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well as apparent accidents of fortune like rather something one feels all the time
car crashes and the weather. Though simply in virtue of the beliefs one holds
retaining personal characteristics such as about God and the world. Given a
love or anger, God operates less like an particular construal of those beliefs—a
individual human person with limited relatively impersonal one, I argue—
reach and partial interests, and more like simply having those beliefs in mind,
light, air or gravity do—quite with some awareness of their quite
pervasively and constantly. obvious presuppositions and
implications, makes clear one is never
Usually one side or the other
alone, never a self-sufficient operator. In
comes to the fore in the way Christians
contrast to the understanding of God as
feel connected to God: for some
friend, here God's invisibility does not
Christians the personal side of God is
threaten to interrupt a sense of God's
central; for others, the more impersonal.
presence and influence. God's
Thus, some Christians expect God to be
invisibility to the contrary enables the
very much like a human friend, offering
sense of God's presence and influence to
companionship and good advice?' As
be the routine backdrop of all one's
Tanya Luhrmann explores in her essay,
experience, to constitute a general
their religious lives often revolve around
outlook on the world, no matter what the
the internal sensory or imaginative
circumstances.
experiences that make a God of that sort
seem real to them--the sense that God is Belief in Creation as a Backdrop to
in the room with them, that God speaks the Whole of Life
to them, and so on. They work to
For example, a common
cultivate a prayer life that heightens the
Christian construal of the belief that God
vividness of those experiences and
is the creator of the world makes it
thereby allays doubts about the actual
possible for the sense that God is with
existence of this invisible, otherwise
one—one's supporter and sustainer—to
seemingly unreal, divine friend. In short,
be a constant feature of one's life as a
good practitioners of prayer gain a
whole. Contrary to first impressions,
stronger and more reliable sense that
God's creation of the world need not
God is present as a friend directing the
refer to the origin of the universe, or to
course of their lives.
the beginning of its more specific
Other Christians have features or components. Were either to
expectations of a more overarching and be its meaning, belief in God as the
impersonal sort about the way God is a creator of the world could not be a very
force in their lives; these expectations. I central component of a generally
suggest below, are the consequence of applicable Christian outlook, of much
their holding certain beliefs about God relevance, that is, for more than the
as the creator, sustainer, and savior of occasional speculation about origins:
the world. In this case a strong sense of e.g., why am I here at all? The belief
God's presence in one's life does not concerns instead a causal dependence
depend on having experiences of a upon God of a more continuous sort,
literally personal sort or on developing spanning, in short, the whole time of the
the spiritual practices that help cultivate universe's existence and therefore the
such experiences. The sense that God is whole time of one's individual life. To
present as an influence on one's life is be created by God is to exist in a relation
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of dependence upon God for what one is, pedagogical correction, just punishment
However, long one exists.'" A human for sin, the necessary testing of one's
being therefore depends upon God for faith, or simply a beneficial form of
more than the fact of his or her birth: he sympathy with God's own suffering on
or she remains dependent upon God in the cross. For both the general reasons
the same way ever after. God's creation just mentioned—because of its holism
of the world in general is simply not and temporal inclusiveness--belief in
temporally indexed; it is no more closely God as the creator of the world
associated with the beginning of things encourages love, gratitude, and trust
than with what comes later. A toward God, and toward the world that
preoccupation with temporal origins God brings about, as constant Christian
therefore commonly drops out of dispositions, basic Christian attitudes of
Christian accounts of creation: the world wide-ranging applicability, whatever
is just as dependent upon God for its might be going on in one's life.
existence whether it has a beginning or
Social Connectedness and Invisibility
always exists?' Belief in God's creation
of the world for these reasons blurs into The same all-inclusive causal
belief in God's supportive maintenance dependence upon God at all times is
of it at every point in time. what ensures individuals arc never left
on their own, never abandoned to their
Also enabling belief in God as
own devices. Christian theologians
creator to form a general backdrop to all
(especially in the Protestant tradition)
one's experience—to be relevant on
usually develop the psychological
every occasion as a universally
implications of this in terms of avoiding
applicable worldview--is the fact that
either anxious or arrogant self-
God is thought to be responsible as
concern.'" According to this theology,
creator for the whole of what happens in
one does not believe he or she ever
the world at any one time. To believe
operates independently of God.
that God is the creator of the world is at
Therefore, one should never attribute
the very least to believe that God holds
successes and achievements in a prideful
into existence the entirety of the world in
way to oneself, but rather one should
any and all respects in which it is good.
always give the glory to God as their
In the case of one's own life, therefore,
ultimate source. For the same reason,
every aspect of value at every moment—
one should never despair of failings, as if
one's existence, fine qualities and
one's own inadequacies were the last
capacities, enjoyments and
word; one believes a supremely
achievements, beneficial connections
powerful and loving influence. God,
with natural and social environments,
remains an operative force in one's life,
and so on—is to be attributed to God's
However, desperate the situation
agency as creator. While there is a good
otherwise appears to be from the
deal of disagreement within Christianity
standpoint of one's own powers and
on this matter, Christians, moreover, not
capacities to improve one's lot in life.
