Introduction
The realisation that the ageing of the population means that in absolute terms the number of lonely older people is increasing, coupled with research which evidences the deleterious impact of loneliness and social isolation on health (Boss, Kang and Branson Reference Boss, Kang and Branson2015; Holt-Lunstad, Smith and Layton Reference Holt-Lunstad, Smith and Layton2010; Holt-Lunstad et al. Reference Holt-Lunstad, Smith, Baker, Harris and Stephenson2015; Valtorta et al. Reference Valtorta, Kanaan, Gilbody, Ronzi and Hanratty2016) have combined to focus policy makers’ attention on tackling loneliness among older people in the United Kingdom (UK) (Department of Health 2012; Department for Work and Pensions 2013; Foresight, Government Office for Science 2015; Local Government Association and the Campaign to End Loneliness 2012), North America and Europe (Cacioppo et al. Reference Cacioppo, Grippo, London, Goossens and Cacioppo2015; US Senate, Special Committee on Aging 2017). At the same time, the rapid spread of digital technologies has encouraged interest in the role the internet plays in exacerbating and alleviating older people's loneliness (Choi, Kong and Jung Reference Choi, Kong and Jung2012; Seepersad Reference Seepersad, Sha'ked and Rokach2015).
Set against the backdrop of cuts to adult social care in the UK and the squeeze on third-sector funding, these developments add impetus to the drive to find out whether services to older people might be delivered more efficiently or effectively using the telephone and internet.
This paper investigates a telephone-based service which was set up nationwide in the UK in 2012 to tackle loneliness in older people. It is based on the qualitative strand of a larger mixed-methods study (Moore and Preston Reference Moore and Preston2015). Unlike previous studies into telephone-based helplines and befriending services, this qualitative research focused on the intersection of three factors: the ways older people express loneliness, the impact of the telephone on communication and the design of the services. This approach helped understand the role of the telephone in how lonely individuals were using the service and in its capacity to respond.
Background
Although conceptions of loneliness have various theoretical foundations, there is agreement that loneliness is a subjective, negative and distressing experience arising from deficiencies in an individual's social relationships. Two distinct but overlapping theoretical approaches are identified in the empirical study of loneliness: the social needs approach and the cognitive approach (Sønderby and Wagoner Reference Sønderby and Wagoner2013). The social needs approach is founded in psycho-dynamic theory and attachment theory and focuses on the affective, emotional components of loneliness. This perspective fits with an emphasis on the multi-dimensionality of loneliness and the identification of its different forms (e.g. Gierveld Reference Gierveld1998; Weiss Reference Weiss1973). The cognitive approach, meanwhile, views loneliness as arising from the perception of a discrepancy between desired and achieved level of social engagement (Perlman and Peplau Reference Perlman, Peplau, Gilmour and Duck1981). An additional route to understanding loneliness is by contrasting it with social isolation. Social isolation is a more objective phenomenon, defined by a lack of social contacts and engagement with others and, unlike loneliness, is not necessarily distressing. Individuals can live solitary lives and yet not feel lonely, while others may experience loneliness despite extensive social networks (Coyle and Dugan Reference Coyle and Dugan2012).
Addressing loneliness has become more urgent as evidence of its contribution to numerous health problems accumulates. The link between loneliness and social isolation and morbidity and mortality is well demonstrated in meta-analyses and has been compared to other major health risks such as obesity and smoking (Holt-Lunstad, Smith and Layton Reference Holt-Lunstad, Smith and Layton2010; Holt-Lundstad et al. 2015). Specifically, loneliness is associated with cardiovascular problems (Hawkley et al. Reference Hawkley, Thisted, Masi and Cacioppo2010; Valtorta et al. Reference Valtorta, Kanaan, Gilbody, Ronzi and Hanratty2016), cognitive function (Boss, Kang and Branson Reference Boss, Kang and Branson2015; Wilson et al. Reference Wilson, Krueger, Arnold, Schneider, Kelly, Barnes, Tang and Bennett2007), depressed immune system (Cole et al. Reference Cole, Capitanio, Chun, Arevalo, Ma and Cacioppo2015), cortisol function (Hackett et al. Reference Hackett, Hamer, Endrighi, Brydon and Steptoe2012), obesity (Jaremka et al. Reference Jaremka, Fagundes, Peng, Belury, Andridge, Malarkey and Kiecolt-Glaser2015; Lauder et al. Reference Lauder, Mummery, Jones and Caperchione2006) and depression (Cacioppo, Hawkley and Thisted Reference Cacioppo, Hawkley and Thisted2010; Peerenboom et al. Reference Nimrod2015). Given these health impacts, it is perhaps unsurprising that loneliness is also linked to more physician visits, higher odds of re-hospitalisation and longer hospital stays (Gerst-Emerson and Jayawardhana Reference Gerst-Emerson and Jayawardhana2015; Newall, McArthur and Menec Reference Newall, McArthur and Menec2015).
