This essay is part of a RealClearPolicy series centered on the American Project, an initiative of the Pepperdine School of Public Policy. The project looks to the country’s founding principles to respond to our current cultural and political upheaval.
It was 3:40 AM when a rattling pager startled me awake. The message read: “38-year-old male with suicidal ideations, please evaluate.” I slid on my shoes, tied back my hair, and splashed water on my face, in an effort to hide my fatigue and failed attempt at sleeping between patients.
Inside a small, sterile emergency room, Mr. White discussed the recent loss of his parents, his struggles with employment and finances, rejection by his siblings, and resulting homelessness. He was particularly distraught when discussing the loss of his dog:
“She was the only thing in this world that viewed me as someone worth loving. I sleep in the park, and everyone that walks by thinks I am worse than a stray; I am sub-human. No one cares about you when you’re in a situation like mine. Except for her … she cared for me, and my whole life’s purpose was to care for her in return. Now she’s gone, and I have nothing left in this world.”
The room filled with the heavy air of despair.
I clicked through the familiar suicide assessment template that is part of all psychiatric evaluations. This assessment was chillingly different from most, though: I couldn’t identify a single protective factor against suicide in Mr. White’s life. Typically, looming responsibility to parents or children is enough to pull people through hard times. In some instances, a strong relationship with a friend or counselor confers enough support that people can find hope in the bleakest of circumstances. But Mr. White had none of these. His dog was his one remaining protective factor. Still, I attempted to reassure Mr. White that, despite how he felt right now, things would get better. Was this true? As I exited his room, I said a silent prayer that for him it would be.
“Deaths of Despair”
Economically, America is more prosperous than it has ever been. We are richer, more connected, electronically, and have more information available to us than ever before. And yet, we are in the midst of a crisis that is claiming thousands of American lives: loneliness.
Since the turn of the century, Americans have been dying from suicide, alcohol-related illnesses, and drug overdoses at a rate that has never before been seen. Princeton economists Anne Case and Angus Deaton have aptly named these tragedies “Deaths of Despair.” In fact, suicide is now the second leading cause of death for American teenagers and the tenth leading cause of death for Americans, overall. The suicide rate has increased more than 30 percent in half of U.S. states since 1999. Equally harrowing, drug overdose is the leading cause of death for Americans under the age of fifty. Since 2015, our nation’s average life expectancy has been declining — suggesting that the toll of American despair can no longer be outpaced by technological or medical advancements. In 2017 alone, approximately 47,000 Americans committed suicide, and over 70,000 individuals died of a drug overdose. To put these number into perspective, 40,000 Americans died in motor vehicles accident during that same year, while roughly 58,000 U.S. soldiers died in the Vietnam War as a whole.
While the statistics are daunting, the reality is devastating. In every age group, and across every geographic region, alarming numbers of mothers are finding themselves childless, husbands suddenly without their wives, and sisters without their brothers. We are having less sex and fewer children than previous generations — another sign of diminished hope. Our material lives may be outwardly prosperous, but our psychological and spiritual lives are in freefall.
What is driving us to self-destruction? There are many factors, all with one unifying theme: We are no longer living in community with one another and, consequently, we are lonely.
Loneliness in America
I recently treated a young woman who intentionally severed her airway and spinal cord with an eight-inch kitchen knife in an attempt to take her own life. She cited as the drivers of her despair the isolation associated with caring for her ill grandmother and the paucity of individuals with whom she could meaningfully discuss such challenges. Unfortunately, I treat patients like her far too often.
This kind of loneliness, defined by an absence of meaningful relationships, now plagues nearly half of all Americans. In fact, American loneliness has doubled since 1980: One in five Americans now report having no one to talk to when going through difficult times. Our isolation is so severe that former U.S. Surgeon General Vivek Murthy recently declared loneliness a public health crisis.
As further evidence that loneliness is at the core of our crisis, consider that the three least densely populated states in the country, Wyoming, Alaska, and Montana, had the highest per capita suicide rate in 2012. Conversely, our republic’s most densely populated regions, such as Washington D.C. and New Jersey, had the lowest suicide rates. No other factor, whether income, family structure, or religious observance, correlates with suicide rates to the same degree.
