Together

Why Social Connection Holds the Key to Better Health, Higher Performance, and Greater Happiness

Vivek H. Murthy, M.D.

• Publisher: Harper
• Year: 2020
• ISBN:
  9780062913319
• Topic: Psychology
• Subtopic: Mental Health in Psychology
• Index: Psychology

The New York Times Bestseller from Surgeon General, Vivek H. Murthy, MD.

"We have a massive, deadly epidemic hidden in plain sight: loneliness. It is as harmful to health as smoking and far more common. And as his gripping stories of the science and suffering make clear, we can do something about it. Together is fascinating, moving, and essential reading."—Atul Gawande, author of Being Mortal

" Together made me rethink much of what I believe about physical health, public policy, and the human condition. By revealing America's epidemic of loneliness—and then offering an array of remedies for the condition—Murthy has done a great service, and made Together the most important book you'll read this year."—Daniel H. Pink, #1 New York Times bestselling author of When and Drive

The book we need NOW to avoid a social recession, Murthy's prescient message isabout the importance of human connection, the hidden impact of loneliness on our health, and the social power of community.

Humans are social creatures: In this simple and obvious fact lies both the problem and the solution to the current crisis of loneliness. In his groundbreaking book, the 19th surgeon general of the United States Dr. Vivek Murthy makes a case for loneliness as a public health concern: a root cause and contributor to many of the epidemics sweeping the world today from alcohol and drug addiction to violence to depression and anxiety. Loneliness, he argues, is affecting not only our health, but also how our children experience school, how we perform in the workplace, and the sense of division and polarization in our society.

But, at the center of our loneliness is our innate desire to connect. We have evolved to participate in community, to forge lasting bonds with others, to help one another, and to share life experiences. We are, simply, better together.

The lessons in Together have immediate relevance and application. These four key strategies will help us not only to weather this crisis, but also to heal our social world far into the future.

• Spend time each day with those you love. Devote at least 15 minutes each day to connecting with those you most care about.
• Focus on each other. Forget about multitasking and give the other person the gift of your full attention, making eye contact, if possible, and genuinely listening.
• Embrace solitude. The first step toward building stronger connections with others is to build a stronger connection with oneself. Meditation, prayer, art, music, and time spent outdoors can all be sources of solitary comfort and joy.
• Help and be helped. Service is a form of human connection that reminds us of our value and purpose in life. Checking on a neighbor, seeking advice, even just offering a smile to a stranger six feet away, all can make us stronger.

During Murthy's research for Together, he found that there were few issues that elicited as much enthusiastic interest from both very conservative and very liberal members of Congress, from young and old people, or from urban and rural residents alike. Loneliness was something so many people have known themselves or have seen in the people around them. In the book, Murthy also shares his own deeply personal experiences with the subject—from struggling with loneliness in school, to the devastating loss of his uncle who succumbed to his own loneliness, as well as the important example of community and connection that his parents modeled. Simply, it's a universal condition that affects all of us directly or through the people we love—now more than ever.

Section I

Making Sense of Loneliness

Chapter 1

Under Our Noses

The whole conviction of my life now rests upon the belief that loneliness, far from being a rare and curious phenomenon, peculiar to myself and to a few other solitary men, is the central and inevitable fact of human existence.

—Thomas Wolfe, God’s Lonely Man

My first day as a doctor began one bright June morning when I walked through the doors of Boston’s Brigham and Women’s Hospital. I was wearing a pressed white coat and my best shirt and tie. I smiled at the security guards and passing staff. For them, this was just another day at a busy urban hospital, but for me, it was a day I’d remember for the rest of my life.

My head was stuffed full of medical facts and trivia that I’d gathered from medical school. My pockets were overflowing with tools, including a stethoscope, ophthalmoscope, tuning fork, reflex hammer, Pocket Medicine handbook, three black ballpoint pens, blank index cards for recording patient details, a list of phone numbers for key hospital services, and laminated cards filled with algorithms for everything from cardiac resuscitation to the treatment of diabetic ketoacidosis. Yet none of those cards and manuals mentioned the most common ailment I was about to encounter among my patients.

In the days ahead, as I went on bedside rounds with my team of medical residents and senior physicians, I focused my attention on getting the right diagnosis and prescribing the right medications, treatments, and tests. It was overwhelming at times, but as the months wore on, I got more and more comfortable managing common illnesses like diabetes and cancer and unusual ones that I had only read about in textbooks. As I slowly ascended the steep learning curve of medical training, I began to notice other aspects of the people I was caring for, including their social lives—or lack thereof.

Some patients always had a visitor in their room to keep them company in the unfamiliar hospital setting. If they took a turn for the worse or were nearing the end of life, they had an entourage of family and friends who traveled from near and far to be with them and to explain to the doctors and hospital staff how much their loved one meant to them. But other patients went days and even weeks with no visits, no phone calls, no one from the outside world asking how they were doing. Some of them died alone with nobody but me and my hospital colleagues to witness their last moments.

