Loneliness is a complex and unpleasant emotional response to isolation or lack of companionship. The pain of loneliness is such that, throughout history, solitary confinement has been used as a form of torture and punishment. More than just painful, loneliness is also damaging. Lonely people eat and drink more, and exercise and sleep less.

Loneliness is a particular problem of modernity. One U.S. study found that between 1985 and 2004, the proportion of people reporting having no one to confide in almost tripled. According to a poll carried out in 2017 for the Jo Cox Commission on Loneliness, three-quarters of older people in the U.K. are lonely. Shockingly, two-fifths of respondents agreed with the statement, “sometimes an entire day goes by and I haven’t spoken to anybody”.

Some of the factors behind these stark statistics include: smaller household sizes, greater migration, higher media consumption, and longer life expectancy. Large conglomerations built on productivity and consumption at the expense of connection and contemplation can feel profoundly alienating. The Internet has become the great comforter and seems to offer it all: news, knowledge, music, entertainment, shopping, relationships, and even sex. But over time, it foments envy and division, confuses our needs and priorities, desensitizes us to violence and suffering, and, by creating a false sense of connectedness, entrenches superficial relationships at the cost of living ones.

Man has evolved over millennia into one of the most social and interconnected of all animals. Suddenly, he finds himself apart and alone, not on a mountaintop, in a desert, or on a raft at sea, but in a city of millions, in reach but out of touch. For the first time in human history, he has no practical need, and therefore no pretext, to interact and form attachments with his fellow men and women.

But, against nature, there are a few people who actively choose to remove themselves from the rest of society, or, at least, not to actively seek out social interaction. Such “loners” (the very term is pejorative, implying, as it does, abnormality and deviousness) may revel in their rich inner life or simply dislike or distrust the company of others, which, they feel, comes with more costs than benefits.

Timon of Athens, who lived at around the same time as Plato, began life in wealth, lavishing money upon his flattering friends, and, in accordance with his conception of friendship, never expecting anything in return. When he ran out of coin, all his friends deserted him, reducing him to the hard toil of labouring the fields. One day, as Timon tilled the earth, he uncovered a pot of gold, and, suddenly, all his old friends came piling back. But rather than welcome them with open arms, he cursed them and drove them away with sticks and clods of earth. Timon declared his hatred of humankind and withdrew into the forest, where, much to his annoyance, people began to seek him out as some sort of holy man.

Did Timon feel lonely in the forest? Probably not, because he did not believe he lacked for anything. As he no longer valued his friends or their companionship, he could not have desired or missed them—even though he may have pined for a better class of man, and, in that limited sense, felt lonely.

Loneliness is not so much an objective state of affairs as a subjective state of mind, a function of desired and achieved levels of social interaction and also of type or types of interaction. Lovers often feel lonely in the single absence of their beloved, even when completely surrounded by friends and family. Jilted lovers feel much lonelier than lovers who are merely apart from their beloved, indicating that loneliness is not merely a matter of the amount or degree of interaction, but also of the potential or possibility for interaction. Conversely, it is common to feel lonely within a marriage because the relationship is no longer validating or nurturing us, but diminishing us and holding us back.

And yet for many people marriage is, among others, an attempt to flee from their lifelong loneliness and escape from their inescapable demons. At the bottom, loneliness is not the experience of lacking but the experience of living. It is part and parcel of the human condition. Unless a person is resolved, it can only be a matter of time before the feeling of loneliness resurfaces, often with a vengeance. On this account, loneliness is the manifestation of the conflict between our desire for meaning and the absence of objective meaning from the universe, an absence that is all the more glaring in modern societies which have sacrificed traditional and religious structures of meaning on the thin altar of truth.

So much explains why people with a strong sense of purpose and meaning, or simply with a strong narrative, such as Nelson Mandela or St Anthony of the Desert, are protected from loneliness regardless of the circumstances in which they find themselves. St Anthony sought out loneliness precisely because he understood that it could bring him closer to the real questions and value of life. He spent fifteen years in a tomb and twenty years in an abandoned fort in the desert of Egypt before his devotees persuaded him to withdraw from his seclusion to instruct and organize them, whence his epithet, “Father of All Monks”. Anthony emerged from the fort not ill and emaciated, as everyone had been expecting, but healthy and radiant, and expired in his hundred and sixth year, which in the fourth century must in itself have counted as a minor miracle.

St Anthony did not lead a life of loneliness, but one of solitude. Loneliness, the pain of being alone, is damaging; solitude, the joy of being alone, is empowering, liberating. Our unconscious requires solitude to process and unravel problems, so much so that our body imposes it upon us each night in the form of sleep. By removing us from the constraints, distractions, and influences imposed upon us by others, solitude frees us to reconnect with ourselves, assimilate ideas, and generate identity and meaning.

For Nietzsche, men without the aptitude or opportunity for solitude are mere slaves because they have no alternative but to parrot culture and society. In contrast, anyone who has unmasked society naturally seeks out solitude, which becomes the source and guarantor of a more authentic set of values and ambitions:

I go into solitude so as not to drink out of everybody’s cistern. When I am among the many I live as the many do, and I do not think I really think. After a time it always seems as if they want to banish my self from myself and rob me of my soul.