On the question of how best to tackle loneliness in older people, despite the wide variety of interventions and associated research studies, literature reviews continue to demonstrate a lack of consensus about which solutions work best and a need for more robust data (Cattan et al. Reference Cattan, White, Bond and Learmonth2005; Cohen-Mansfield and Perach Reference Cohen-Mansfield and Perach2015; Gardiner, Geldenhuys and Gott Reference Gardiner, Geldenhuys and Gott2016; Masi et al. Reference Masi, Chen, Hawkley and Cacioppo2011). These reviews tend to categorise interventions by the kind of support they offer, for example, according to whether they seek to improve social support, social skills, opportunities for social contact or maladaptive cognition (Masi et al. Reference Masi, Chen, Hawkley and Cacioppo2011). There has also been some debate over whether one-to-one interventions work better than group interventions (for a summary, see Gardiner, Geldenhuys and Gott 2016). Less prominent, however, is comparison according to the mode of communication used to deliver the intervention (although this feature is often noted in the description of the intervention). A focus on mode of communication is found more often in relation to reviews of the impact that digital technologies have on loneliness, and here online interventions have been divided between those that increase the opportunities for social interaction by enabling internet access and those that focus on building social skills or addressing maladaptive social cognition (Seepersad Reference Seepersad, Sha'ked and Rokach2015). Meanwhile, a number of individual empirical studies also help to reveal the impact that particular communication technologies might have on efforts to tackle loneliness.
Face-to-face and telephone befriending
Befriending consists of an affirming and emotion-focused relationship which is set up and overseen by an agency (Mead et al. Reference Mead, Lester, Chew-Graham, Gask and Bower2010). It is also characterised as non-judgemental, mutual and purposeful (Dean and Goodlad Reference Dean and Goodlad1998). Although companionship is central, face-to-face befriending may also include accompanying people on activities or helping with chores (Cattan, Kime and Bagnall Reference Cattan, Kime and Bagnall2011; Findlay Reference Findlay2003; Mead et al. Reference Mead, Lester, Chew-Graham, Gask and Bower2010). It is recognised that befriending can help people in ways that go beyond the immediate scheme. For example, one study interviewing people who were using various types of befriending schemes found they gained emotional support and help connecting back into the community (Lester et al. Reference Lester, Mead, Graham, Gask and Reilly2012).
Studies of face-to-face befriending schemes showed mixed results in terms of their impact on loneliness but they tend not to focus on the impact of face-to-face rather than other forms of contact. Also, the relief of loneliness is not always the primary objective of befriending schemes. A randomised control trial of a face-to-face befriending scheme for carers of people with dementia found it failed to demonstrate any impact on psychological wellbeing or quality of life, nor on loneliness, which was among the secondary outcomes measured (Charlesworth et al. Reference Charlesworth, Shepstone, Wilson, Reynolds, Mugford, Price, Harvey and Poland2008). More positively, another small randomised study into a scheme which combined befriending with accompanied walking found that the conversation alone was associated with increased happiness (McNeil Reference McNeil1995). Positive results were also found in a face-to-face befriending service for people confined to the home (Andrews et al. Reference Andrews, Gavin, Begley and Brodie2003). This study, based on interviews with 13 clients, found they were very satisfied with the service and appreciated the reliability of the volunteer befrienders. People reported feeling less lonely and many valued the friendly reciprocity in their relationships with the befrienders, likening it to ‘real’ friendship (Andrews et al. Reference Andrews, Gavin, Begley and Brodie2003). A study into a Senior Companion Program found that clients said they valued the scheme for various reasons, including that it provided companionship and reduced anxiety (Butler Reference Butler2006).
Telephone befriending has been subject to fewer studies but a key contribution is the evaluation of the Call-in Time phoneline (Cattan, Kime and Bagnall Reference Cattan, Kime and Bagnall2011). The telephone delivery of the service was central to its rationale: telephone befriending was believed to provide a low-level, low-cost, low-risk intervention which enabled volunteers to offer emotional support to housebound older people from their workplace or home. The study found that people who used the service said it benefited them in various ways, including relieving their anxiety and loneliness, and improving their self-esteem and confidence. The authors also commented that many participants expressed a desire to meet their befriender face-to-face. The authors stated, however, that they could ‘only speculate’ about the reasons for this and about the distinctions older people made between face-to-face and telephone services (Cattan, Kime and Bagnall Reference Cattan, Kime and Bagnall2011: 204). The authors proposed that the relative anonymity of telephone communication might help people with low levels of self-esteem and self-confidence to build them to a point where they feel more ready and able to meet people in person. However, the speculative tone of this proposal suggests the study did not explore directly with participants the differences brought by the befriending being delivered by telephone rather than by alternative modes of communication.
Helplines and loneliness
Research into helplines shows they rarely identify tackling loneliness as an explicit objective. Insofar as they do, the implication is that the service can help lonely people by empathetic listening (O'Shea Reference O'Shea2006) or giving emotional support (Mental Health Foundation 2012). Studies do not necessarily envisage a need for emotional support as constituting a form of loneliness. However, defining loneliness as a lack in the quantity or quality of relationships does suggest that inadequate emotional support is a form of loneliness. Lonely people are sometimes viewed as a problem in helpline services, due to the perception that their needs are at odds with the core purpose of the service, particularly when that core purpose is responding to crisis (Pollock et al. Reference Pollock, Armstrong, Coveney and Moore2010).