It wasn’t just the physical presence or absence of friends and family that I noticed. It was the hunger for companionship that was evident in so many of the men and women who came through our hospital doors. While most patients were eager to get out of the hospital and resume their lives, a sizable minority turned to the medical staff for a long-missed friendly ear. They shared lengthy stories of their lives with anyone willing to bear witness to their existence. I often found myself torn between wanting to be there for those patients and knowing that I had many other patients who were waiting for me.

My focus as a physician was medical. The social issues, as wrenching as they were, seemed outside the domain of doctoring. It would take a patient named James to teach me just how wrong I was about this.

I only met James once, on the afternoon he walked into our clinic for help with his diabetes and high blood pressure, but this middle-aged gentleman taught me a profound and indelible lesson about loneliness and connection that day.

James was stocky, with brown hair and red, rugged skin that bore the signature of many New England winters. His face was set in a grim look of frustration, which I assumed was related to the health problems I saw noted in his chart.

“It’s good to meet you,” I said. “Tell me how I can help.”

James described the challenges of dealing with diabetes, high blood pressure, his weight, and the accompanying stress he often felt. He looked tired as he spoke. His gestures were listless. He seemed defeated by life.

Then, out of the blue, he delivered what seemed to me at the time a complete non sequitur. “Winning the lottery was one of the worst things that ever happened to me,” he said.

“Really?” I’m sure my bewilderment showed in my voice. “Why?”

Given this invitation, James poured out his whole story. It turned out he was being quite literal: he actually had won the lottery. Prior to that, he told me, he’d been a baker. He was good at his craft, and his customers appreciated his talent. He enjoyed his work and was gratified that the food he prepared gave people happiness and pleasure. Although he was single, he had a community of people he liked. They worked alongside him at the bakery, so he never felt alone. When he won the lottery, all that changed.

Suddenly, he was “rich,” so he thought he should upgrade his life. Taking his cue from the messages he’d absorbed from television and movies and advertising and other cultural media, he decided to enter the world of luxury and leisure. He assumed this would make him happier than slaving away in the kitchen. It was as if his new status compelled him to become a different person.

James quit his job and moved to an upscale neighborhood in an oceanside community. There, with all his needs met and a constant stream of money coming in, he was living the proverbial dream. Yet despite his new trappings, this dream felt like a nightmare. Instead of being fulfilled, he was sick and miserable. Previously good-natured, humorous, and outgoing, James grew increasingly withdrawn, isolated, and angry. He put on weight and eventually was diagnosed with the diabetes and high blood pressure that brought him in to see me. Instead of spending time with his bakery colleagues and regular customers, he now visited doctors and otherwise sat alone at home.

Too late, James realized that it had been a terrible mistake to do what he thought a lottery winner ought to do, instead of heeding his own heart. “I traded in my friends and a job I loved and moved to a neighborhood where people keep to themselves in their giant houses. It’s lonely.”

James’s experience was an example of how what we seem to value most in modern society—status, wealth, achievement, and fame—doesn’t guarantee happiness. With more money, we can purchase more privacy, we can live on secluded estates, we can even travel exclusively on our own boat or plane. While all of these privileges have their appeal, there can be a hidden human cost. If we’re not vigilant, such success can lead to a life that feels increasingly lonely as the distance between the individual and other people grows.

If James could find a way to break out of his gilded cage and strengthen his human connections, I suspected his health would improve dramatically. He’d likely become more active, engaged, happier, and more himself. After all, he’d had community and connection before he won the lottery. But that would mean bucking the prevailing assumptions about success and redefining his own ambitions in social, rather than financial terms. He seemed to understand this, but the process of change was daunting, especially now that his health was in jeopardy. How could I, as his doctor, help him?

In our one session together, I did my best to serve James. I listened carefully and asked questions. I recommended adjustments to the doses of his diabetes and blood pressure medication to bring his readings into a healthier range. And I offered to refer him to our hospital social worker, who might be able to help him make some community connections. Beyond that, though, I honestly had no idea how to address the loneliness that seemed to be driving his medical problems. It saddens me even now to think about it, but as a fledgling doctor, I learned far more from James on this subject than I was able to offer him.

My medical education did not prepare me to recognize the impact of social connection on health, and it certainly didn’t give me tools to help my patients who were struggling with loneliness. Instead, my training had been focused almost entirely on the physical body. When we did discuss emotions, it was primarily in the context of managing a psychiatric illness like depression or building a trusting doctor-patient relationship so that patients would feel comfortable to participate in the healing process.

This was simply not enough when meeting patients like the young woman I took care of who had a bacterial infection on her heart valve related to her intravenous drug use. I could counsel her on the dangers of future intravenous drug use and the precautions she needed to take going forward. I knew how to discuss the complexities of treatment pathways, antibiotic courses, and the timing of follow-up imaging studies. I could empathize with the stress and emotional toll of being seriously ill, and I could listen to her and her family as they shared their worries. All of this was very important, but it failed to address the critical need for healthier connections in her life. Her relationships or lack thereof were an important factor in both causing addiction in the first place and determining whether or not she would return to drugs again. I was never trained to assess or address loneliness, and now when confronted with it, I didn’t know where to start.