Solitude removes us from the mindless humdrum of everyday life into a higher consciousness which reconnects us with our deepest humanity, and also with the natural world, which quickens into our muse and companion. By setting aside dependent emotions and constricting compromises, we free ourselves up for problem solving, creativity, and spirituality. If we can embrace it, this opportunity to adjust and refine our perspectives creates the strength and security for still greater solitude and, in time, the substance and meaning that guards against loneliness.

The life of St Anthony can leave the impression that solitude is at odds with attachment, but this need not be the case so long as the one is not pitted against the other. True lovers, says RM Rilke, should not only tolerate but “stand guard over” the solitude of the other.

In Solitude: A Return to the Self, the psychiatrist Anthony Storr convincingly argues that:

The happiest lives are probably those in which neither interpersonal relationships nor impersonal interests are idealized as the only way to salvation. The desire and pursuit of the whole must comprehend both aspects of human nature.

Be this as it may, not everyone is capable of solitude, and for many people aloneness will never amount to anything more than bitter loneliness. Younger people often find aloneness difficult, while older people are more likely, or less unlikely, to seek it out.

So much suggests that solitude, the joy of being alone, stems from, as well as promotes, a state of maturity and inner richness.

  1. Don’t panic. Be philosophical about your exams. Put them into perspective. And remember that as long as you do your bit, you are statistically very unlikely to fail. Book a holiday to a sunny Greek island starting on the day after your exams to help focus your attention.
  2. Read the instructions carefully and stick to them. Sometimes it’s just possible to have revised so much that you no longer ‘see’ the instructions and just fire out the bullet points like an automatic gun. If you forget the instructions or the actor looks at you like Caliban in the mirror, ask to read the instructions again. A related point is this: pay careful attention to the facial expression of the actor or examiner. Just as an ECG monitor provides live indirect feedback on the heart’s performance, so the actor or examiner’s facial expression provides live indirect feedback on your performance, the only difference being – I’m sure you’ll agree – that facial expressions are far easier to read than ECG monitors.
  3. Quickly survey the cubicle for the equipment and materials provided. You can be sure that items such as hand disinfectant, a tendon hammer, a sharps bin, or a box of tissues are not just random objects that the examiner later plans to take home.
  4. First impressions count. You never get a second chance to make a good first impression. As much of your future career depends on it, make sure that you get off to an early start. And who knows? You might even fool yourself.
  5. Prefer breadth to depth. Marks are normally distributed across a number of relevant domains, such that you score more marks for touching upon a large number of domains than for exploring any one domain in great depth. Do this only if you have time, if it seems particularly relevant, or if you are specifically asked. Perhaps ironically, touching upon a large number of domains makes you look more focused, and thereby safer and more competent.
  6. Don’t let the examiners put you off or hold you back. If they are being difficult, that’s their problem, not yours. Or at least, it’s everyone’s problem, not yours. And remember that all that is gold does not glitter; a difficult examiner may be a hidden gem.
  7. Be genuine. This is easier said than done, but then even actors are people. By convincing yourself that the OSCE stations are real situations, you are much more likely to score highly with the actors, if only by ‘remembering’ to treat them like real patients. This may hand you a merit over a pass and, in borderline situations, a pass over a fail. Although they never seem to think so, students usually fail OSCEs through poor communication skills and lack of empathy, not through lack of studying and poor memory.
  8. Enjoy yourself. After all, you did choose to be there, and you probably chose wisely. If you do badly in one station, try to put it behind you. It’s not for nothing that psychiatrists refer to ‘repression’ as a ‘defence mechanism’, and a selectively bad memory will do you no end of good.
  9. Keep to time but do not appear rushed. If you don’t finish by the first bell, simply tell the examiner what else needs to be said or done, or tell him or her indirectly by telling the patient, for example, “Can we make another appointment to give us more time to go through your treatment options?” Then summarise and conclude. Students often think that tight protocols impress examiners, but looking slick and natural and handing over some control to the patient is often far more impressive. And probably easier.
  10. Be nice to the patient. Have I already said this? Introduce yourself, shake hands, smile, even joke if it seems appropriate – it makes life easier for everyone, including yourself. Remember to explain everything to the patient as you go along, to ask them about pain before you touch them, and to thank them on the second bell. The patient holds the key to the station, and they may hand it to you on a silver platter if you seem deserving enough. That having been said, if you reach the end of the station and feel that something is amiss, there’s no harm in gently reminding them, for example, “Is there anything else that you feel is important but that we haven’t had time to talk about?” Nudge-nudge.
  11. Take a step back to jump further. Last minute cramming is not going to magically turn you into a good doctor, so spend the day before the exam relaxing and sharpening your mind. Go to the country, play some sports, stream a film. And make sure that you are tired enough to fall asleep by a reasonable hour.
  12. Finally, remember to practise, practise, and practise. Look at the bright side of things: at least you’re not going to be alone, and there are going to be plenty of opportunities for good conversations, good laughs, and good meals. You might even make lifelong friends in the process. And then go off to that Greek island.

Adapted from the new sixth edition of Clinical Skills for OSCEs.

First time I do a Christmas book offer, so here goes… 😃

Buy a paperback copy of Hypersanity for yourself or to gift 🎁, send me a copy of the receipt, and, as a thank you, I’ll reply with an e-copy of the new Heaven & Hell, which isn’t due to be published until next year.

Offer expires 21/12 🎄

neel@neelburton dot com