Helplines have traditionally operated via a phoneline and studies of various types of helplines identify particular advantages of this mode of communication. These include wider accessibility and low operation costs (Boddy, Smith and Simon Reference Boddy, Smith and Simon2005; Bos et al. Reference Bos, Visser, Tempert and Schaalma2004; Mental Health Foundation 2012; Pollock et al. Reference Pollock, Armstrong, Coveney and Moore2010). The anonymity of helplines is seen as an additional advantage, enabling people to broach embarrassing or stigmatising issues (Boddy, Smith and Simon Reference Boddy, Smith and Simon2005; Bos et al. Reference Bos, Visser, Tempert and Schaalma2004; Mental Health Foundation 2012; Pollock et al. Reference Pollock, Armstrong, Coveney and Moore2010). Some evaluations of phoneline services which also offer alternative modes of communication such as email, text or webchat have asked callers about their views regarding the pros and cons of these alternatives. The greater privacy of written modes of communication is seen as an advantage by some (Mental Health Foundation 2012; Pollock et al. Reference Pollock, Armstrong, Coveney and Moore2010). Another reason for preferring written communication is that it is an easier or less-embarrassing way to express oneself (Pollock et al. Reference Pollock, Armstrong, Coveney and Moore2010). Some people who are hearing impaired or otherwise disabled in such a way that it is difficult to use the telephone also prefer written communication (Pollock et al. Reference Pollock, Armstrong, Coveney and Moore2010).
Friendships in digital environments
The relationship between the internet and loneliness has been the subject of much debate and previous claims that the internet makes people lonely (Seepersad Reference Seepersad, Sha'ked and Rokach2015) have been modified by the finding that lonelier people and people with social anxiety tend to use the internet in solitary or problematic ways (Caplan Reference Caplan2006; Seepersad Reference Seepersad, Sha'ked and Rokach2015). Positive impacts of the internet on older people's loneliness are found when it is used to maintain existing friendships and rekindle previous ones (Choi, Kong and Jung Reference Choi, Kong and Jung2012; Khvorostianov, Elias and Nimrod Reference Khvorostianov, Elias and Nimrod2012; Lindley, Harper and Sellen Reference Lindley, Harper and Sellen2008; Nef et al. Reference Nef, Ganea, Müri and Mosimann2013). It is also increasingly common for older people to form new relationships online when they join groups that may be about support for health problems or based around shared interests or leisure activities. Studies show these can be helpful in forming friendships (Attard and Coulson Reference Attard and Coulson2012; Cotten, Anderson and McCullough Reference Cotten, Anderson and McCullough2013), as well as bringing fun and improving wellbeing (Nimrod Reference Nimrod2010). Overall, there is some agreement that the way people use both the internet and social media is key to whether it amplifies or reduces feelings of loneliness (Seepersad Reference Seepersad, Sha'ked and Rokach2015).
There are also a number of studies of online or computer-based interventions designed to address loneliness in older people. One looked at a device that enabled users to listen or watch regular broadcasts on a computer and then join in a group chat via a telephone handset. As a pilot study, it was more concerned with understanding patterns of use than outcomes, but it found that people who were socially lonely were more likely to be regular users of the technology and that there was a general consensus among all users (some of whom were neither socially nor emotionally lonely) that the technology would work best if used in conjunction with face-to-face meetings (Garattini, Wherton and Prendergast Reference Garattini, Wherton and Prendergast2012). Another group of studies focused on a friendship enrichment programme which was developed offline (Martina and Stevens Reference Martina and Stevens2006; Stevens Reference Stevens2001) and then online (Bouwman et al. Reference Bouwman, Aartsen, Tilburg and Stevens2016). Participants in the original version gained friendships but the study failed to demonstrate that it had a positive effect on their loneliness. The online version experienced a high dropout rate, as is common in other online self-guided interventions, but it showed some evidence of reduced loneliness among those who stayed the course (Bouwman et al. Reference Bouwman, Aartsen, Tilburg and Stevens2016). Although there are relatively few online interventions of this type addressing loneliness in older people (Seepersad Reference Seepersad, Sha'ked and Rokach2015), they may become more common as the number of older people using the internet rises.
When it comes to the impact of internet-based communication on relationships, there has tended to be an assumption that online communication equates to written communication. On this basis, one review identifies a set of characteristics in online written communication that may foster greater communication and increased relationship quality. These are: relative anonymity, which facilitates disclosure; reduced importance of physical appearance; reduced importance of geographical location; and greater control over the timing and pace of interactions (Seepersad Reference Seepersad, Sha'ked and Rokach2015). Similar observations are made in reflective commentaries which favourably compare internet-based friendships with their face-to-face alternatives (e.g. Briggle Reference Briggle2008; Elder Reference Elder2014).
Understanding how technologies affect interpersonal relations also depends on how technology is conceived in the first place. This study takes the view that technology is both socially constituting and socially constituted (Dahlberg Reference Dahlberg2004). This position avoids the extremes of user determinism at one end of the spectrum and technological determinism at the other. Rather, it sees us as interacting with technologies, shaping them and being shaped by them in the process. It is also consistent with the idea that digital technologies have cultural meaning, an approach which has proved helpful in making sense of what matters to older people with assisted living needs (Greenhalgh et al. Reference Greenhalgh, Wherton, Sugarhood, Hinder, Procter and Stones2013). A related notion, also present in the literature on assisted living, is the concept of ‘bricolage’. This captures the way in which people customise and adapt available technologies to suit their needs (Greenhalgh et al. Reference Greenhalgh, Wherton, Sugarhood, Hinder, Procter and Stones2013).
