Editorial: Circle of Friends, an Encouraging Intervention for Alleviating Loneliness.

COVID-19 lockdown has crystalized the significance of older people’s loneliness. This editorial defines loneliness and its adverse effects on the health and wellbeing of older adults. It describes how professionals in the health and social care sector can recognize and address older people’s loneliness and how to offer them appropriate interventions. The Circle of Friends is a group intervention developed specifically for lonely, older people and has shown to effectively improve their health and wellbeing. We present the essential elements and current state of Circle of Friends.

“Loneliness is like you have been dropped down into an empty, dark room. And you can only hear your own voice echoing off the walls.”

This poem was written by an older person and describes his miserable feelings of loneliness at the beginning of the “Circle of Friends” group intervention. The COVID-19 pandemic and lockdown have highlighted how important social relationships are to all of us. We have also seen and been worried about older people in social isolation, separated from their meaningful others (1). However, people may also still feel lonely when surrounded by a social network. Loneliness derives from the gap between the desired and actual level of social interaction (2).

In recent decades, aging research has consistently shown that loneliness has many adverse health outcomes. It predicts cognitive and functional decline (3–5), chronic diseases (6), the use of health services (7) and mortality (6, 8). Loneliness impairs quality of life (QOL) (9) and psychological wellbeing (10).

Although loneliness is a health risk, it is also part of normal human life and almost every one of us occasionally suffers from it. Thus, loneliness may be transient, and people often cope with it on their own (11). Reading, walking, having pets, and gardening have been suggested as appropriate means of self-management for lonely older people (2). Older adults also maintain many relationships in later life, which prevents loneliness (12).

However, about 20–30% of older people in developed countries suffer from loneliness and about 5–10% suffer constantly (13). A large proportion of these people are unable to use appropriate means for coping or alleviating their loneliness. Furthermore, although many of them have a wish to escape their loneliness, they may be ashamed to express their feelings (14). In this situation, loneliness can become chronic and harmful if not addressed in time. The social and health care sector needs to become more aware and recognize loneliness among older people and, in particular, offer effective interventions (15).

Addressing older people’s loneliness can be difficult for many reasons. Firstly, we have to trace older people who suffer from loneliness and who may benefit from interventions. Asking about loneliness is challenging for professionals (15). Secondly, recruiting lonely older people for interventions is problematic. Admitting and expressing feelings of loneliness may be difficult for older people because of its stigmatizing, undesirable nature (16). Thirdly, the results concerning the effectiveness of loneliness interventions are conflicting. Those offering social activity with peers in a group format, in which older people play an active role have shown efficacy (17).

When intervening in loneliness, three approaches seem to be useful (18) 1) increasing contacts and reducing the perceived discrepancy between actual and desired relationships 2) decreasing relationship standards to meet realities, or 3) reducing the effect of the discrepancy by accepting and coping with feelings of loneliness. An effective intervention using these approaches to improve the well-being of lonely older people is the “Circle of Friends” (7, 19) developed and run by The Finnish Association for the Welfare of Older People. According to Hawkley & Cacioppo [6], it may be the only form of intervention that is also effective for preventing adverse health effects of loneliness. Savikko et al. (20) presented the essential elements required of the participants and facilitators, favourable processes among and within the group, and the mediating factors that occurred during the group process and promoted the alleviation of loneliness. In the randomized controlled trial, the Circle of Friends improved lonely older people’s health, cognition and wellbeing, reduced the use of health care services and mortality among the participants (7, 19, 21).

The Circle of Friends is a closed face-to-face group of six to eight participants suffering from loneliness, who meet with their peers 12 times, once a week, for three months. A closed group means that a facilitated group process has a clear beginning and end. New participants are not added after the intervention has started, even if some group participant(s) drop(s) out (22). The main idea of the group is to value older people’s active agency, empower them to take mastery over their own lives, and to allow them to gradually take over the responsibility of interaction in the group. A properly facilitated group process and group dynamics are used as means to empower participants to confront their loneliness, to support their peers in the group and to start keeping in touch with each other on their own without the facilitators (23). Each group always has two facilitators. Their competence in favourable group processes and group dynamics is important, and skills in empowering and supporting interaction among the participants is essential. The facilitators’ working approach is objective oriented and client centred. They receive thorough training and work supervision along with the group process (22).

The Circle of Friends it is not about more frequent social relationships, but how these relationships really meet the participant’s own expectations. Nor is it important that the group members have a diverse program but how the contents meet the participants’ wishes. The main objective is that the group process progresses well and that it is in line with the pace of the participants. The facilitators guide the group towards self-direction and the participants’ own empowering leadership. The facilitators’ final goal is to step back when it is time, and to gradually become unnecessary and encourage the participants to continue the group meetings on their own (24). According to the ten-year (2006–2016) follow-up, nine out of ten Circle of Friends participants felt their loneliness had been alleviated in the group, and over 60% of the participants had continued the meetings after the facilitated group (22). “Give a man a fish and you feed him for a day; teach a man to fish and you feed him for a lifetime” is very much true the Circle of Friends.

“Now it’s been three years since our group started and this gang still meets at the café nearby. Our “coffee moments” are something that all of us look forward to…they are moments among friends that really don’t lack talking and laughter.”

Over the last two decades, the Circle of Friends has been widely disseminated in Finland (22). More than 10 000 lonely older people have participated in these groups. The Circle of Friends is feasible in long-term care facilities and among people with cognitive decline (24). The model has also been modified and exported to some other countries (25). At the beginning of the COVID-19 pandemic, The Finnish Association for the Welfare of Older People started to modify the original Circle of Friends model into online group sessions. These online groups are on an electronic platform which is easy and safe to use, and its virtual meeting room is free of charge for the participants. The online version of the Circle of Friends has the elements of the original group model. Of the first online groups, all the participants have kept in touch with each other independently.