uncommonly affirm that God is equally
behind the bad things that happen, at By discouraging isolated self-
least insofar as those bad things can be regard or self-understanding generally,
turned to good account--for example, the same nexus of Christian ideas about
harm suffered turned into a salutary God as creator has clear consequences
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for loneliness or perceived social Having God as one's creator (in
isolation. Because they believe the best case scenario) is like having a
themselves to be creatures of God, perfectly loving human benefactor; but it
Christians feel related to God whatever is the unusual invisibility of this
happens. Whatever their social benefactor that allows Christians to think
circumstances--no matter, at the God present even when not apparently
extreme, how isolated or strong their so. Being in a relationship with God for
feelings of abandonment by human Christians who believe God is a good
others--individuals are to remember that creator is something like being in a
they remain in a relationship with God, relationship with a human person who
who is concerned about them. Even never lets one out of her sight and who
when they feel themselves utterly intends one's good comprehensively. It
forsaken by others, Christians have is, for example, very like being in a
reason to believe God cannot be relationship with a loving parent who is
forsaking them. They can believe they fully responsible, not just for the fact of
are never alone even when they appear one's existence, but in a comprehensive
to be absolutely so. In such way for one's nurturance throughout an
circumstances, Christians can always extended minority. Unlike a relationship
avail themselves of a completely with an ordinary human person of that
counterfactual sense of social connection sort, however, God is believed to be
with the best-connected "superfriend" of invisible and this is what allows
all—the God who remains, they believe, individuals to assume God's constant
in a relationship of ultimately beneficial presence, all appearances to the contrary.
causal efficacy with not just themselves
The invisibility that underlies the
but everyone and everything.
Christian affirmation of God's constancy
It is the very unapparent, here is a function of the very diffuseness
counterfactual character of God's of God's influence, a diffuseness of
influence on human lives—the influence no human person, invisible or
invisibility of God's influence, in short— otherwise, could possibly match. Belief
that permits Christians to perceive their in God as the creator of the world does
relationship with God as an unbreakable not encourage one to single out God as
constant. Because God's influence is the cause of any specific happening in a
unapparent or invisible Christians can way that suggests God is one cause
continue to believe God is operative for among many, the cause of this particular
creation's benefit in the absence of any happening rather than some other with a
of the obvious confirming evidence different cause. Belief in God as the
required in ordinary cases of beneficent creator of the world does not allow one
human influence. Christians who believe to identify God's influence in overly
that God is a universal influence for close fashion with any particular causal
good as the world's creator do not influence of a beneficent sort. Instead, as
expect God to be present in the way one I have suggested, whatever is of benefit
expects a human person to be; and to the individual, over the long or short
therefore God's apparent absence, in term, taken as a whole, is to be attributed
human terms, need not break down their to God's influence.
sense of being in relation to God.
The Christian cannot, then, locate
or pick out God as one could a loving
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parent from within the field of variously out of sight and mind, drops out of
operative forces or influences on one's Christian consideration for most intents
life, and for that reason the Christian and purposes, most of the time. Such a
need neither fear God's loss nor rue God has little to offer as a "pare-social"
God's absence as one would such a entity, as a factor fomenting or
parent's. Unlike relations with human supplementing a sense of social
others, which are situation-sensitive and connection.
thereby susceptible to change of
In the back of thcir minds
character, rupture, and decline, God,
Christians may believe that God is the
Christians believe, is with one, whatever
source of everything, but they may not
happens, in exactly the same capacity--
feel compelled to consider that fact
as the creator and sustainer of whatever
actively in the course of their everyday
it is that remains good about one's life,
lives. God hides behind, so to speak, all
be that only at a minimum the bare fact
the creaturely influences that God is
that one continues to live. The Christian
working through, which become matters
who believes God is his or her creator is
of primary Christian preoccupation. At
therefore confident that God continues to
the center of attention arc all the
work for his or her ultimate good, that
ordinary influences and connections with
God is engaged in the effort to increase
one's natural and human environments;
it, whatever the impediments in human
preoccupation with them pushes out of
life suggesting the contrary, absent, that
focal awareness the fact of God as the
is, almost any confirming evidence.
ultimate source of them all. Apart from
The Problem of Inattention specifically religious obligations—say,
the demand to give God thanks and
Although invisibility and
praise at times of worship—Christians
apparent absence do not pose the same
who believe God is their creator would
problem here as they do when God is
have no particular reason to dwell on
one's friend, this rather more impersonal
that fact.
understanding of God's influence as
creator and sustainer has its own Christian theologians commonly
problem maintaining a strong sense of tie this sort of practical worry--about
connection to God. The diffuseness of what from a Christian point of view
influence that lies behind God's constant amounts to sinful neglect of one's
invisible presence can prompt simple connection to God--to the understanding
Christian inattention to God. The very of double agency in the account of
monotony of the always pertinent creation I sketched above." According
Christian affirmation that everything is to that account, it is true, God's
to be attributed to God can make that influence on human life does not have to
affirmation recede from focal awareness, go by way of the human and natural
make it fail to come focally to mind. causal powers and influences on human
Belief in God's uniform presence would life that God creates; God can influence
thereby become functionally human life without producing sufficient
indistinguishable from the sense of created causes for what God wants to
God's absence. The invisibility of God happen in human life. (The Christian
that follows from a belief in the claim that Jesus was resurrected from the
comprehensiveness of God's influence dead—an event without natural causes—
simply means in that case that God drops is a case in point, one that Christians are
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usually very reluctant to give up.) But and so on. God also acts to give them
part and parcel of the account of creation God's very presence—by way, for
is the suggestion that God ordinarily example, of their relationship with Christ
influences human life by bringing about who Christians believe is God in human
the very natural and human influences flesh. The very presence of God in
that shape it. In general, because God human life means one's relationship
influences the world as its creator, God's with God cannot be ignored. The created
working does not begin where created causes and influences, through which
causes break off; God works, instead, in God also influences human life,
and through the created causes that God consequently no longer have the same
brings about. Christians are therefore capacity to distract human attention from
able to give a double account of most God.
happenings in the world: one that
Christians often believe,
discusses what has happened in terms of
moreover, that God's direction of human
the coordinated created powers and
life by way of God's own presence to or
activities sufficient to explain it within
within it is no optional matter: God's
the created order; and one that talks
presence forms an essential component
about God's creative activity in bringing
of human life. In addition to created
about those same coordinated created
capacities and influences brought about
powers, activities, and their
by God, God's presence is necessary for
consequences in their totality. It is the
ordinary human capacities to operate as
sufficiency of the explanation in terms of
they should.' To be morally good, for
created causes—the self-containment of
example, requires not just virtuous
that explanation within its own order—
capacities of one's own, given to one by
that allows human beings to attend to the
God, but the presence of the Holy Spirit
created order without taking into account
within one. Knowing well requires not
the relationship of dependence upon God
just the formation of good ideas through
that is its presupposition.
the usual human processes of
The temptation to lapse into investigating one's environment—the
habitual obliviousness of one's entirety of which has its source in a good
relationship with God is easily creator God--but also a mind informed
countered, however, by other beliefs by the very Word of God. And so on.
about God that Christians hold.