Summary
Overall, this review demonstrates that although there is a range of ways of delivering interventions, focus on the effects of the mode of delivery occurs most often in studies on internet or computer-based interventions. There is also a large body of research which considers the impact of the internet and social networks on loneliness, outside the context of any intervention. These studies tend to equate the internet with written communication and there is some agreement about the benefits this can bring to relationships. In regards to telephone-based services for older people, studies of befriending services provide some reflection on the impact of the mode of delivery. The accessibility, low cost and relative anonymity of telephone communication are identified as benefits. However, the views of people using these services on the impact of telephone communication have not been studied in detail. Similar advantages are claimed for telephone helplines but the issue of how these impact on lonely people's use of helplines is not explored. More generally, there is an absence of research which considers how technology–service combinations influence the ways lonely people interact with them and, as a result, how well suited they are to meet people's needs. This study therefore made these questions a central part of its enquiry.
The study
The telephone-based service (henceforth the ‘Phoneline’) at the centre of this study has operated nationwide in the UK since 2012 and comprises a number of interlinked services for older people. Its main service is the helpline, which operates seven days a week, 24 hours a day. The helpline is free to callers and offers information, advice, referrals to other organisations and the chance for an informal chat. The helpline was designed to be particularly friendly so that it could reach out to older people who might feel lonely but be reluctant to seek help from services explicitly aimed at lonely people due to the associated stigma. In addition to the helpline are the befriending services, which comprise two interlinked services: the friends service and the wellbeing service. These befriending services more overtly tackle loneliness. The friends service matches callers to a volunteer friend who calls them every week at an agreed time for a chat, typically lasting about 30 minutes. The wellbeing service is an adjunct to the friends service. Callers who have asked for a friend but are waiting to be matched to a volunteer are offered the option of receiving regular friendly calls from paid staff. A main difference between the helpline and the two befriending services is that callers make calls to the helpline, whereas with the befriending services they receive regular calls from staff and volunteers, respectively. There are other interlinked services but this study focuses on the helpline and the wellbeing and friends services, and their aim to tackle loneliness in older people.
Research aims and methods
This article reports on the qualitative strand of a wider mixed-methods research study that ran from May 2014 to November 2015. The research as a whole focused on the Phoneline's central aim of tackling loneliness in older people. The purpose of the qualitative research was to explore the associations between telephone-delivery, how individuals were using the services and how the services were able to respond.
The research methods comprised four focus groups with staff from the helpline and befriending services, and 42 semi-structured interviews with regular callers to the helpline and people receiving regular calls from the befriending service. Full ethical approval for the research was obtained from the university's ethics panel.
The researchers conducted one focus group with six staff at the Phoneline's head office, where the befriending services were based. They also carried out three smaller focus groups with helpline staff in their office. Staff were recruited via an invitation emailed to all staff about the research. There were 11 female and two male participants in the focus groups, reflecting the overall gender split in staff numbers.
The researchers undertook 42 interviews in a room set aside for their exclusive use at the Phoneline's offices, so as to protect the confidentiality of participants. For the same reasons, the researchers did not record the interviews but instead took detailed notes during them using the interview schedule as a template. Phoneline staff had the initial conversations with individuals using the services about their interest in participating in the research. On designated days, people who were known to be regular callers to the helpline were asked, when they called, whether they would like to hear more about the research and, if so, their details were passed to the researchers. A similar process was used to recruit people from the befriending services. Researchers then called would-be participants to gain informed consent before conducting the interviews. Participant's contact details were not removed from the Phoneline offices and were securely disposed of after they had been used. About 67 per cent of the interview participants were female and 33 per cent male. Ten per cent were aged 50–59 years, 27 per cent 60–69 years, 30 per cent 70–79, 30 per cent 80–89 and 3 per cent over 90 years. The participants were roughly equally split between those who were regular callers to the helpline, those who received calls from wellbeing and those who had a friend. The demographic profile of the whole population of people using each of these services differs but the interview participants reflected the age and gender distribution of service users as a whole.
The research team chose the telephone as a medium for the interviews for various reasons. Firstly, it seemed a natural choice in the context of a telephone-based service and it could be assumed therefore that participants were relatively accustomed to the medium. Secondly, it facilitated the recruitment of participants in the natural course of Phoneline's processes. It also enabled the inclusion of geographically dispersed participants and those who might face mobility or other issues accessing face-to-face interviews. Telephone interviews are also recognised for being well suited to discussing sensitive or stigmatised issues, such as loneliness (Sturges and Hanrahan Reference Sturges and Hanrahan2004).
