I think of this as potentially soothing white space in our lives, but I see it quickly evaporating, mostly because of smart phones. Just when the moment for solitude arrives, we might pull out our phones and fill the time with news or emails or stories in our social-media feed. I don’t mean to judge that response. I often pull out my own phone in those moments.

    So why does solitude matter? Well, it’s the time in our day when we can allow the noise around us to settle a bit. We can feel a moment of calm. We can reflect on what’s been happening in our life, on conversations we’ve had, on both pleasant talks and disagreements that have come up. We can process more, and allow ourselves to recognize and appreciate what we’re feeling. That sounds so simple, but so often doesn’t happen. You can move from day to day through a busy, filled, over-scheduled life, and never really acknowledge the grief or pain or worry you’ve been feeling. And the more you pursue solitude in structured ways (say through prayer, or gratitude, or spending time in nature), the more you might find yourself able to direct your mind towards feelings of joy or peace. Solitude then can end up playing this extraordinarily important part in anchoring us and centering us — in a world moving at such a fast pace, often pushing us off-kilter.

    Could you describe a bit your lived experience of both knowing yourself as someone who needs this solitude, and yet taking on a demanding (often quite public) professional role? And do you sense, say in government or equivalent executive-level professional life, many people with part of themselves thriving in this high-intensity environment, as another part of themselves feels great dissonance?

    Absolutely. During my time researching this book, I talked to many, many people in positions of leadership (both in government and the private sector) who struggle with loneliness, or who have a deep need for solitude that often doesn’t get met. We live in an extroverted culture. This culture tells us that to succeed as a CEO or politician, you need to be gregarious. It tells us that we all should be out there shaking people’s hands, attending events, soaking up social contacts whenever we can. But at the same time, you can find today endless examples where somebody’s position on an introvert/extrovert axis just doesn’t correlate with their abilities as a good leader.

    So when I thought about how I wanted to live my own life as Surgeon General, I considered it very important to create a reflective organizational culture, and to allow time for solitude, and to recognize this as a key part of how we could maximize our contributions to public health. We actually offered to train anybody in our office who wanted to try out meditation. We made it okay for people to take time if they wanted to meditate or just get some solitude during the day. You didn’t have to slink off to the corner, and hope nobody accused you of being an irresponsible slacker. We deliberately normalized these activities as part of our office culture. I too would take (not as often as wished, but often enough) 20 minutes when I could just breathe and allow myself to be.

    Over time, Andy, I’ve come to recognize that in the rapid-paced, action-oriented society in which we live, it is easy to prioritize doing (action) over being (our state of mind). But “being” precedes and enables doing. The time we spend focused on being centered, calm, and at peace is like a force multiplier. It enables us to “do” more, and to do it more efficiently and effectively, whether this means connecting with others or executing on a task. When faced with a difficult problem, we might first think: Okay, I’ve got to spring into action and deal with this. But sometimes we actually need to step back and pause and let things settle, and remember who we want to be, and then bring the full force of ourselves to a situation. Again, that simple-sounding practice in fact makes a bigger countercultural point in a fast-moving world always pushing us to act.

    I think back to certain moments before we went onstage to unveil a major Surgeon General report. I think about the evening before we hosted a town hall in Flint, Michigan, during the height of Flint’s water crisis. I think of important moments before launching our big opioids campaign. In all these instances, we made it a point to pause before leaping to action. We literally stood together. We closed our eyes. We took a deep breath, and then each person around the circle shared a reflection on what they most hoped for in that moment. Some people drew on their faith backgrounds. Others gave a statement of optimism and spoke to all they wished for in the campaign we were about to launch. Andy, these centering moments probably took us less than two minutes. But they allowed us to make big decisions, and often to take on difficult questions — standing firmly together rooted in our values, recognizing who we wanted to be, and feeling more capable of bringing our full selves to that moment.

    The truth is that we all have 30 or 60 seconds, even before big moments in our lives, to pause this way. I can think of countless times when I should have done that. Writing this book made extra clear to me that those moments of pause can offer a distinct and very important type of solitude. Those moments ground us and center us and empower us — all at the same time. I want to build more of those moments into my life.

    Here maybe we can bring in certain biological and evolutionary components to the lived experiences you describe. So first, pivoting back to loneliness: what about the lonely person who takes preliminary steps to connect with others, but who then finds the whole process pretty fraught and frustrating? What sorts of hypervigilance might play a problematic part? What might such internalized vigilance signal to lonely people about the level of external threat they supposedly face? And what might their self-preoccupations signal in turn to would-be companions?

    As hunters and gatherers, we evolved to depend on trusted relationships. Those relationships became key to our survival — so much so that if separated from our tribe, we faced greater risk of getting attacked by a predator or starving from an insufficient food supply. And given how we had grown so tethered to each other, humans would feel loneliness at a deep visceral level (as we might today feel fear or panic) when separated from their tribe. Feeling lonely meant feeling exposed to danger. Our overall threat level would spike.