Such beliefs imply that attention
Christians do not just believe that God is
to God's presence, some sort of God-
the creator and sustainer of the universe,
directedness, should be a constant
but believe a lot of other things about
feature of an individual's everyday,
God. For example, the common
ordinary life, in order for that life to be
Christian belief that God acts as more
lived well. The individual Christian is
than a creator in individual lives helps to
accordingly given a reason to bring to
counter obliviousness to God. God does
mind his or her relationship with God,
not merely act as creator by giving
motivated to attend to that relationship
individuals the created gifts that make
as much as possible, indeed, in the effort
them what they are—for example, their
to lead a better life. An active God-
own capacities and operations, the
reference becomes part of a prospective,
ability to influence and be influenced by
goal-oriented process of self-reformation
their human and natural environments.
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in accord with what is believed to be Christian claims about salvation
God's intentions for one. often have an eschatological edge. They
frequently point, that is, to an end time,
Beliefs like this about God's
indefinitely deferred from the
presence as a constituent feature of
perspective of anything achievable in
human operations arc at times
this life. What God gives to remedy the
incorporated by Christians within an
sin of human life through Christ is,
account of creation: God's presence to
accordingly, not commonly thought to
or within them is then believed to be an
be fully effective in any visible way in
element of what God as the creator of
this life. Christians typically think that
the world gives to every human being;
their connection to Jesus brings with it a
and is in that sense part of the natural or
new availability of the presence of God
ordinary constitution of human life that
as a force for change in their lives, but
God intends in creating the world.'" But
what they expect to achieve by way of
more often than not the gift of God's
that constantly available relationship
presence as an effective influence on
remains invisible in the form of an
human life is specifically associated by
always deferred hope. Once again it is
Christians with salvation. Human beings,
invisibility—here the invisibility of the
Christians typically believe, have either
revolutionary changes in one's life for
lost altogether, or at a minimum,
which one continues to hope--that
habitually fail to attend properly to a
permits Christians to believe the
presence of God always theirs, in ways
presence of God, made available to them
that corrupt human well-being. The
in a new way in Christ for the very
Christian claim is that God saves human
purpose of bringing about those changes,
beings by giving them the presence of
is nevertheless always with them.
God as an effective force for human
transformation in virtue of something Conclusion
that Jesus suffers or accomplishes.
The main intention of this
God acts as an invisible force in chapter was to make the case that basic
human lives here because God Christian beliefs are likely to have a
influences humans through God's very bearing on perceived social isolation.
presence. Christians, if they follow the After suggesting that Christianity is not
common teaching of theologians in this all of a piece on that score, I developed a
regard, believe God is invisible or particular construal of basic Christian
unapparent because God is not capable beliefs that would seem to have great
of being delimited or circumscribed by potential to alleviate perceived social
the usual boundary drawing and sorting isolation through attention to connection
mechanisms used to cordon off and pin with God. While that argument was
down other things.' God is not, in merely a logical or prima fade one, it
short, a kind of thing, set off by clear forms a testable—though as yet
boundaries that distinguish God from untested—hypothesis: Does the
what God is not. But there is also here particular construal of the beliefs
the kind of invisibility discussed earlier: commended here for their
the invisibility of apparent absence in encouragement of a focal sense of
human terms. constant connection with God really
have those consequences? Do people
actually feel less lonely, in other words,
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when they hold such beliefs? Can they See Luhrmann in this volume.
be made to feel less lonely by calling
Thomas Aquinas is one prominent theologian
them to mind? More specifically, how
in the Christian tradition who highlights this
does the influence of this construal on
idea: "creation ... is the very dependency of the
feelings of social isolation compare with
created act of being upon the principle (God]
that of other construals—for example, a from which it is produced." Summo Contra
construal that directly associates God's Gentiles, Book Two: Creation, trans. James F.
creative influence with the irredeemable Anderson (Notre Dame and London: University
bad? How might the stronger sense of of Notre Dame Press, 1975), chapter 18, section
2, p. SS.
God's presence in the hardships one
suffers balance out in the latter case
See again, for example, Thomas Aquinas,
against the unhappy quality of the Summo Contra Gentiles, Book Two: Creation,
connection? Might one feel oneself to be chapters 31-38, pp. 91-115.
better off alone, in other words, if God is
See, for example, Martin Luther, Lectures on
as much one's tormentor as one's
Galatians (1535), in Luther's Works, ed. Jaroslav
benefactor? Finally, comparable
Pelikan (St Louis, Missouri: Concordia Publishing
problems to the ones for belief surface in
House, 1964), vols. 26-27.
the more experience-driven God-as-
friend outlook in Christianity, and make Thomas Aquinas again provides a clear
experimental testing pertinent?" If the theological exposition of this view. See, for
example, his Summa Contra Gentiles, Book
problem in both cases is that a strong
Three: Providence, Pan 1, trans. Vernon J.