Analysis
The analysis was based on a multi-stage method of inductive thematic coding (Miles and Huberman Reference Miles and Huberman1994). The coding process was theory driven, which meant the researchers approached it with the specific research topics (outlined above) in mind. The researchers familiarised themselves with the data in the process of transcribing recorded focus groups and re-reading the detailed notes of the 42 interviews. The first stage of coding consisted of line-by-line coding of the text, which aimed to organise the data into meaningful groups. The next stage was Pattern Coding in which codes were sorted into potential themes (Miles and Huberman Reference Miles and Huberman1994). During this process, the researchers together reviewed and refined the themes in an iterative and reflexive manner. This led to the final stage, which involved drawing conceptual and theoretical conclusions. The quotes used to illustrate the themes are not chosen primarily for their vividness but rather as examples that encapsulate a pattern evident from a comprehensive and inclusive review of the data.
Findings
The focus of the study was to explore the associations between telephone-delivery, how individuals were using the services and how the services were able to respond. Each of the central themes identifies a characteristic of the telephone as a mode of communication, in the context of the services. Within each of these, patterns of use which the research suggested were associated with that characteristic are set out. Where relevant, staff and service users’ reflections on the suitability of the services to address these patterns of use is also included. The impressions of how these factors relate to one another arose out of the process of analysis. These are therefore broad, overlapping categorisations and outlined here to stimulate further thought and research, rather than to provide a definitive list.
Availability
Availability is used here in the sense of when and how the services operate; this differed for the helpline, which was available to call 24 hours a day, seven days a week, and the befriending services which provided regular contact once a week. The choice in this research to use the term ‘availability’ contrasts with other literature which discusses similar issues but under the wider term ‘access’ (Boddy, Smith and Simon Reference Boddy, Smith and Simon2005; Mental Health Foundation 2012; Pollock et al. Reference Pollock, Armstrong, Coveney and Moore2010). Access can encompass how and when the service operates, the type of person who uses it and its capacity to reach them.
On the narrower issue of availability, this analysis suggested that the services’ different operational models were associated with different patterns of use. This included differences in factors such as the needs people were expressing, the way they expressed them and the frequency with which they used the services. Within these themes, the attitudes of staff about their ability to respond are included.
Readily available emotional support
It was clear from the focus groups with helpline staff that a large number of regular callers had mental health problems ranging from mild depression to more severe conditions. Many of these callers were seeking emotional support, particularly empathy and reassurance.
I think we're just, sort of, like maintenance really. You know, we're not medically trained but we're just sort of there to talk to. (Helpline adviser, focus group)
Staff told the researchers that calls to the helpline tended to peak when the specialist mental health phonelines close at night. This impression was corroborated by interview participants who spoke about valuing the 24-hour nature of the helpline because it enabled them to call at night or at other times when they felt down, depressed or in pain. As one woman who regularly used the helpline said, ‘I call them because I feel miserable and they chat me out of it.’
Callers also appreciated the fact that the helpline offered friendly support as opposed to the client–professional relationship available through some specialist phonelines.
However, it was also evident that certain categories of caller with profound or complex needs were presenting significant challenges for helpline staff:
We are becoming a favourite with a lot of folk who have real mental health, anxiety, depression or suicide problems because we engage them in conversation and act as a ‘comfort blanket’. It can be very testing and an emotional roller-coaster. (Helpline adviser, focus group)
The sense among staff that they could not do enough for callers arose from a mismatch between the ease with which people could reach the service and the limits of offering help over the telephone.
There was a lady today who's got very bad memory issues … she can remember so little that she's in a state of anxiety all the time and really somebody, probably from social services, should be stepping in and looking after her more … We know that but we can't do anything further about it. All we can do is try and calm her down, reassure her … that's where talking seems like it's not enough really. (Helpline adviser, focus group)
Staff also told the researchers that some people were calling so frequently that they had instigated call plans as a way of limiting the number of calls any individual could make per day.
Availability of ‘disguised’ support
Staff felt that some regular callers to the helpline were primarily seeking relief for their loneliness but did not want to be explicit about asking for this support, perhaps due to the stigma of loneliness. For these people, the helpline was an available route to express their loneliness.
I'd say everybody that phones is lonely and sometimes they can have a different way of sort of expressing it you know? It might be sort of like initially picking a fight with you on the phone, which is their way of saying that I'm lonely. (Helpline adviser, focus group)
Readily available light-hearted companionship
The helpline seemed well suited to meeting the needs of people who were confined to the home due to mobility issues or lack of transport but who wanted a readily available source of light-hearted companionship.
You find it most days, they want somebody at the end of a phone who will have a quick chat and it doesn't get emotional, they tend to be quite: ‘What shall I make for my tea?’ and everything like that, ‘What's on telly, what shall I watch?’ (Helpline adviser, focus group)
Helpline staff spoke about men, in particular, using the service in this way, and one described how on Saturday nights men would often call to chat about the football results.
Regularly available light-hearted companionship
The befriending services, which provided regular telephone calls to service users, were also answering a need for companionship, but in this case on a pre-arranged basis rather than at the will of the service users. People who were matched with volunteer friends talked about enjoying having someone to chat or ‘natter’ with about interests such as gardening or cooking. They also mentioned the importance of ‘having a laugh’ and even flirting. Wellbeing staff also spoke about this pattern of use. According to one head office staff member, ‘Some of the callers we have just want a bit of banter, a bit of flirtation.’
The delivery of the service by telephone facilitated this kind of companionship for people who were unable to access it locally, either because their friends had died or moved away, or because they were confined to the home or lacked socialising opportunities locally.
