Improving participation: Addressing loneliness and social isolation in populations

Loneliness and social isolation are recognized public health crises: In 2024, the U.S. Centers for Disease Control and Prevention (CDC; 2024) declared loneliness an epidemic. Occupational therapy practitioners (OTPs) are addressing this issue by embedding social participation goals into practice, supporting engagement in meaningful occupations, and collaborating across disciplines. In this article, we share an example from occupational therapy practice in home health that highlights how OTPs help clients rebuild social routines after life changes, using the Occupational Therapy Practice Framework: Domain and Process (OTPF-4; American Occupational Therapy Association [AOTA], 2020).

Strategies that OTPs can apply immediately include incorporating loneliness screening into evaluations, embedding goals into treatment planning, using technology to expand access, and leveraging everyday occupations to combat loneliness. The lessons OTPs can learn from our experience are the importance of structured activities, how to acknowledge and address stigma wellness, and how to navigate reimbursement challenges. Although prevention programs often rely on grants or partnerships, traditional occupational therapy services addressing loneliness are reimbursable in mental health, rehabilitation, and primary care. By addressing loneliness through client-centered and evidence-informed practice, occupational therapy enhances health outcomes, quality of life, and community well-being.

Background

Loneliness and social isolation are emerging public health crises that significantly affect the well-being and health outcomes of individuals across all demographics (CDC, 2024; Collins et al., 2020; Washington State Department of Health, 2024). Loneliness and social isolation are similar in concept but have different clinical definitions. Loneliness involves feelings of isolation or unpleasant emotions that reflect an absence of contact or bond with someone, whereas social isolation is an absence of support, social contact, or social network that gives a sense of belonging (Collins et al., 2020; Yanguas et al., 2018). People can experience loneliness both in solitude and within a crowd as well as in various social contexts (Perissinotto et al., 2012; Yanguas et al., 2018). Loneliness can affect anyone regardless of age, gender, or sociodemographics (Yanguas et al., 2018). Both loneliness and social isolation carry significant health risks, such as cardiovascular disease, stroke, Type 2 diabetes, depression, anxiety, dementia, and increased early mortality (CDC, 2023; Perissinotto et al., 2012; Valtorta et al., 2016). Occupational therapy has been proven to improve social determinants of health and enhance physical health outcomes across populations (Collins et al., 2020; Smallfield & Molitor, 2018). OTPs can help improve physical and psychosocial health outcomes during the lifespan through meaningful and purposeful activities, which, in turn can decrease health costs for those experiencing loneliness.

Adults living with chronic illness frequently have described the loss of meaningful social roles, the aging process, and the ability to communicate, which also affect their ability to engage in purposeful social or group roles (Collins et al., 2020). Adolescents with mental health challenges have reported withdrawal from peer activities, and people on the autism spectrum have often expressed a lack of close connections as well as feelings of isolation (Collins et al., 2020; Jefferson et al., 2023). These examples show the effects across the lifespan. The case example that follows demonstrates that loneliness is not simply an absence of contact but a disruption in occupational engagement. Loneliness requires a unique lens to target OTPs’ assessment and intervention in this area.

Occupational Therapy in Action

Case Example: Rebuilding Routines in a Home Health Setting

Marta (name changed for privacy) is a 62-year-old woman with a health history of chronic obstructive pulmonary disease (COPD). She is prescribed 2 liters of oxygen continuously at home and recently fell, resulting in a fractured tibia. After acute care she was admitted to a skilled nursing level of care for rehabilitation, and she has now been referred to home health occupational therapy services for treatment after being discharged home. Because of her COPD, Marta has been unable to work for 2 years. She has two adult children who have moved to different states, thus requiring a day of travel to physically connect. Marta reports talking to both of her children on the phone but states she never sees them anymore, and they only call once a week. She has become increasingly isolated since she stopped working and only leaves the house once a week to go to the store.

After her fracture and return home, Marta has been relying on online shopping services to deliver what she needs. She is successful in using adaptations to complete much of her ADLs but requires environmental modifications for showering, meal preparation, and other IADLs. She reports being lonely and struggles to connect with others. Her current stated goals obtained from completing her occupational profile indicate she wants to be able to complete food shopping weekly, spend some time with other people, be independent with meal preparation and cooking, and identify leisure activities to engage in.

Strategies to combat loneliness and isolation are critical to consider across all practice settings. Using a holistic lens in both evaluation and intervention is important to gather a whole person understanding of this client’s needs. To assist in this process, this case can benefit from assessments, such as the Leisure Interest Checklist (Gillen, 2016), Quality of Life Assessment/Checklist (Frisch, 1992), Role Checklist (Oakley et al, 1986), or UCLA Loneliness Scale (Russell, 1996).