sense of connection with God is hard to
Bourke (Notre Dame and London: University of
sustain—because God is invisible in the
Notre Dame Press, 1975), chapter 70, section 8,
one case or crowded out by more
p. 237: "It is also apparent that the same effect
obviously pressing matters in the is not attributed to a natural cause and to divine
other—how is the imaginative force of power In such a way that it is partly done by
the idea of relationship with God better God, and partly by the natural agent; rather, it is
shored up? By imagining that one is on a wholly done by both."
date with God, or by imagining that God
For prominent examples of such a view in the
is always all around one like the air one
history of Christian thought, see Augustine, The
breathes or the sun that shines? And Literal Meaning of Genesis, trans. John
what works for the greater number of Hammond Taylor (New York: Newman Press,
people? What if the former imaginative 1982), chapters 10-12, pp. 49-51; and Cyril of
capacities are hard to cultivate, and Alexandria, Commentary on the Gospel
According to John, trans. P. E. Pusey (Oxford:
require in any case exceptional abilities
James Parker, 1874), Book 1, chapters 7-9, pp.
of concentration or inward focus that
66-87.
many people lack? Might beliefs be
easier for most people to hold in mind See, for example, Athanasius, "On the
without sustained or disciplined Incarnation of the Word," trans. Archibald
practice? A simple visit to church or Robertson, in Philip Schaff and Henry Wace
(eds.), Nicene and Post-Nicene Fathers, vol. IV,
occasional perusal of a prayer book
Second Series (Grand Rapids, Michigan:
would do?
Eerdmans, 1957), sections 3-5, pp. 37-39.
References
See, for example, Gregory of Nyssa, "Answer to
For the general importance of belief for such Eunomius' Second Book," trans. M. Day, in Philip
investigation, see the essays by W. Clark Gilpin Schaff and Henry Wace (eds.), Nicene and Post-
and Tanya Luhrmann in this volume.
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Nicene Fathers, vol. V, Second Series (Peabody,
Massachusetts: Hendrickson, 1994), p. 257.
`See luhrmann in this volume.
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cycle are not notably successful, in large
The Elusiveness of Meaningful
part because the preconscious
Connection
disposition of lonely people toward the
Kathryn Tanner's chapter has world is difficult to change. Like Tanner,
developed the classical Christian idea although using different terminology,
that God is the creator and sustainer of Masi's review of the scientific literature
the world, in order to suggest the ways suggests both that the character of one's
in which this notion of the creator might general disposition toward the world is
be one factor providing persons with a profoundly important for one's
sense of social connection and a hopeful, connections to others, and that the
generous, and caring disposition toward processes by which these general
the world that assuages the adverse dispositions change are complex and
health consequences of loneliness. In warrant further scientific attention.
this classic interpretation of God as
creator, the idea refers not to the origins
of the universe but rather to the all-
inclusive dependence of life upon God at
all times. This sense of a sustaining
divine presence spanning the whole time
of one's life thus contributes a deep
sense of one's connection to the whole
order of creation. However, as Tanner
notes, people may become inattentive to
a presence so pervasive, just as people
can become inattentive to the forces of
gravity holding them to the surface of
the Earth as they go about their everyday
life. In more extreme versions of this
inattention, the person understands
humanity as "alone" in the universe, a
sort of metaphysical loneliness that
might exacerbate more concrete feelings
of loneliness.
Perhaps surprisingly, Chris Masi,
from the perspective of a physician and
medical researcher, casts a fascinating
and fresh perspective on the theological
notion that we live in a sustaining
connection to creation as a whole. After
describing the negative health
consequences of loneliness, Masi
proceeds to describe a cycle of
loneliness in which a person's sense of
isolation frustrates well-intended efforts
to make social connections. Masi finds
that efforts to intervene and break this
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l' a g e 1130
loneliness
The I7th century English
philosopher Thomas Hobbes proposed
that without the organizing structure of
mterventiorfg_
government, humans would experience
helium omnimum contra omnes (war of
all against all) and life would be
"solitary, poor, nasty, brutish, and
Chapter 1414
short"( I). While this colorful description
Visible Efforts to Change Invisible
is often quoted, less attention is paid to
Connections
Hobbes' premise that such misery can be
avoided if humans codify and enforce
the rules of a civil society. Not everyone
"The lead author is Christopher M. Masi, M.D.,
Ph.D., an assistant professor in the Department agrees with Hobbes' views, but history
of Medicine at the University of Chicago. He is is replete with examples of human
co-founder of Every Block A Village Online, an misery when anarchy reigns and of
Internet-based community development
relative peace when a social contract is
program, and is past president of the Illinois
observed. A question that philosophers
chapter of Physicians for a National Health
Program. He is the current president of the continue to debate is whether
Midwest Society of General Internal Medicine collaboration for mutual benefit is part
and has received numerous awards, including a of human nature or whether promotion
Models That Work Award from the United
of the self above all others is man's
States Bureau of Primary Health Care and the
primary motivation. In this volume,
New Investigator Health Sciences Research
Award from the Gerontological Society of Cacioppo argues that sociality is an
America. With a medical degree, as well as a integral part of human nature. He notes
PhD in social service administration, Dr. Masi's that given each child's prolonged period
research focuses on the socioeconomic factors
of total dependence, survival into child-
underlying health disparities. lie currently has
bearing age depends entirely upon the
two projects, one aimed at developing an
intervention to reduce loneliness and one focused support and protection of adults, most
on the role of sex hormones in gender, age, and often parents or kin. As a result, those
racial differences in cardiovascular disease. He who survive long enough to procreate
is a reviewer for several scientific journals and
pass along genes for nurturing and
grant-making organizations and has published
protection, thereby hardwiring a form of
research and reviews on diverse topics, including
health insurance reform and racial disparities in sociality into our genetic code.
breast cancer and hypertension.