    So if you put yourself in one of our ancestors’ place thousands of years ago, if you get separated from your tribe, you actually want this elevated threat level and increased vigilance. If a twig snaps behind you, even with only a one-percent chance of it being a predator, you want to assume it’s a predator, because your life may depend on that. The problem is, if you transport that same response system to the modern world (of course not very far away, in evolutionary terms), this kind of hypervigilance accompanying loneliness may become counterproductive.

    Hypervigilance shifts your focus inwards as you fear for your personal safety. When experienced chronically, that elevated level of threat, leading to suspicion and increased focus on self, can make it much harder to connect with other people. Again, to put this in a lived personal context, if you find yourself overly focused on other people’s reaction, or overly suspicious of others perhaps talking about you, or of their intentions when they’ve simply reached out to ask if you want to spend time together — to me those offer classic examples of how an elevated threat level can have the consequence of deepening our loneliness.

    Similarly, hypervigilance and an increased focus on ourselves can come across as off-putting or unnatural to others. When you sense a fraught social situation, and go out of your way to be who you think the other person wants you to be, that often backfires. Most of us have fairly sharp (and often accurate) gut feelings telling us whether the person before us is being real or not. So here again the behavioral consequences of loneliness can make our social interactions more strained, precisely when we need to reach out and be ourselves in order to build stronger social connections with others.

    For the shame then that you’ve mentioned a couple times, could you describe the importance of health professionals, of policymakers, of us all recognizing “human relationship” as an embodied need (both for individuals, and for the species), akin to existential reliance on food and water? How might this designation help to destigmatize loneliness — so that those afflicted by loneliness feel less compelled to hide it, and so that others in their life don’t shy away from discussing such topics? And how might recent decades’ destigmatization of addiction or depression provide useful precedents?

    Social stigma is one of the greatest (and most unnecessary) challenges we face with substance-use disorders. Something similar plays out with loneliness. If we feel a sense of shame around our struggles with addiction or feel like we’re the only ones dealing with loneliness, that makes them much, much harder to acknowledge — not just to others, but to ourselves. And if we can’t even acknowledge the problem, then we can’t start taking concrete steps to address it.

    From the existing work on substance-use disorders, I’ve learned that one most powerful way to start overcoming stigma is to speak openly about our own struggles. When we do this, two things happen. First, we ourselves feel a sense of relief, as we begin closing this gap between the person we are and the person we represent to the outside world. Second, we empower others to speak up as well — people struggling with addiction themselves, or their family members. The same principle applies to reducing stigma around loneliness. When you look at the data, when you start to grasp how many people in the modern world struggle with loneliness, you also recognize that each of us undoubtedly has very lonely people in our lives, whether or not we know precisely who. And the more we can open up about our own struggles, the more other lonely people will feel empowered to do the same.

    Of course that takes courage. Here again, I think of all the people I’ve met who not only have lived with addiction, but have become advocates for others and for better treatment. Many have described how the first time they spoke up to share their struggles with addiction…how those moments didn’t come easy. They felt a lot of fear and worry beforehand. They often needed a good friend to keep encouraging them, or some similar source of strength they leaned on, whether through prayer or through family support. But once they did speak the truth, that act itself had extraordinary effects. And one of my basic hopes, Andy, with this book, is to help people struggling with loneliness recognize that they aren’t alone in feeling this way — or that, even if you yourself don’t feel lonely, you likely know somebody who does. Our ability to start up those conversations with each other (those conversations about loneliness, those reflective conversations about the place of social connection in our life) can help us take a couple really important steps towards reducing the shame.

    Your formulation of loneliness as “the great masquerader” (perhaps appearing as anger, alienation, sadness) also stood out. Could we consider, for example, gang membership and gang violence as classic manifestations of profound personal loneliness projected into the public sphere? And while progressives might absorb such an account with a good deal of sympathy, where might it likewise help to see (within limits, of course) expressions of distrust, hostility, and aggression on today’s populist right as expressing unmet needs to feel secure, welcome, connected, respected, understood?

    I consider this a really important topic, and I’d start from the basic suggestion to think about anger, resentment, meanness, as almost always a reflection of some deeper pain people are experiencing. Again emotional pain can isolate us. It often makes us feel even more alone. It can push us even further away from others — including from those reaching out on purely friendly terms. When pain makes you express anger, you push people away. When you resent somebody, that increases the social distance. When your communication gets harsh, you typically don’t draw people towards you.

    So emotional pain can itself drive loneliness, which can drive more anger and pain, which drives more loneliness. This doesn’t mean every instance of anger happening around us comes entirely from loneliness. But it does mean that, more often than we might think, when people express anger or related feelings, they may themselves face a powerful mix of pain and separation. And one of our most powerful tools for healing in such circumstances is this force of social connection.