According to Abraham Maslow’s hierarchy of needs, after basic physiologic and safety requirements have been met (i.e. food and shelter), the next greatest human need is social connectedness: to feel that we belong. Without this, Maslow postulated that humans could not successfully pursue higher aspirations such as growth, autonomy, and self-actualization. The death toll that has resulted from America’s lack of connection certainly seems to give credence to Maslow’s theory. It also suggests that to return to a state of health and prosperity, we must solve the problem of loneliness.
Happiness and Human Flourishing
To understand how America got here, we must first consider what contributes to happiness and human flourishing. Social scientists have identified various factors or building blocks of human happiness. In his book on loneliness, “Them: Why We Hate Each Other — and How to Heal,” Senator Ben Sasse (R-NE) suggests thinking about these building blocks in terms of the following four questions:
- Do you have family you love, and who love you?
- Do you have friends you trust and confide in?
- Do you have work that matters — callings that benefit your neighbors?
- Do you have a worldview that can make sense of suffering and death?
Sasse suggests thinking about these “as the legs of a chair.” “When all four are in place, things are sturdy. When one goes missing, your happiness begins to wobble.” Unfortunately, over the past several decades, daily life has shifted so dramatically that many Americans can no longer affirmatively answer these questions — suggesting that our happiness is very wobbly.
1. Do you have family you love, and who loves you?
First, the good news: the American divorce rate has decreased 18 percent in the last decade and teen birth rates are at an all-time low. The not so good news: Over half of American adults are choosing to forego marriage altogether. Rates of nonmarital cohabitation have skyrocketed and 40 percent of American children are now born to unwed parents. Statistically, half of these couples will separate before their child is nine years old, placing the entire family at risk for anxiety, depression, or addiction.
Even for traditionally structured families modern life is challenging. American homes have fewer children, but more square footage than ever before. Our quality time together has dropped precipitously: We spend time in separate rooms, doing separate tasks. According to Harvard sociologist Robert Putnam, we spent 43 percent less time at our own family dinner table than we did just 25 years ago. When we do sit down together, technology frequently interferes. Historically, family has been the first society, where children gain social identity and security. But our homes are becoming less stable, less intimate, and, consequently, less formative than ever before.
2. Do you have friends you trust and confide in?
Last month, I was able successfully to ween an elderly widow off her antidepressant medication in part by helping her to engage in therapy and to join a line-dancing group. While hesitant to enroll at first, her daily dancing commitment was the perfect prescription for meaningful social engagement, allowing her to connect with people in a way she hadn’t experienced since her husband passed away.
In an era dominated by technological connection and abounding online “friends,” the dearth of flesh-and-blood relationships has become devastating. Since the mid-1980’s, the average number of friends with whom Americans say they could “discuss important matters” has dropped from three to just one.
Moreover, adolescence is no longer characterized by a growing desire for independence. According to Jean Twenge, the number of teenagers who get together with their friends nearly every day has dropped 40 percent since 2000. One teenager described this phenomenon simply: “I think we like our phones more than we like actual people.” Not only does this make for more lonely teenagers, it also hinders their social, emotional, and psychological development. A lack of interaction now will make it significantly harder for these young people to begin new relationships, interview for jobs, navigate courtship, and build healthy families in their adult life.
3. Do you have work that matters — callings that benefit your neighbors?
The 1970’s was the era of the “Blue Collar Aristocracy.” This was a time-period where union jobs were thriving, laborers came to expect annual promotions and raises, and employees tended to develop loyalty to their companies, often expecting to spend their entire career at just one institution. With this security and steady predictability, working-class citizens were able to access the American dream. Such a worker could reasonably hope to own a home with a white picket fence and to support children, with a spouse who had the option to stay home, raise children, and run the household.