This protective behavior helps
Human capacity for creativity,
ensure that genes within a family are
compassion, and learning is unparalleled in the
animal kingdom. However, humans reach their passed on to future generations.
full potential only when they are socially Cooperation among unrelated adults or
engaged. Lack of social engagement impairs
the support and protection of children by
creativity and learning, and limits opportunities
adults exists beyond kin, as well,
for caregiving and emotional growth. Numerous
because these activities also provide
studies have shown that loneliness is also a risk
factor for illness and premature mortality. survival benefit. Examples from early
Because loneliness is increasing in modern human existence include hunting and
society, it is critically important to understand
gathering, which are more likely to
this condition, as well as strategics to reduce it.
succeed when pursued as a group than
This essay describes our review of the literature
individually. To these structural benefits
regarding loneliness reduction interventions.
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of non-familial sociality, we may now "saw the people set on the sunny
add physiological benefits. A 1979 side of some high mountain,
population-basal study showed that there refreshing themselves with
adults lacking social ties were 1.9 to 3.1 the pleasant beams of the sun,
times more likely to die during a 9-year while I was shivering and
follow-up than those who had more shrinking in the cold, afflicted
social contacts, all else being equal (2). with frost, snow, and dark
Since then, at least five population-based clouds. Methought, also, betwixt
prospective studies (3) and numerous me and them, I saw a wall that
smaller studies have found positive did compass about this mountain
associations between social integration
and either survival or improved health
For chronically lonely people,
outcomes. The mechanisms by which
the wall between themselves and others
social integration enhances survival are
is partly of their own making and
several and include improved health
reflects continuous surveillance for
behaviors, increased access to resources
negative signals from others (5). The
and material goods, and strengthened
challenge is to help lonely individuals
immunity against infection (4).
break down the barriers between
Whereas sociality is a normal themselves and others and ultimately
state, loneliness is an unusual state, akin return to the normal state of sociality. In
to hunger, thirst, or pain (5). As with his vision, Bunyan achieved this, but
those states, loneliness is unpleasant and only through great effort:
serves to remind us that we should
"About this wall I thought
change the status quo. Therefore,
myself, to go again and again,
loneliness can be an adaptive motivator
still prying as I went, to see if I
for increased social surveillance and
could find some way or passage,
interaction. Unfortunately, not all
by which I might enter therein,
individuals succeed at achieving the
but none could I find for some
level of social connectedness they desire
time. At the last, I saw, as it
and suffer instead from chronic feelings
were, a narrow gap, like a little
of loneliness. Cacioppo and others have
doorway in the wall, through
shown that lonely individuals interpret
which I attempted to pass; but the
events and social interactions more
passage being very strait and
negatively than non-lonely individuals.
narrow, I made many efforts to
As a result, they unconsciously develop
get in, but all in vain, even until I
defense mechanisms, including social
was well-nigh quite beat out, by
barriers, which shield them from insults
striving to get in; at last, with
and rejection. While this approach may
great striving, methought I at first
achieve its goals of self-protection, it
did get in my head, and after that,
also reduces opportunities for positive
by a sidling striving, my
social interactions and perpetuates
shoulders, and my whole body;
feelings of social isolation (5). John
then I was exceeding glad, and
Bunyan, a 17th century Christian writer
went and sat down in the midst
and preacher, described the barriers
of them, and so was comforted
associated with loneliness when he
with the light and heat of their
wrote of a vision in which he
sun (6)."
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Genetic studies indicate that chapter, interventions are needed to help
heritability accounts for approximately lonely individuals regain normal social
50% of loneliness while social connections. As Bunyan's account
circumstances account for the other 50% suggests, breaking through the wall of
(7). Research also suggests that loneliness may require considerable
loneliness is common - reported by as effort. When individual effort is not
many as 20 percent of the population at sufficient, assistance from others may be
any given time (8). In addition, some needed. Unfortunately, contemporary
evidence suggests that the prevalence of interventions to reduce loneliness have
loneliness may be increasing, at least in fared more poorly than has been
the U.S. A recent national survey found recognized.
a threefold increase in the number of
Repairing Broken Connections
Americans who indicated they had no
confidant or person with whom to Almost a century ago, scholars
discuss important matters (9). Although began to propose strategies for reducing
differences between this survey and its loneliness. Karen Rook (11), for
1985 predecessor may be sufficient to instance, amassed over 40 interventions
account for this increase, this suggestive dating back to the 1930's in her attempt
report raises the possibility that to identify effective loneliness reduction
contemporary societal factors may be strategies. Since Rook's review, five
interfering with the natural tendency for scientific publications have provided
humans to form meaningful, long-term qualitative reviews of strategies to
social connections. One factor is social reduce loneliness, social isolation, or
mobility, which increased dramatically both (12-16). The most recent
during the 20'h century. A second is the publication identified 30 interventions
aging of the U.S. population. In 1900, published between 1970 and 2002 (16),
4.1% of Americans were 65 years or and evaluated the effectiveness of those
older. By 2006, that percentage had intervention studies that were not flawed
increased to 12.4%, representing 37.3 by poor design. Among the thirteen trials
million Americans (10). With less value deemed to be of high quality, six were
placed on older individuals in the U.S., considered effective, one was considered
we have witnessed an increase in partially effective, five were considered
marginalization of this segment of ineffective, and one was inconclusive.
society. Third, as life expectancy The authors' conclusions were similar to
increases, more elders are living longer those of prior reviewers who found that
as widows or widowers and are therefore interventions which emphasized social
at increased risk for loneliness. Other skills training and/or group activities
factors which may place Americans at were the most successful.
increased risk for loneliness include less
However, qualitative reviews are
intergenerational living, delayed
subject to invisible biases that can color
marriage, increased dual- career
our judgments of the scientific evidence
families, increased single-residence
we see. Thomas Kuhn, a 20'h century
households, and increased age-related
physicist and epistemologist, noted that
disabilities and health conditions. Given
scientists too easily accept results which
the mental and health risks associated
conform to previous intuitions and too
with loneliness described in Hawkley's
readily reject results which do not (17).