One Isn’t Always the Loneliest Number

What is loneliness, anyway? This seemingly simple question becomes unexpectedly complex upon closer examination.

Many people think of loneliness as isolation, but the difference between these two terms is substantial. Loneliness is the subjective feeling that you’re lacking the social connections you need. It can feel like being stranded, abandoned, or cut off from the people with whom you belong—even if you’re surrounded by other people. What’s missing when you’re lonely is the feeling of closeness, trust, and the affection of genuine friends, loved ones, and community.

Researchers^{1 2 3} have identified three “dimensions” of loneliness to reflect the particular type of relationships that are missing. Intimate, or emotional, loneliness is the longing for a close confidante or intimate partner—someone with whom you share a deep mutual bond of affection and trust. Relational, or social, loneliness is the yearning for quality friendships and social companionship and support. Collective loneliness is the hunger for a network or community of people who share your sense of purpose and interests. These three dimensions together reflect the full range of high-quality social connections that humans need in order to thrive. The lack of relationships in any of these dimensions can make us lonely, which helps to explain why we may have a supportive marriage yet still feel lonely for friends and community.

Because everyone’s level of need for social connection is different, it’s impossible to say how many friends are required to prevent loneliness. The level varies not only throughout life, but also by personality. People who are more extroverted tend to crave human contact and social activity, feeling energized by networking with strangers. Those who are more introverted need more time by themselves and feel drained by too much interaction, preferring to socialize in smaller groups or one on one. Both introverts and extroverts can experience loneliness, however, and both need strong relationships in order to feel a secure sense of belonging. What often matters is not the quantity or frequency of social contact but the quality of our connections and how we feel about them.

Unlike the feeling of loneliness, which is subjective, isolation describes the objective physical state of being alone and out of touch with other people. Isolation is considered a risk factor for loneliness simply because you’re more likely to feel lonely if you rarely interact with others. But physically being alone doesn’t necessarily translate into the emotional experience of loneliness. Many of us spend long stretches by ourselves when we’re so involved in our work or creative pursuits that we don’t feel at all lonely. On the other hand, we can feel lonely and emotionally alone even when we’re surrounded by other people. What defines loneliness is our internal comfort level.

This is what makes loneliness distinct from solitude. When we feel lonely, we’re unhappy and long to escape this emotional pain. Solitude, by contrast, is a state of peaceful aloneness or voluntary isolation. It is an opportunity for self-reflection and a chance to connect with ourselves without distraction or disturbance. It enhances our personal growth, creativity, and emotional well-being, allowing us to reflect, restore, and replenish. For millennia, monks and ascetics from various spiritual traditions have sought out solitude as an opportunity for introspection and to renew their connection with the divine. Unlike loneliness, solitude is not burdened with shame. Rather, it can be a sacred state.

Solitude also can feel a bit daunting, even scary, since it allows both positive and negative thoughts and emotions to surface. The space where we confront our demons is not always a space we enter willingly. But it’s in the grappling that we work through issues, gain clarity about our feelings, and build comfort with ourselves. Developing comfort with solitude, then, is an essential part of strengthening our connection to ourselves and by extension enabling our connection with others. Solitude, paradoxically, protects against loneliness.

The Loneliness Question

According to a 2018 report by the Henry J. Kaiser Family Foundation, 22 percent of all adults in the US say they often or always feel lonely or socially isolated.⁴ That’s well over fifty-five million people—far more than the number of adult cigarette smokers and nearly double the number of people who have diabetes. A 2018 AARP study using the rigorously validated UCLA loneliness scale found that one in three American adults over the age of forty-five are lonely.⁵ And in a 2018 national survey by the US health insurer Cigna, one-fifth of respondents said they rarely or never feel close to people.⁶

Studies in other countries echo these findings. Among middle-aged and elderly Canadians, nearly one-fifth of men and around a quarter of women said they feel lonely once a week or more.⁷ One-quarter of Australian adults reported being lonely as well.⁸ More than two hundred thousand seniors in the United Kingdom “meet up with or speak on the phone with their children, family and friends less often than once a week”;⁹ 13 percent of Italian adults report having no one to ask for help;¹⁰ and in Japan, over 1 million adults meet the official government definition of social recluses, or hikikomori.^{11 12}

What prevents all these people from simply joining a club, making new friends, or reconnecting with family and old friends? In a word, loneliness itself.

When we already feel lonely and then see others having fun together, enjoying the company of those around them, there’s a natural tendency to withdraw instead of approaching the group. We fear being labeled and judged as social outcasts. (To understand this worry, just spend some time in a grade school cafeteria or playground.) So we hide our true feelings even from those who may try to connect with us. Shame and...