Since 1996, we have been studying loneliness and the decrease in the average number of confidants that most people have.1,2 We are gratified that the topic of loneliness is now less taboo, thanks in large part to press coverage during the pandemic about how difficult the isolation was for everyone. But we have also noticed how much Americans rely on their therapists to help them with their most intimate conundrums. We could not be more grateful to our patients who have entrusted us with their confidences over many years. But we also worry: have we contributed to a fraying of the social fabric by implying that confidences about the usual human conundrums are better saved for the ears of a therapist than shared with a close friend? Too many Americans are lonely “frequently” or “almost all the time or all the time” 36% in a recent study, including 61% of young people aged 18–25 and 51% of mothers of young children.3 We hear from our patients that it is often a friend who says the equivalent of “This is too much for me to handle; maybe you should see a therapist.” And despair and suicidal depression increase while our nation turns increasingly to the mental health profession rather than friends and relatives to help them with life’s knotty problems.
We have noted in our previous work on social isolation that the culture of most Americans includes a deep distaste for depending on others, and an over-valuing of independence and “having things one’s own way.”1,2 Even college students have the notion that only after successfully living alone and learning to enjoy their own company will they be well suited for a love relationship with someone else. Yet many of them get snagged by depression along this journey. People in their twenties find life notoriously difficult, a fact highlighted during the pandemic, when many started relationships with whomever was around, just not to be alone for the endless months of lockdown.
This emphasis on self-sufficiency means that although most Americans do not like relying too much on friends for fear of being too dependent, they make an exception for a health care provider. Our experience suggests that there is reason to be concerned that because mental health care is dominated by the medical model and the promise of a quick solution through medication, people use it preferentially to relying on a friend in a moment of mental anguish. For this reason, we believe that as a society we have come to believe that that is the right and sensible thing to do.
But over time, this emphasis on self-sufficiency hollows out the meaning of many friendships. Huge secrets used to be the currency of friendship. You told your important secrets to the people you liked best and trusted the most. Now if you entrust an important secret to a friend, that person might well recommend that you pursue therapy to figure out your next move. People impute an almost magical knowledge to therapists as if their medical training gave them some super-power to solve life’s difficult problems.
Through their disapproval of relying on others—and having others know their secrets—Americans seem no longer to have the skills of close friendship. We would like to suggest that between the pandemic and a culture that disapproves of dependence, most Americans have lost the knack for friendship with the various reciprocal rules that make it work. An unfortunate part of psychotherapy that both patients and therapists can forget is that it is a one-way relationship in which reciprocity gets deep-sixed for the sake of understanding the patient. This has the wonderful advantage of jump-starting a person who might have gotten stuck for a combination of reasons, including too much alone time, and too much belief in self-reliance. But when patients experience good psychotherapy, they can easily come to believe that it is the perfect blueprint for everything a friendship should be. Along the way, it can be easy to forget the joys of giving back empathy and understanding in a true friendship.
Certainly, there are some problems that a person should not take to a friend, problems that need the formal confidentiality and neutrality that a therapist offers and problems that can be solved (i.e., treated) by a specific brief psychotherapeutic approach. Some problems are also too much for most friends to “sit with”: suicidality, self-harm, psychosis, or any problem that makes the reciprocity of friendship impossible. Friendships are both very resilient and very fragile. They can only withstand an absence of give and take for short periods of time. That is one of the major differences between a therapist and a friend.
And of course, many patients simply do not have friends they can turn to. Their answer to the question, “Why don’t you take this to a friend?” would be, “What friend?” Sometimes loneliness and isolation are the very problems that bring them to treatment. Sometimes loneliness emerges alongside their presenting problem, at times a consequence of it, more often a cause. Then the problem of aloneness must become a focus of treatment, understanding the barriers to human connection, both internal and external, and developing a path to overcoming them.
A first step often involves patients relearning the joys of having someone they can talk to from their heart. With some people, this discovery in therapy will ripple into their everyday lives with others, transforming an acquaintance into a confidant, but more often both patient and therapist will treat it as a special gift of therapy. We need to remind our patients and ourselves that an important goal of therapy is to make it possible for the patient to experience that same satisfaction, that same experience of being thoroughly known by another, outside of a therapy relationship.
One obstacle many patients face is that they do not do their part to sustain friendships. Therapists may inadvertently make the problem worse through their skill in sustaining a relationship with very little help from the other person, creating a very unfortunate model of a good relationship for the patient. We hear often about patients who do not do their part in therapy, which is after all a relationship where the patient is the sole subject and object of interest. Usually, this problem signals that someone has not mastered the art of reciprocity in relationships. Outside of therapy, it translates into failing to respond to texts, emails, invitations and emotional gifts in a timely fashion. As therapists, we have a bird’s eye view of the problem of lack of whole-hearted engagement, and we can inquire about whether the patient has heard any complaints about not carrying their weight in other relationships. That very question often leads to a wealth of information about what goes wrong in relationships and may help patients deepen the relationships in their lives.