The following is our exploration of traditional home care areas of focus (headings in italic) for using a holistic lens (words in bold) to increase awareness of how OTPs can incorporate a holistic lens into assessment or intervention to specifically combat the negative effects of loneliness for Marta. Using our OTPF to guide our holistic lens (AOTA, 2020)

· ADLs

• Showering/bathing and functional mobility:

§ Traditional lens: Make environmental modifications to adapt for change in performance because of orthopedic injury.

§ Holistic lens: Consider visual aesthetics to match clients’ preferences and ensure comfort to encourage visitors. Address proper grooming and hygiene, including clothing, to encourage socialization in the community.

· IADLs

• Meal preparation:

§ Traditional lens: Have the client cook a meal at home using a grocery delivery service.

§ Holistic lens: Consider the social aspect of meals. Explore meals and meal preparation. Solutions could include inviting a friend or neighbor for a meal they could bring a dish to share, and prepare a meal together. Takeout food could be substituted for food preparation: The client could order the food, set the table, add food to the dishes, and serve the food to share with others. Virtual context could also decrease isolation.

• Driving and community mobility:

§ Traditional lens: Explore and identify appropriate and reliable community resources.

§ Holistic lens: Include all desired activities as well as needed activities, including spiritual, leisure, and social activities, then consider mobility options.

• Safety and emergency maintenance:

§ Traditional lens: Ensure that clients can navigate current safety risks at home and implement a safety action plan.

§ Holistic lens: Preprogram family and friend contact information into a phone or tablet and have the client identify a social plan to combat loneliness, such as contacting one person each day—not just her children.

· Health management

• Social and emotional health promotion and maintenance:

§ Traditional lens: Ensure the client has a plan to increase socialization within her community to combat isolation.

§ Holistic lens: Encourage exploration of local resources, including senior centers, libraries, and hobby groups with peers or hobbies by herself. Explore virtual context for ease of access.

• Symptom and condition management:

§ Traditional lens: Ensure that the client will manage medical aspects of COPD, energy conservation, and pacing.

§ Holistic lens: Explore the effects of isolation as well as successful communication (e.g., energy conservation, pacing) and strategies that encourage social contact and decreased isolation as the result of symptoms.

• Physical activity:

§ Traditional lens: Have the client complete a home exercise program for lower extremity fracture and COPD management.

§ Holistic lens: Explore the use of virtual context to encourage exercise, use preferred or pleasurable activities to increase endurance, explore games in group settings, use home management for exercise to keep space clean and inviting for guests, and explore physical activities with others.

· Leisure

• Leisure exploration and participation:

§ Traditional lens: Identify and trial leisure activities appropriate for health conditions.

§ Holistic lens: Explore virtual outreach groups and consider the client’s identified challenges, including isolation and conditioning. Consider online hobby groups and tasks for connection (e.g., knitting, backgammon, collecting, recipe sharing).

· Social participation

• Community and peer group participation:

§ Traditional lens: Explore community and peer group activities appropriate for the client’s health condition.

§ Holistic lens: Review the occupation of social participation with the client. Educate on the risks and benefits of increasing social participation and decreasing isolation as an overarching goal.

• Family participation:

§ Traditional lens: Establish habits and routine phone conversation with the client’s children.

§ Holistic lens: Establish a routine with the client’s children and the client to ensure feasibility and explore virtual context options for activity connections (e.g., visiting museums online together).

Meeting a Critical Need

OTPs are well positioned to be leaders in addressing the loneliness epidemic. They have the skill for identifying and providing interventions to reduce isolation, feelings of loneliness, and stigma, thus improving overall quality of life. OTPs can use a holistic lens to explore areas of occupational engagement, such as roles, social and emotional health, social participation, and community resources with clients as an adjunct to a traditional lens, and use both lenses to improve safety, community mobility, ADLs, and IADLS. By consistently using a holistic lens in practice, OTPs can identify barriers and supports to each client receiving traditional services in the setting they are in. Marta’s case example demonstrates how structured and intentional opportunities for connection within a common practice setting can decrease the risk of loneliness. Using a holistic process can help occupational therapy clients improve social participation and quality of life while highlighting the profession’s distinct value.

Understanding that addressing loneliness is an inherent part of providing occupational therapy services is essential; indeed, that knowledge is central to supporting health, well-being, and participation. Clients may hesitate to acknowledge feelings of loneliness, and OTPs are well positioned to address this hesitancy within the occupational therapy process.