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In the case of loneliness interventions, scientific integrity of the findings),
all of the reviews essentially confirmed between 1970 and 2009 (to include and
the findings of previous reviews that extend the time interval reviewed
social skills training and group-based qualitatively in prior research), and had
interventions can succeed in reducing to measure loneliness quantitatively.
loneliness. Is this conclusion justified, or
Fifty-two intervention studies for
is this a case in which prior conclusions
loneliness met our inclusion criteria.
have been perpetuated in the manner
These studies were divided into three
Kuhn describes?
categories based on the experimental
To combat bias favoring results design used to assess the effects of the
that confirm dominant theories, some intervention. Twelve studies used a
scientists have argued that specific study single group pre-post design in which
criteria should be met to warrant an loneliness among participants was
evaluation of the effectiveness of the assessed at baseline and again after
intervention (18). These criteria include exposure to the intervention. The single
random assignment of study participants pre-post design is weak in terms of
to receive the intervention, evidence that measuring the effectiveness of an
the intervention is more effective than no intervention, however, because
intervention, findings that are replicated individuals who have high scores on a
by at least one independent research loneliness measure on one occasion are
group, and results that are published in likely to score less extremely on a
peer-reviewed journals. Previous second occasion even if no intervention
reviewers of loneliness interventions had occurred. Said differently, people
have, in fact, placed a premium on whose measurements suggest they are
randomized trials that contrast a group very lonely at one point in time, on
randomly selected to receive the average, appear to be less lonely when
intervention with a group randomly measured at a later point in time. Our
selected to receive no intervention. meta-analysis of these studies indicated
However, none has employed meta- there was indeed a lowering of
analysis, a quantitative technique for loneliness as measured before and after
calculating the average effect of diverse the interventions, but we cannot
interventions designed to accomplish the conclude from this evidence that the
same goal. Whereas qualitative reviews reductions in loneliness were due to the
are subjective and vulnerable to interventions.
confirmatory biases, quantitative reviews
Eighteen studies utilized a non-
are objective and relatively impervious
randomized group comparison design in
to bias as long as all relevant studies are
which some of the participants sought
included in the analysis.
out the intervention (the experimental
To minimize bias in our meta- group) while others (the control group)
analysis, we first combed the literature did not. In this design, assignment of
to identify all the intervention studies individuals to the experimental or
that specifically targeted loneliness. To control groups was based upon
further meet our criteria for inclusion in convenience, participant preference, or
the meta-analysis, studies had to be some other factor, which means the
published in a peer-reviewed journal or groups that did and did not receive the
as a doctoral dissertation (to ensure the intervention may differ in ways that
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explain different outcomes in the two contact with others. However, people
groups. For example, people who not only tend to like lonely individuals
volunteer to be in the experimental arm less than nonloncly individuals, lonely
of a study may be more gregarious by individuals are especially negative
nature and may be more likely to toward other lonely individuals.
become less lonely over time regardless Therefore, bringing lonely individuals
of exposure to the intervention. Results together is unlikely to result in warm,
of the meta-analysis suggested the satisfying social connections. Finally,
interventions might be effective, but to some interventions were designed with
know it's the intervention and not an the notion that what lonely individuals
artifact of subject selection, we need to need is social support, such as someone
look at the effect of these interventions who is available to provide help when
when assessed using randomized group needed. However, loneliness affects not
comparison designs in which only how people think, but how people
participants are randomly assigned to the think about others: loneliness
experimental or control group. diminishes people's executive
functioning and biases them to see others
Twenty-two studies utilized such
as threatening and rejecting even when
a design. Quantitative analysis revealed
they are not (5).
that, on average, the interventions had a
small but significant effect in reducing Cacioppo and Patrick (5)
loneliness. Moreover, efficacy in proposed a framework for reducing
reducing loneliness did not differ loneliness which includes four elements.
significantly as a function of First, unconscious barriers that
intervention strategy nor as a function of chronically lonely people develop to
individual- versus group-based shield against being hurt by others tend
implementation. Whereas once a to reduce their likelihood of having
consensus existed that social skills positive social interactions, and they
training and/or group activities could may benefit, therefore, from
reduce loneliness, we found insufficient encouragement and practice in forming
evidence to support that conclusion. social connections gradually in "safe"
environments where threat of rejection is
Why have successful
minimal. For instance, because
interventions to reduce loneliness been
chronically lonely people are self-
so elusive? There are several possible
focused in their hypervigilance for social
reasons. Some of the interventions have
threat, they may benefit from learning to
been designed with the notion that if
shift their attention from themselves to
only lonely individuals had better social
others through other-oriented activities
skills they would be able to form
such as volunteerism. The notion is to
satisfying connections with others.