Today, the employment landscape looks very different. Blue collar workers now receive lower relative wages and enjoy lower social esteem compared to their 1970’s counterparts. Globalization and technology contribute to a growing sense that employees are disposable, all the while contract work is on the rise. This creates a culture of transient work and rootlessness, particularly for those without sufficient skills for the knowledge-intensive and service-oriented sectors such as education, health care, and business services.
Moreover, while the American unemployment rate is historically low, this antiquated index fails to account for individuals who are not employed but also not looking for work. Since 2000, for every working-age American male who is unemployed and looking for work, there are another three men who are “idle,” not looking for work. On average “idle Americans” spend 2,000 hours per year in front of a screen — the equivalent of a full time job. Nearly half of this population takes daily pain medication and three-fifths receives disability benefits, providing a potentially long-term alternative to paid employment. Most telling, however, is that these individuals report very low levels of emotional well-being, and say they derive little meaning from their daily activities. With a waning sense of identity and purpose, they frequently fall victim to drug addiction and suicide.
4. Do you have a worldview that can make sense of suffering and death?
A Harvard research study followed 89,000 women over a 15-year period in order to understand the relationship between religion and suicide. Results showed that Catholic women who attended Mass weekly had a suicide rate that was half that of the general population. Of the 7,000 women who attended Mass more than once a week, not a single one committed suicide during the 15 years of the study.
Why might this be? The “horizontal” component of faith ties us to a real-life, hold-hands-and-pray-together community. This community is rich with cradle-to-grave relationships founded on a shared biblical appreciation of human nature and its flaws and the importance of forgiveness. Psychiatrist and author M. Scott Peck encapsulated this well: “When I am with a group of human beings committed to hanging in there through both the agony and the joy of community, I have a dim sense that I am participating in a phenomenon for which there is only one word: ‘glory.’”
The “vertical” component of faith is equally important. Christianity, Islam, Judaism, Hinduism, and Buddhism all have, to varying degrees, teachings on the immorality and prohibitions on suicide. Perhaps more importantly, faith does not promise a life free from suffering. Instead, it offers purpose in and guidance through suffering. Religious faith can instill a sense of meaning and purpose that transcends the present struggle; it allows people to survive anguish and find meaning in suffering. I have seen this first-hand, time and time again, with many of my patients reporting they would have attempted suicide long ago if they did not have faith, which provided them with hope in otherwise hopeless circumstances.
But religion can only help combat loneliness if Americans actually practice religion. In roughly the same timeframe that America has experienced an uptick in “deaths of despair,” active religious affiliations have been declining. Religiously affiliated Americans, on average, are as actively devout as they have always been. The number of religiously affiliated individuals, however, is in sharp decline. As of 2014, for every American that adopted a specific religious affiliation, 4.2 Americans did just the opposite, abandoning their formal religious identity.
A Call for Connection
As we lose our connectedness to one another, these words of Alexis de Tocqueville no longer serve as a celebration of American life:
“As soon as several of the inhabitants of the United States have taken up an opinion or a feeling which they wish to promote in the world, they combine. From that moment they are no longer isolated men, but a power seen from afar…. If men are to remain civilized or to become so, the art of associating together must grow and improve.”
In our current moment, we do not stand for embodied ideals and interdependence, but isolation, anger, and despair. Unfortunately, there is now morbid truth to Abraham Lincoln’s warning that America need only fear itself, “as a nation of freemen, we must live through all time, or die by suicide.”
There is no straightforward solution to our current problem, but everyone can play a role in helping America heal. The first step: be present. Close your computer and engage your colleague while waiting for a meeting to start. Re-define “FaceTime” by opting for a shared coffee instead of a phone call. Check in on the widow down the street. Recognize the sacred space of the home, by designating “tech-free” spaces. Reclaim the dinner table and engage in religious and other institutions of civic life. In short, re-cultivate the virtues of association and community.
Francie Hart Broghammer, MD, is the chief psychiatry resident at UC Irvine Medical Center, where she is doing clinical work and research examining the social, relational, and spiritual determinants of mental health. She serves as an American Psychiatric Association Leadership Fellow and is a member of the UC Irvine Medical Ethics Committee. Francie can be reached at email@example.com.