Regularly available emotional support and guardianship
Some people receiving a regular telephone call from the befriending services valued someone getting in touch with them rather than vice versa because it made them feel ‘cared for’ and ‘cared about’. People receiving these calls talked gratefully of having someone ‘phone to check how I'm going’ or ‘to see if I'm still alive’. Staff also described people wanting this type of support:
They might not want to get into a long phone call but they very much appreciate just having someone contacting them and asking how they are. Literally a two-minute phone call. (Head office staff, focus group)
Some people in this category were seeking more extended regular emotional support, often in the form of someone who would listen to their problems. According to staff who were involved in matching people with volunteer friends, this kind of caller, who mainly wanted a good listener so they could ‘offload their problems’, was harder to match.
There are a lot of people like that, I would say, but those people tend to be the people who we take a lot longer to match because we need to get a very specific kind of volunteer. (Head office staff, focus group)
One interviewee who told the researchers she was depressed explained why she preferred regular emotional support from the wellbeing, as opposed to the friends service:
If I had a [volunteer] friend, there might be an ongoing topic or something. With people calling at random, it's always something different. I have some friends with a lot of problems who call me to discuss them and it gets me down, whereas the [wellbeing] callers never say anything to distress you. It is very supportive. (Woman using wellbeing service)
This type of response to the service did, however, sometimes present a challenge for the staff, particularly if the person used the service to disclose sensitive issues about themselves.
If a caller comes in and they want to lead the conversation down a route of, ‘I am going to open up to you and I'm going to tell you everything’ and, really, this is better heard by a therapist but perhaps they are not getting access to a therapist. Then you have to be very aware of your boundaries, I think, to be responsible as a charity because you do not know what you are saying to them that might unravel something for them, that they don't have the support around them at home. (Head office staff, focus group)
This point is similar to that made in the section above about the services enabling the identification of problems but not necessarily being able to provide adequate solutions.
Reach
Another theme which came out of the analysis was the ‘reach’ of telephone-based services. This included geographical reach, or the ability to connect people who are distant from one another, as well as what might be thought of as ‘social reach’, or the ability for people using the telephone to reach others outside their immediate social circle.
Reaching compatible people for in-depth or light-hearted friendship
The friends service seemed well suited to helping people find others they were compatible with, either through shared interests or shared life experiences. This might be the basis of forming a light-hearted friendship or a closer more intimate one.
Staff involved in matching callers to volunteers described various successful incidences of pairing people with unusual interests. People who used the service also spoke about wanting to find others who faced the same difficulties as themselves and could, as a result, relate to them. One woman in this category talked about how her volunteer friend had also lost her husband and so was able to understand how she felt in a way that many of her other friends whose husbands were still alive could not. Another said that the service ‘must have put a lot of time’ into matching her with her volunteer friend, who was a similar age, who had a husband who did the same job and who shared her interests. As a result, she said, ‘We always have something to talk about.’
People were also looking for a volunteer friend to compensate for a particular gap in their life, often as a result of losing a partner. One man, for example, said he had a number of male friends whom he spent time with at the pub but that he had asked for a woman friend because he wanted to be able to talk to her about the kinds of things he had talked to his wife about. One woman similarly described missing the close companionship of her lifelong female partner and wanting a close friendship as a result.
While many people looked to the capacity of the friends service to reach a wide pool of people to address these gaps, some also suggested an ambivalence about the mode of communication.
I really like it. She's a real friend, an important part of my life. I'd like a face-to-face friendship though, someone to pass the time with. (Woman using friends service)
It's brilliant. If I met her in real life, I'd make friends. We have in-depth conversations, nothing contrived. Of course it is contrived. But the bottom line is it does feel real. (Woman using friends service)
Other people talked more explicitly about the difficulties of forming meaningful relationships over the telephone, and although some said they were ‘getting used to it’, others were finding it more problematic.
I find the phone quite inhibiting. I like human beings, the presence of another human being. I'm not used to using the phone for long chats. It's not what I did in the past. I used the phone for making arrangements about meeting up. (Man using wellbeing service)
Reaching people to share confidences
Some people using the helpline and befriending services valued the contact with someone outside their circle of friends or family which telephone communication enabled. For these people looking for a friend as ‘confidante’, the distance of a telephone-based relationship became an advantage.
You don't know them [referring to her friend]. If they saw you in the street they wouldn't know you, so you can tell them anything. You don't worry about them telling other people. You can tell them things deep inside you. I tell her about my husband who used to come in drunk and beat me up. Things I wouldn't tell other people. (Woman, regularly using the helpline and friends service)
With some individuals, the capacity of the telephone to reach people outside their social circle made them feel less inhibited, not only about sharing confidences but in their general behaviour.
You can get away with so much! There's no comeback over the phone, the most someone can do is put the phone down. (Man, regularly using the helpline)
This sense of disinhibition in this comment echoes the challenge identified in the previous section that staff faced from people who ‘over-disclosed’ when using the service as a means of emotional support.
Non-visual communication
Forming relationships in comfortable circumstances
Some people evidently found the lack of a visual element to the services made the environment more comfortable for forming relationships, whether those were in-depth or light-hearted. In some cases, individuals who described themselves as shy or embarrassed about their appearance valued communication without a visual component.