intervene to diminish or eliminate the
However, recent research suggests that
negative effects loneliness can have on
at least for most adults, the social skills
social perception and cognition. Second,
they know are not related to the
we tend to think of loneliness as the
loneliness they feel. Other interventions
same thing as a personal weakness, as
have been developed with the notion that
being a social isolate, being depressed,
lonely individuals simply need to
or being weak. As noted above, we now
interact more with others, so the
know these accounts to be incorrect, and
interventions are designed to increase
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that acute loneliness, just like acute throughout the school year to assist the
physical pain, serves an important teachers in supporting and encouraging
biological function for our species. children in reading, writing, and
Being aware of how loneliness fits into mathematics. This strategy engages at
our remarkable achievements as a social least two of the principles that emerged
species and what loneliness does to our out of Cacioppo and Patrick's theoretical
social cognition and behavior can help framework (5)—the provision of a
us better understand the actions of others "safe" venue for making social
toward us. Third, to the extent that connections (i.e., the classroom of non-
desperation for social connections leads threatening children), and the shifting of
chronically lonely individuals to older adults' attention away from their
misguidedly vest their interest in those own concerns and toward the needs of
who are unlikely to meet their someone else. In addition, this strategy
relationship needs, they may need to capitalizes on Erikson's notion of
learn how to be selective and choose gencrativity (i.e., helping future
friends and groups with whom generations) (20). Interventions of this
reciprocally rewarding relationships can form deserve further assessment (21).
be expected. This decision is critical to
Conclusion
success. Research indicates that the
people with whom we are most likely to We began this chapter by noting
form positive, lasting relationships are that loneliness is not uncommon and,
those who have similar attitudes, beliefs, although unpleasant, may prompt
values, interests, and activities to our individuals to attend to and repair their
own. Therefore, people should not seek social connections. Loneliness affects
friendships based on physical cognition as well as well-being,
appearance, status, popularity, or however, and when loneliness persists it
convenience, but rather on attitudes, is a risk factor for myriad health
beliefs, values, and behaviors. Finally, problems. Previous reviewers have
because chronically lonely people expect suggested that loneliness can be reduced
to be disappointed with themselves and through interventions that emphasize
others in their relationships, they may social skills development and group-
benefit from training and practice in based activities. By quantitatively
taking a more optimistic perspective, in analyzing twenty-two well-designed
expecting the best from themselves and studies, we found no evidence that these
from others. We play a much more strategies were any more effective in
important role in shaping our social reducing loneliness than increasing
environment than we often realize. social opportunities or social support, or
modifying maladaptive social
Although no intervention to date
cognitions, whether in a group or
has incorporated all of these elements, at
individual context. A larger number of
least one randomized trial has
intervention studies may be needed to
demonstrated that an intervention based
determine the relative efficacy of these
upon volunteerism (Experience Corps)
intervention strategies. In the interim, it
can increase social activity in older
is clear from this review that global
adults (19). In this trial, older adults are
impressions and intuitions will not
paired with grade-school children and
suffice when trying to reduce loneliness.
dedicate at least fifteen hours per week
Future interventions should
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acknowledge that loneliness is not 5. Cacioppo JT, Patrick W.
synonymous with social isolation but is a Loneliness: Human Nature and
social pain that functions to motivate the the Need for Social Connection.
formation and renewal of meaningful New York: W.W. Norton &
social relationships. When feelings of Company, 2008.
loneliness fail to accomplish their
6. Bunyan J. Grace Abounding to
adaptive purpose, chronic loneliness
the Chief of Sinners. Grand
may ensue. Chronic loneliness tends to
Rapids, MI: Baker Book House,
be self-perpetuating through
1986.
confirmatory biases that alter cognitions,
emotions, and behaviors. Given the 7. Boomsma DI, Willemsen G,
importance of social connection to Dolan CV, Hawkley LC,
people's health and well-being, it is Cacioppo JT. Genetic and
important that we solve the puzzle of environmental contributions to
how to help the chronically lonely loneliness in adults: The
connect with others in meaningful and Netherlands Twin Register
satisfying ways. Study. Behavioral Genetics
2005;35(6):745-52.
8. Steffick DE. Documentation on
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attesting to the challenge of effectively
Reflections on Invisible Connections
addressing the problem of ruptured
Echoing a prominent theme in social connections.
this volume, Christopher Masi highlights
Invisibility should not thwart
once again the centrality of social
attempts to alleviate distress, however.
connectedness for human well-being and
Biological causes of disease were no
the function of loneliness in signaling a
more visible or evident in the 18th
rupture in a sense of social
century than psychological causes arc
connectedness. One might reasonably
today. Yet significant scientific advances
expect that a social species like Homo
during the l9`" and 20th centuries
sapiens would have a sufficiently large
completely revolutionized medical
behavioral repertoire to be able to
practice, life expectancy, and quality of
resolve feelings of isolation and restore a
life. Farr Curlin is less interested in the
sense of social connectedness. Although
invisible causes of disease than in the
resolution is accomplished readily in
primordial need for social connection
some instances for some people some of
that John Cacioppo introduced and that
the time, the reality is that at times
Curlin regards as a preexistent condition
people are at a chronic loss for how to
for medicine. If science can be viewed as
satisfy their need for social connection.
a cognitive system that steps us back so
Unfortunately, the invisible bonds of
that we can deal more objectively and
social connection are not easily repaired.
effectively with another person's
We see others' social activity, but we do
distress, then religion can be viewed as a
not see how they feel about their social
cognitive system that steps us forward to
lives and sense of connection. Despite
connect and care for others. Curlin
our inability to recognize loneliness in
argues that the practice of medicine
others, or, as Nick Epley and Jean
requires a balance of these forces, and
Decety argued earlier in this volume,
that the resulting tension between the
because of this handicap in seeing into
two produces better care for the patient
the minds of others, we tend to attribute
than does the practice of medicine using
to others what we ourselves have felt or
either alone.
would expect to feel in particular
circumstances. Is it any surprise that we
target for intervention those
circumstances where we observe few
opportunities for social interaction,
inadequate social skills, and poor social
support? On the other hand, because
loneliness is in the mind of the sufferer,
it is perhaps surprising that we would
expect changes in objective social
circumstances to be sufficient to
alleviate loneliness in all its sufferers.