As OTPs continue to refine interventions, share lessons learned, and advocate for sustainable reimbursement models, occupational therapy’s unique value in addressing the epidemic of loneliness will become increasingly visible. OTPs are already bridging the gap and can be leaders in meeting this need. This is a call to all OTPs to include assessment (and intervention as needed) of loneliness for each practice setting to best serve our clients’ needs across all settings.

References

American Occupational Therapy Association. (2020). Occupational therapy practice framework: Domain and process (4th ed.). American Journal of Occupational Therapy, 74(Suppl. 2), 7412410010. https://doi.org/10.5014/ajot.2020.74S2001

Collins, T., Davys, D., Martin, R., Russell, R., & Kenney, C. (2020). Occupational therapy, loneliness and social isolation: A thematic review of the literature. International Journal of Therapy and Rehabilitation, 27. https://doi.org/10.12968/ijtr.2019.0044

Frisch, M. B. (1992). Quality of Life Inventory. In A. Freeman & F. M. Dattilio (Eds.), Comprehensive casebook of cognitive therapy (pp. 27–52). Plenum.

Gillen, G. (2016). Leisure Interest Checklist. In Stroke Rehabilitation: A Function-Based Approach (4th ed., pp. 296–300). Elsevier.

Jefferson, R., Barreto, M, Verity, L., Qualter, P. (2023). Loneliness during the school years: How it affects learning and how schools can help. Journal of School Health, 93, 428–435. https://doi.org/10.1111/josh.13306

Murthy, V. (2022, May 3). Our epidemic of loneliness and isolation [Video]. YouTube. https://www.youtube.com/watch?v=B8pa506BFk4

Oakley, F., Kielhofner, G., Barris, R., & Reichler, R. K. (1986). The Role Checklist: Development and empirical assessment of reliability. Occupational Therapy Journal of Research, 6(3), 157–170. https://doi.org/10.1177/153944928600600303

Perissinotto, C. M., Cenzer, I. S., & Covinsky, K. E. (2012). Loneliness in older persons: A predictor of functional decline and death. JAMA Internal Medicine, 172, 1078–1084. https://doi.org/10.1001/archinternmed.2012.1993

Russell, D. W., Peplau, L. A., & Cutrona, C. E. (1980). The revised UCLA Loneliness Scale. Journal of Personality and Social Psychology, 39(3), 472–480.
Russell, D. W. (1996). UCLA Loneliness Scale (Version 3). Journal of Personality Assessment, 66(1), 20–40. https://doi.org/10.1207/s15327752jpa6601_2

Smallfield, S., & Molitor, W. L. (2018). Occupational therapy interventions supporting social participation and leisure engagement for community-dwelling older adults: A systematic review. American Journal of Occupational Therapy, 72, 7204190020. https://doi.org/10.5014/ajot.2018.030627

U.S. Centers for Disease Control and Prevention. (2023, May 26). Loneliness. https://www.cdc.gov/howrightnow/emotion/loneliness/index.html

U.S. Centers for Disease Control and Prevention. (2024, May 15). Health effects of social isolation and loneliness. https://www.cdc.gov/social-connectedness/risk-factors/index.html

Valtorta, N. K., Kanaan, M., Gilbody, S., Ronzi, S., & Hanratty, B. (2016). Loneliness and social isolation as risk factors for coronary heart disease and stroke: Systematic review and meta-analysis of longitudinal observational studies. Heart, 102, 1009–1016. https://doi.org/10.1136/heartjnl-2015-308790

Washington State Department of Health. (2024, July 2). Public Health Connects: Rx for a lonely nation [Video]. YouTube. https://youtu.be/AOe0k29afhQ?si=p6f4-Z8mjEt6hjrt

Yanguas, J., Pinazo-Henandis, S., & Tarazona-Santabalbina, F. J. (2018). The complexity of loneliness. Acta Biomedica, 89, 302–314. https://doi.org/10.23750/abm.v89i2.7404

Colleen Muse, OT, OTD, MHE, OTR, is an Assistant Professor at MGH Institute of Health Professions in Boston and remains active in clinical home care setting. She has more than 20 years of clinical experience and is passionate about supporting clients in home and community-based settings to enhance participation, especially with client populations of chronic and lifespan conditions with a quality of life and wellness focus to practice. 

Deborah James, OT, OTD, MBA, OTR, is full time Faculty at Western New England University in the OTD program. She is passionate about raising awareness around mental health issues for all practitioners in order to better serve those we treat and has more than 30 years of clinical experience.