It would be awfully nice to meet someone in the flesh but it depends what they are like and I'm a bit untidy these days. When you see someone, you may be distracted by how they look or what they are wearing, whereas in this instance everything is judged by the voice. (Man using the wellbeing service)
Others felt freed-up because of the inability to see the person they were talking to:
If you are not seeing someone you are not seeing the reaction. You may be more guarded if you could see them. If they were looking grave in response you would try to put it right. You are more responsible for their reaction. (Woman using the wellbeing service)
A number of service users had visual impairments. This affected their ability to go out and meet people and engage in certain activities. For some, it also meant that non-visual communication carried fewer drawbacks:
Being blind it doesn't matter whether you are in the same room with people or on the phone with them. I'm perfectly happy with the phone. (Man regularly using the helpline and friends service)
Discussion
This study identified various characteristics of the telephone as a communication medium in the context of the helpline and befriending services. It focused on the combined effect of the technology and service. This made it possible to identify the kinds of support people were seeking from these services as telephone services, as opposed to the kind of support they might seek from a similar service delivered via another communication medium, or face-to-face. It also enabled consideration of how suitable the services were to answer these needs.
The notion that technologies are not neutral objects but are subject to our interaction with them is evident in literature on new technologies (Dahlberg Reference Dahlberg2004; Greenhalgh et al. Reference Greenhalgh, Wherton, Sugarhood, Hinder, Procter and Stones2013) but is less often applied to the telephone and technology–service combinations, such as telephone befriending.
One characteristic of the telephone was that it made the services ‘available’. We separated this theme into the ‘ready availability’ of the 24-7 helpline service, and the ‘regular availability’ of the befriending services, which entailed weekly calls to users at pre-arranged times. Our research suggested that these forms of availability prompted people to interact with the services in different ways and seek different things from them. These patterns of use varied from seeking readily available emotional support to seeking regular light-hearted companionship. The ability of the services to respond to these requirements also varied and the difficulties encountered reflected those found in comparable research.
For example, staff found it challenging to meet the complex needs of some of the large number of people using the helpline as a source of readily available emotional support. This echoes research which finds that among volunteers working for the Samaritans helpline, the phenomenon of regular or repeat callers who are seeking relief primarily from their loneliness is considered a troubling issue, with some volunteers feeling that it is an inappropriate use of the service (Pollock et al. Reference Pollock, Armstrong, Coveney and Moore2010). It also has parallels with research that finds lonely individuals are more likely than individuals who are not lonely to use the internet in problematic ways (Seepersad Reference Seepersad, Sha'ked and Rokach2015). One study, for example, found that lonely individuals found it harder to cut back on time spent online and harder to stop thinking about going online. It also found that individuals were using the internet as a way of modulating negative moods associated with loneliness (Morahan-Martin and Schumacher Reference Morahan-Martin and Schumacher2003). Considered together, these observations suggest that the availability of support from certain technologies and technology–service combinations is very attractive to some lonely individuals and may serve their needs well in certain respects but can also lead to problematic behaviour and may present operational problems for those providing services.
A similar set of benefits and drawbacks arose with individuals seeking emotional support from the befriending services. Some individuals who used the services spoke favourably of being able to discuss issues over the telephone that they found hard to broach face-to-face but staff also talked about the challenges they faced when people used the service to ‘open up’ and discuss things which staff felt might be better discussed in a therapeutic environment. This situation may well have been arising, in part, because of the lack of alternative, more specialist sources of help for these people, particularly at a time of extensive cuts to mental health services. However, it also brings to mind other research demonstrating both positive and negative impacts of online counselling on the therapy process, including a greater propensity for self-disclosure and disinhibition (Richards and Viganó Reference Richards and Viganó2013). Again, it seems that this service–technology combination was prompting particular patterns of use, some of which proved challenging to the service providers.
More positively, some of the individuals seeking emotional support from the services mainly wanted someone to listen to them and, in this respect, the services seemed well suited to meeting their expectations. Other helplines for older people have been set up specifically as listening services staffed by volunteers and have reported perceived positive results on callers’ loneliness (O'Shea Reference O'Shea2006). This might be a way of overcoming the difficulty noted in this research of matching people with volunteer friends when they mainly want someone to listen to them, rather than have a more reciprocal exchange. If the volunteer comes to the role with the expectation that they are primarily there to listen rather than befriend or act as a counsellor, matching people exhibiting this type of loneliness might present fewer problems. The capacity for online environments to give an individual the sense of being listened to is not clear and is likely to vary according to numerous factors, including the context, but one experimental study found that merely posting statuses on Facebook decreased loneliness among students (Deters and Mehl Reference Deters and Mehl2013).