Masi provides a quantitative review of
strategies employed to alleviate
loneliness to show that interventions to
date have been only modestly successful
in reducing feelings of loneliness,
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Pa gc 1139
Social Brain, Spiritual Medicine?
corseven E No one ever asks what science
has to do with medicine any more than
.patients!
Wes eler s they ask what books have to do with
r ir eft
education or what tools have to do with
:irras-OUP5saoarimair
carpentry. Before the middle of the 19th
-Sigalar
century, there was almost nothing that
medicine
physicians, however well intended,
could do to actually restore health to the
Chapter 1515
ill. Modern science changed that. Over
the past century and a half, dramatic
improvements in health outcomes have
IS The lead author is Farr A. Curlin, M.D., a
been wrought through the application of
hospice and palliative care physician, researcher,
and medical ethicist at the University of sterile surgery techniques, specialized
Chicago. His empirical research charts the hospital care, public health measures to
influence of physicians' moral traditions and prevent the spread of infectious diseases,
commitments, both religious and secular, on
antibiotics to treat those diseases, and
physicians' clinical practices. As an ethicist he
myriad subsequent technologies. All of
addresses questions regarding whether and in
what ways physicians' religious commitments these have been undergirded by the
ought to shape their clinical practices in our discoveries of biomedical science.
plural democracy. Curlin and colleagues have
authored numerous manuscripts published in the As a result, the life expectancy in
medicine and bioethics literatures, including a developed nations has doubled. People
New England Journal ofM edicine paper titled, live not only longer but with much less
"Religion, Conscience and Controversial
disability. Diseases that formerly
Clinical Practices." As founding Director of the
disfigured and killed, such as smallpox
Program on Medicine and Religion at the
and polio, have been almost completely
University of Chicago, Dr. Curlin is working
with colleagues from the Pritzker School of eradicated. Epidemics of malaria, yellow
Medicine and the University of Chicago Divinity fever, measles and diphtheria have been
School to foster inquiry into and public discourse
restrained. Injuries from war or other
regarding the intersections of religion and the
traumatic events, which in earlier
practice of medicine.
periods led predictably to death or
In the world of contemporary medicine.
science is front and center, and for good reason. profound disability, now can be
Science provides modem medicine with ameliorated using sophisticated surgical
extraordinary diagnostic and therapeutic
reconstruction techniques, advanced
capacities that can be employed to care for
prostheses, and intensive rehabilitation.
patients. Yet there is more to medicine than
Medical science already has
science can know. Science cannot provide
visions to animate care of the sick, moral accomplished an extraordinary amount
frameworks to guide the application of medical in alleviating human illness and
technology, or practices that nurture and extend
forestalling death, and there is good
ow sociobiological capacity to care for others.
reason to expect further progress. Yet,
For these medicine turns to religious and secular
for all that science has made possible,
moral traditions and practices. This essay
examines how religious concepts are implicit and medicine is animated by other, less
operative in practices of medicine and in the tangible, forces.
formation of fully human physicians. By
attending to these concepts, we may gain a richer
understanding of the way self-conscious human extend our unique, human, biopsychosocial
practices like medicine both depend on and capacities.
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To give a robust account for the own brains that mirrors (albeit at a level
practice of medicine, one must explain attenuated by training and other
why sick and debilitated strangers are contextual factors) the response we
worthy of attention and care, and how would have if we were suffering the pain
the medical arts contribute to human ourselves. These features of the human
flourishing. For some Americans, such brain allow us to pay attention to and to
accounts begin in secular moral some extent share in the suffering of
tradition, but for most they begin in others—capacities that are psychological
religion; nine out of ten Americans building blocks for caring for the sick.
endorse a religious affiliation. Either
Yet to explain medicine strictly
way, medicine looks beyond science to
on the basis of empirical science, one
find a vision that animates care of the
must solve a particularly thorny version
sick, a moral framework that guides the
of the more general problem of
application of medical technology, and
explaining altruistic human behavior.
practices that nurture and extend the
Decety notes, "The emergence of
human capacity to care for patients as
altruism, of empathizing with and caring
persons rather than as mere objects. In
for those who are not kin, is ... not
this sense, even though religious
easily explained within the framework of
concepts are rarely made explicit in
neo-Darwinian theories of natural
public and professional discourse about
selection." Indeed one can scarcely
medicine, they are everywhere implicit
imagine a practice less conducive to the
and operative, and necessarily so.
reproductive fitness of a population than
Why care for the sick? spending enormous resources caring for
the sick, the deformed, the weak, and the
Humans in all cultures are moved
aged. Natural selection and the physician
to care for the sick. The question is why?
would seem to be at cross-purposes: one
The concept of the social brain provides
works to eliminate the sickly, the other
the beginning of an answer. The peculiar
to save them from elimination. On this
human need and capacity for
account, medicine appears to be the sort
constructive, complex and meaningful
of dead end into which the evolutionary
relationships seems to involve
process sometimes blindly drifts.
neurological structures and functions
that also facilitate attending to the sick. Cacioppo, however, argues that
For example, Epley describes the human altruistic behaviors can be explained
capacity to pay attention to our own within evolutionary theory by paying
mindedness and the mindedness of attention to inclusive fitness and the
others. We are not only conscious of multiple levels of selective pressure:
ourselves, but we are conscious of others
...for species born to a period of
being conscious of themselves and of us.
utter dependency [e.g., humans],
This capacity allows us to be mindful of
the genes that find their way into
others' bodily suffering and mindful of
the gene pool arc not defined
their consciousness of our relation to
solely or even mostly by
them in that suffering. To mindfulness is
likelihood that an organism will
added the capacity to empathize. Decety
reproduce but by the likelihood
describes a neurological structure
that the offspring of the parent
through which the sight of pain in
will live long enough to
another person triggers a response in our
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