Care by companionship – a proposal for prescription friends
Authors: Benjamin Waterhouse, Rory J O'Connor
Journal: Journal of the Royal Society of Medicine (2009)

All clinicians are familiar with patients who are lonely, particularly at this time of the year. It has long been suspected that loneliness can affect health, and therefore wellbeing, with some evidence that loneliness is as significant a risk factor for poor health as obesity or smoking.1 Disabled people are especially vulnerable to loneliness because of their functional or psychological limitations combined with the inaccessibility of our society.2

If we are serious about promoting health and wellbeing for all patients, then what should we do to ameliorate the contribution of loneliness to poor health? We could combat loneliness through health promotion and greater cooperation with existing support organizations. But, maybe we should go further and prescribe friends? These would not only be beneficial to people's health, but may also be economically viable.

The medical benefits of companionship are increasingly recognized within medical and social care.3 The health differences between socially active and socially isolated people are as significant as those between non-obese and obese people, and non-smokers and smokers.4 Serum cortisol is higher in people who are lonely, contributing to the risk of vascular disease through increased blood pressure and increasing vulnerability to infections. The positive effect of friendship on wound healing is evident in people with good social contacts who demonstrate faster wound repair than those in social isolation.5

The benefits of friendship are psychological as well. The companionate function of friendship supports positive mental health and serves to support individuals during stressful life events. Loneliness is negatively correlated with happiness and perceived life satisfaction.6 Alcoholism, depression, psychosomatic illness and poor self-esteem are also more common among lonely people.7 Loneliness is a factor in poor sleep patterns and could contribute to the progression of dementia. Living a life of solitude can also contribute to a shorter life expectancy.8

Disability can have a profound impact on an individual's social intercourse and their experience of loneliness. A study of disabled people with a variety of conditions found that those with a physical impairment were significantly more likely to be lonely than those without impairments.2

So why are disabled people lonely? One could postulate that physical impairments can impact on an individual's dexterity, movement, hearing or vision and therefore makes meeting and communicating with others more difficult. Difficulties in communication may arise directly from cognitive or communication impairments and indirectly from displaced feelings, fear and anger.9 It has been suggested that the problem lies not with disabled people but with the organizational and architectural inaccessibility of our society, which is generally designed for non-disabled people. In addition, stigmatization may result from those impairments which produce a visible difference, for example, Down's syndrome or neurofibromatosis.

We have identified three initiatives that could ameliorate the impact of loneliness on health, some of which have already been implemented successfully elsewhere.

The Friends Can Be Good Medicine initiative in California has demonstrated that health promotion campaigns can influence positive relationship behaviour.10 Through media promotions, educational materials and community activities, members of the general public became more knowledgeable about the beneficial effects of friendship and had more relationship-minded intentions following the campaign. Such initiatives in the UK would prove beneficial to disabled people, as well as the general population which is increasingly socially isolated.

Healthcare, social services and non-statutory organizations perform an invaluable job in providing social support. However, these supports are not always available, or are insufficient. A potential solution to loneliness would be to strengthen ties between doctors and support agencies so that particularly vulnerable people can be referred for support more easily. There is no reason why the NHS, with its organizational capacity could not help to coordinate links between disabled people and support agencies, remembering that health encompasses social and emotional as well as physical wellbeing.

Finally, as one of us mused in clinic, ‘maybe the NHS should prescribe friends’. This is novel, but contentious for a number of reasons. First, friendship is supposed to be unconditional, voluntary and not a means to an end, such as financial reward. Second, it might be argued that lonely, disabled people need sustainable relationships in order to benefit from friendship. However, this service would provide friends and immediate companionship to those in desperate loneliness so that they felt more valued, and consequently developed the self-assurance to venture outside and forge their own relationships. The logic is much the same as prescribing anti-depressants to a patient who is depressed, not as a long-term cure, but to enable that individual to develop the strength required to address their underlying problems. A prescription friend may not perhaps generate a sustainable friendship, but it might empower a disabled person with the confidence to initiate his or her own supportive relationships.

There is a theoretical basis and empirical evidence for the negative impact of loneliness on physical and mental health. Strong associations between loneliness and disability have also been highlighted, thereby making the health of disabled people a particular concern. We have briefly proposed three practical solutions in the form of health promotion, greater coordination between organizations and, more radically, prescription friends. By adopting such initiatives the much segregated population of disabled people could be helped to flourish through social intercourse with others, thereby reaping the health benefits of companionship.