In 1964, Sidney Jourard wrote about the necessity of having at least one person in your life with whom you “could truly be yourself.”4 He felt this was necessary for a sense of well-being in the world and an essential goal of therapy. We worry that if therapists and patients allow themselves to believe that therapy is the sole relationship in which persons can truly be themselves, all other relationships in patients’ lives can be devitalized, deprived of the questions and the worries closest to a person’s heart—and that despite the comforts of therapy patients end up living in a lonelier and more disconnected world.
As a transformative first step to address the problem, the psychotherapy research community can define it more precisely. Measures that assess the effects of psychotherapy on a patient’s interpersonal connectedness and social supports should become a standard part of psychotherapy outcome studies. The social consequences of psychotherapy remain under-examined. Some studies have fueled our concern,5,6 while others suggest that for certain conditions (specifically depression and obsessive compulsive disorder), all treatments including biological ones improve social adjustment.5,7,8 Other illnesses like schizophrenia seem to require targeted interventions for improvement in social connection.9 The importance of positive social networks for maintaining sobriety has already led others to call on providers “to increase the extent to which they involve the social networks of clients when designing new treatment approaches for substance use disorders.”10
While by no means certain, it seems likely that we will find that different approaches to psychotherapy have different effects on social connection. A reasonable assumption is that the brief psychotherapies carry less risk of undermining connection. We suspect that is true, but we still wonder about the effects on the “natural” confiding relationships in a person’s life from turning to a professional at the most important moments, especially since brief psychotherapy is often sought multiple times and, in many settings, does not always remain brief. Interpersonal psychotherapy (IPT) stands out among the brief psychotherapies for its explicit focus on the interpersonal context and treatment strategies for improving close relationships. From the beginning, it offered evidence of enhanced social function with treatment.11
While we wait for further research-based answers to the question of specific psychotherapies differential effects on social connection, however, some simple adjustments in approach can, in our experience, have a major effect on preserving or enhancing patients’ engagement with others outside of the therapy. We can be explicit about the danger of reserving the most important conversations for therapy. Patients should be encouraged not to keep the content of their therapy secret, especially from a spouse or partner, who often these days is their best friend, a relationship we cannot afford to weaken. We can pay active attention to the state of patients’ other relationships, even if that is not the primary focus of treatment. We can point out that much of the relief, comfort, and perspective that we offer as professionals can often come as easily and effectively from a friend. And with certain questions and worries that come up, we can actually suggest, “Why don’t you take this to a friend?”
Declaration of interest
The authors report no conflicts of interest. The authors alone are responsible for the content and writing of this article.
1. Olds J, Schwartz RS, Webster H. Overcoming loneliness in everyday life. New York: Birch Lane, 1996.
2. Olds J, Schwartz RS. The lonely American: drifting apart in the 21st
century. Boston: Beacon Press, 2009.
3. Weissbourd R, Batanova M, Lovison V, Torres E. Loneliness in America: how the pandemic deepened an epidemic of loneliness and what we can do about it. Making Caring Common Project, Harvard Graduate School of Education, February 2021. https://mcc.gse.harvard.edu/reports/loneliness-in-america
4. Jourard S. The Transparent Self. New York: Van Nostrand Reinhold, 1971.
5. Schwartz RS: Psychotherapy and social support: unsettling questions. Harvard Rev Psychiatry 2005;13:272–9.
6. Sandell R, Blomberg J, Lazar A, et al. Varieties of long-term outcome among patients in psychoanalysis and long-term psychotherapy: a review of findings in the Stockholm Outcome of Psychoanalysis and Psychotherapy Project (STOPPP). Int J Psychoanal 2000;81:921–42.
7. Vittengl JR, Clark LA, Jarrett RB. Improvement in social-interpersonal functioning after cognitive therapy for recurrent depression. Psychol Med. 2004; 34: 643–58.
8. Asnaani A, Kaozkurdin AN, Alpert E, et al. The effect of treatment on quality of life and functioning in OCD. Compr Psychiatry. 2017 73:7–14.
9. Kopelowicz A, Liberman RP, Zarate R. Psychosocial treatments for schizophrenia. In: Nathan PE, Gorman JM, eds. A Guide to treatments that work. 2nd ed. New York: Oxford University Press, 2002:201–28.
10. Pettersen H, Landheim A, Skeie I, et al. How social relationships influence substance use disorder recovery: a collaborative narrative study. Substance Abuse Research and Treatment. 2019;13:1–8.
11. Weissman MM, Klerman GL, Paykel ES, et al. Treatment effects on the social adjustment of depressed patients. Arch Gen Psychiatry 1974;30:771–8.