    If you look at any number of polarizing issues plaguing us today (whether how to address gun violence, or reproductive rights, or climate change), you find a lot of anger. This anger won’t get resolved by putting two people in the same room and asking them to talk through their policy arguments so they can find a middle ground. Reducing polarization requires true dialogue. The foundation of dialogue is relationship. We build relationship by approaching people with a desire to understand who they are (their values, their hopes, their fears, their life experiences), and by being willing to share the same about ourselves. When we build relationship, we can listen better to others, and give each other the benefit of the doubt. It’s a lot harder to hate somebody when you get close enough to see them as a human being with common aspirations and fears. And without dialogue, we can’t come together to take on big collective problems like economic inequality, climate change, or a global pandemic.

    Turning then to gang violence, the stories I heard at ARC (the Anti-Recidivism Coalition) will always stick with me. I spoke with two extraordinary men who felt driven to join gangs because of a chronic lack of belonging they experienced throughout childhood. The need to belong is our evolutionary birthright, and can drive us to do extraordinary (sometimes reckless) things. In everyday life, you’ll find young boys and girls at times engage in dangerous activities just to feel like part of the group. They actually feel that’s less dangerous and less painful than getting shut off from their community.

    And here again, we all react quite differently to pain. Some of us express our pain in the form of anger. Some of us lash out at others, manifesting our pain through violence. But other people retreat further and further into their shell when they feel pain. We might see them and say: “Gosh they’re so aloof. They think they’re just better than everybody else.” Though that might not account at all for what’s happening. That’s why I think of loneliness as the great masquerader — showing up in many different forms, and in different parts of our lives. To some extent or other, we all walk around with masks on, trying to look like happier or smarter or funnier or better-adjusted versions of ourselves. But in those moments when people feel you won’t judge them, when they sense you understand who they are and where they’re coming from, they might take their masks off, and let you see much more of them. That’s when you can build relationship and develop the foundation for dialogue.

    Yeah, here your depiction of various cultures and demographic subgroups having their own distinct loneliness thresholds stoked my sense of personal guilt — say for failing to grasp certain elders’ reluctance to follow COVID-19 physical-distancing guidelines. Could you describe a few ways in which, as you researched this book, loneliness among elderly populations especially stood out?

    While writing Together I was often struck by the toll loneliness takes on all age groups, but especially on the elderly. That kept reminding me of certain basic cultural differences in how we treat people as they age. In some societies, older generations stand out as sources of knowledge and wisdom. They merit extra respect. They occupy a larger and larger space of social significance. In many of these societies (often more traditional societies, including the village in which my father grew up), the elderly still have intimate emotional connections, and still live in close physical proximity to younger generations. They often head (at least in some symbolic sense) the extended household in which they live.

    But in other societies (with our US culture here standing out), as people get older they feel less relevant, less useful, less respected, less valued, less cared for, and less seen. They sense themselves disappearing to the periphery of life, closeted away in their own residences or in nursing homes, often limited both by physical disabilities and by sensory deficits like hearing loss. Since many of them don’t live with family, they also feel increasingly disconnected. Their friends also develop immobilizing limitations, and start to pass away. They have fewer and fewer people to interact with. This doesn’t happen to everyone, to be sure — many elderly Americans live lives with rich social connection, and feel deeply valued. But so many feel quite the opposite.

    Could you close then by pointing to a few most effective loneliness interventions that you have seen for this group — maybe, for instance, targeted approaches to gendered aspects of loneliness?

    We don’t always need to fundamentally transform our family routines and social patterns in order to restore a strong sense of connection. Small steps can make a big difference. The Men’s Shed movement definitely stands out in this way. Who would have thought that giving groups of men some space to do woodwork or metalwork a couple times each week would have such a powerful impact on how they feel about themselves and about each other? But it does.

    I did a recording for this virtual book club the other day, and at the end the producer said: “I just have to tell you, on a personal note, that I read what you wrote about loneliness often manifesting as irritability and anger — with older people facing heightened risk as they retire or get ill or lose a loved one. And I looked at my father and realized that this is exactly what has been going on ever since he retired from practicing medicine. And I actually went to him and said: ‘Dad, I think I know what’s going on. I think you’re lonely. I think you need more connection.’” Her father first expressed skepticism. So she literally took the book to him, and said: “You know, a fellow physician wrote this book about loneliness, and how it can manifest in these deep and complicated ways, and take over your whole life.” So he started reading through the book, and eventually shared that he has in fact been feeling disconnected. And now she’s actively considering starting a Men’s Shed in LA, so that her dad can participate and build more connection.

    Loneliness is more common than we think. But the solution doesn’t have to involve completely reinventing our lives. It can mean making sure to offer opportunities like the Men’s Shed. It can mean having relatives and friends reach out with time to spend — with the intention of just showing up, listening, and being fully present. A few years ago, my high-school history teacher said to me: “Remember that the greatest gift you can give your parents is the gift of your time and attention. More than any material object you could offer, that’s what will make the biggest difference in their life.” And she’s right. In a very concise way, she captured what we need to give (and in fact what we owe) to older members of our community.

     

    Photo Credit: Meredith Nierman.

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