The present study showed that because the phoneline enabled individuals to reach others beyond their immediate social circle, they felt freer to discuss sensitive issues. People explained their reluctance to discuss these issues with family or friends in various ways, including not wanting to feel judged or not wanting to burden others with their problems. The facility for some service–technology combinations to reach beyond family and friends is not the same thing as anonymity, although it may coincide with complete or partial anonymity, and shares with it a capacity to prompt disclosure. People using the befriending services could not remain anonymous as they needed to give the service their contact details. So, in this case, it was the arm's length nature of the relationship which facilitated confiding. Research into the Samaritans phoneline quotes callers explaining that they felt able to disclose their true level of need to the service in a way that they could not to friends or family (Pollock et al. Reference Pollock, Armstrong, Coveney and Moore2010). The Samaritans study suggests this may be about a desire to sustain social roles, which is a point also made in literature outlining the advantages of internet communication for older people (Lindley, Harper and Sellen Reference Lindley, Harper and Sellen2008). Confidentiality and anonymity are often cited as reasons why telephone or internet communication are conducive to confiding (e.g. Cattan, Kime and Bagnall Reference Cattan, Kime and Bagnall2011; Nimrod Reference Nimrod2010) but this study suggests that the notion of ‘social reach’ can also be a distinct contributory factor which applies across various technologies and technology–service combinations. As discussed above, however, it should not be assumed that facilitating confiding will necessarily be advantageous either to the individual or to service providers, as the phenomena of over-disclosing and disinhibition testify.
This study also uses the word reach in the context of the geographic reach, which refers to the services’ ability to link individuals with a wide pool of other people and thereby increase their chances of finding others who share their views, interests or life experiences. Service users and staff applauded this feature, particularly in regards to the befriending services, where they described it enabling both companionable relationships based on shared interests, as well as deeper relationships based on shared experiences and outlooks. The ability to link geographically dispersed individuals is a feature more often remarked on with regards to the internet (e.g. Cotten, Anderson and McCullough Reference Cotten, Anderson and McCullough2013), where it has also been found helpful for people who feel stigmatised due to their lifestyles or illnesses (Bargh and McKenna Reference Bargh and McKenna2004). If people's loneliness is primarily due to a lack of opportunities to socialise with the kind of people they would like to, technologies such as the telephone and internet which offer access to large numbers of people have the potential to be particularly helpful. In these cases, people may also welcome technologies which include visual communication if they find that makes forming relationships easier. If, however, people are lonely because they have underlying difficulties in forming relationships, solutions which solely offer more opportunities for relationships may be insufficient to address their loneliness and may even exacerbate it. This highlights the general observation that because the nature of loneliness differs between people, one type of solution will not be of equal benefit to all. This point has been made previously in the literature (e.g. Gierveld and Fokkema Reference Gierveld, Fokkema, Sha'ked and Rokach2015; Victor et al. Reference Victor, Scambler, Bowling and Bond2005) and gains further support from this study.
Another characteristic of the telephone which the analysis highlighted was its non-visual element. The absence of a visual component to communication is now less common in digital technologies than previously, but earlier research on computer-aided communication often assumed a solely written form of communication. The list of advantages this was found to bring to relationships included relative anonymity and the reduced importance of physical appearance (Seepersad Reference Seepersad, Sha'ked and Rokach2015). The present study found that similar advantages applied to the telephone, not because communication was written but because it was non-visual. People using the services spoke about the value they found in not being judged on appearances and in feeling freer to say what they wanted because they could not see the reaction in the person they were speaking to. Anonymity was therefore seen to arise both from the arm's length nature of the communication and its non-visual nature, with the possibility of mutual reinforcement between the two. A similar finding occurred in a study that applied gerontographics to older people's online communities. It reported that so-called ‘healthy hermits’ and ‘frail recluses’ found the anonymity and invisibility of online communities enabled them to express their feelings more (Nimrod Reference Nimrod2013).
Focus on the effects of non-visual communication also helped to clarify a wider point that different forms of communication prompt different kinds of relationship and that any assumption that face-to-face relationships are a gold standard overlooks the positive features of alternatives, particularly for people who do not thrive in face-to-face situations. Those who are shy or poor at interpreting visual social cues may find other forms of relationship more comfortable or liberating, for example.
Conclusion
The context of this study was a telephone helpline and befriending service targeting loneliness among older people in the UK. It aimed to understand the effects that telephone delivery had on the way the service was used and its capacity to impact individuals’ loneliness. The research was based on an understanding that expressions of need both affect and are affected by technologies and technology–service combinations. Through interviews and focus groups with staff and service users, the study identified the characteristics that telephone delivery brought to the services and the patterns of use associated with these. As a result, it was possible to consider how well suited the services were to addressing individuals’ needs. The study found that the record was mixed, with some patterns of use presenting challenges for the services and others being a more harmonious fit. This variation also reflected a difference in the nature of loneliness among people using the service. By unpacking particular characteristics of telephone communication, it was also possible to compare responses in this context with those identified in other literature about different technologies and technology–service combinations. This avoids assumptions about the distinctions between telephone and internet communication and is therefore more in keeping with ongoing developments such as smartphone-based visual communication and internet-based voice communication. As a result, this approach could be useful in informing the development of interventions to address loneliness in older people, and in considering how lonely older people might interact with new communication technologies.
Acknowledgements
We wish to thank all study participants and our colleague Sanna Markkanen for their help with data gathering. This research was part-funded by the South Essex Partnership University NHS Foundation Trust (SEPT). SEPT played no role in the design, execution, analysis and interpretation of the data or writing of the study. There are no conflicts of interest.
